Provider Demographics
NPI:1639111206
Name:MADISON PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MADISON PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DM, RN
Authorized Official - Phone:208-359-9879
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0700
Mailing Address - Country:US
Mailing Address - Phone:208-359-9898
Mailing Address - Fax:208-359-6764
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:208-359-9898
Practice Address - Fax:208-359-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002855800Medicaid
ID8K867OtherBLUE CROSS OF IDAHO
ID000010006290OtherREGENCE BLUE SHIELD OF ID
ID002855800Medicaid