Provider Demographics
NPI:1134592017
Name:MADISON CO MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MADISON CO MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DM, RN, RODP
Authorized Official - Phone:208-359-6900
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-356-5401
Mailing Address - Fax:208-356-3111
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-356-5401
Practice Address - Fax:208-356-3111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON CO MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-02
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty