Provider Demographics
NPI:1649357229
Name:MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Entity type:Organization
Organization Name:MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
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 1:200 ST. MARY
Mailing Address - Street 2:P O BOX 523
Mailing Address - City:PILOT KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:63663-0523
Mailing Address - Country:US
Mailing Address - Phone:573-546-7000
Mailing Address - Fax:573-546-6420
Practice Address - Street 1:200 ST. MARY
Practice Address - Street 2:
Practice Address - City:PILOT KNOB
Practice Address - State:MO
Practice Address - Zip Code:63663-0523
Practice Address - Country:US
Practice Address - Phone:573-546-7000
Practice Address - Fax:573-546-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO595679408Medicaid
MO268572Medicare Oscar/Certification