Provider Demographics
NPI:1629024286
Name:FORT MADISON COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:FORT MADISON COMMUNITY HOSPITAL
Other - Org Name:FORT MADISON COMMUNITY HOSPITAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-376-2124
Mailing Address - Street 1:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-1470
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT MADISON COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207V00000X, 208000000X, 208600000X, 208800000X
IA02397207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0122978Medicaid
IA51179OtherBLUE CROSS BLUE SHIELD
IA51179Medicare PIN
IA0122978Medicaid