Provider Demographics
NPI:1346643038
Name:MADISON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MADISON MEMORIAL HOSPITAL
Other - Org Name:MADISON CLINIC PHYSICIANS
Other - Org Type:Doing Business As
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 130
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0130
Mailing Address - Country:US
Mailing Address - Phone:208-359-6419
Mailing Address - Fax:208-359-6915
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-359-6419
Practice Address - Fax:208-359-6915
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care