Provider Demographics
NPI:1477122570
Name:MADISON CO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MADISON CO MEMORIAL HOSPITAL
Other - Org Name:MADISON MEMORIAL BEHAVIORAL HEALTH CLINIC
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:
Mailing Address - Fax:
Practice Address - Street 1:37 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1906
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON CO MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-22
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty