Provider Demographics
NPI:1679673081
Name:FORT MADISON COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:FORT MADISON COMMUNITY HOSPITAL
Other - Org Name:FORT MADISON COMMUNITY HOSPITAL HOME HEALTH
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 1:5445 AVENUE O
Mailing Address - Street 2:SUITE 114
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9611
Mailing Address - Country:US
Mailing Address - Phone:319-376-2166
Mailing Address - Fax:319-376-2167
Practice Address - Street 1:5445 AVENUE O
Practice Address - Street 2:SUITE 114
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9611
Practice Address - Country:US
Practice Address - Phone:319-376-2166
Practice Address - Fax:319-376-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA560087H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0163438EMedicaid
IA167281OtherMEDICARE OSCAR CERTIFICATION
IA167281OtherMEDICARE OSCAR CERTIFICATION