Provider Demographics
NPI:1609874338
Name:MADISON MEMORIAL HEALTHCARE CLINIC
Entity Type:Organization
Organization Name:MADISON MEMORIAL HEALTHCARE CLINIC
Other - Org Name:MADISON CO HOSPITAL HEALTH SYS., INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-973-1366
Mailing Address - Street 1:201 E MARION ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-2525
Mailing Address - Country:US
Mailing Address - Phone:850-973-3456
Mailing Address - Fax:850-973-3338
Practice Address - Street 1:201 E MARION ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2525
Practice Address - Country:US
Practice Address - Phone:850-973-3456
Practice Address - Fax:850-973-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-3427Medicare ID - Type Unspecified