Provider Demographics
NPI:1750457586
Name:MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Entity Type:Organization
Organization Name:MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Other - Org Name:MADISON MEMORIAL HOSPITAL STOCKHOFF MEMORIAL NURSING HOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TWIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-3341
Mailing Address - Street 1:611 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645
Mailing Address - Country:US
Mailing Address - Phone:573-783-3341
Mailing Address - Fax:573-783-1096
Practice Address - Street 1:611 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645
Practice Address - Country:US
Practice Address - Phone:573-783-3341
Practice Address - Fax:573-783-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO25619251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO580155109Medicaid
MO267263Medicare Oscar/Certification