Provider Demographics
NPI:1720163025
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
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
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 W MAIN ST
Mailing Address - Street 2:PO BOX 431
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1111
Mailing Address - Country:US
Mailing Address - Phone:573-783-3341
Mailing Address - Fax:573-783-1096
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1111
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:2006-10-26
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO209-45282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010155109Medicaid
MO000050067Medicare PIN
MO261302Medicare ID - Type Unspecified
MO010155109Medicaid