Provider Demographics
NPI:1740301688
Name:MADISON COUNTY BOARD OF MRDD
Entity type:Organization
Organization Name:MADISON COUNTY BOARD OF MRDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-852-7050
Mailing Address - Street 1:1423 STATE ROUTE 38 SE
Mailing Address - Street 2:P.O. BOX 88
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-8700
Mailing Address - Country:US
Mailing Address - Phone:740-852-7050
Mailing Address - Fax:740-852-7051
Practice Address - Street 1:1423 STATE ROUTE 38 SE
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-8700
Practice Address - Country:US
Practice Address - Phone:740-852-7050
Practice Address - Fax:740-852-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4900012251B00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2558585Medicaid