Provider Demographics
NPI:1730800897
Name:MADISON CO MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MADISON CO MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DM, RN, RODP
Authorized Official - Phone:208-359-6900
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0700
Mailing Address - Country:US
Mailing Address - Phone:208-359-6516
Mailing Address - Fax:
Practice Address - Street 1:25 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2057
Practice Address - Country:US
Practice Address - Phone:208-359-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON C O MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-07
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty