Provider Demographics
NPI:1164698338
Name:MADISON COUNTY HOSPITAL HOSPICE
Entity Type:Organization
Organization Name:MADISON COUNTY HOSPITAL HOSPICE
Other - Org Name:MADISON COUNTY COMMUNITY HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-845-7000
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-1115
Practice Address - Country:US
Practice Address - Phone:740-845-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0036HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820179Medicaid
OH0820179Medicaid
OH361537Medicare UPIN