NPIMap

Organization Active NPI

Madison Co Memorial Hospital

Doing business as Madison Memorial Rexburg Medical Clinic

  • Family Medicine Physician
  • Rexburg, ID
National Provider Identifier
1134592017
Registry record updated Oct 23, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
40 Issued in ID
Legal business name
MADISON CO MEMORIAL HOSPITAL
Doing business as
Madison Memorial Rexburg Medical Clinic
Practice address
393 E 2ND N
Rexburg, ID 83440-1605
Phone
(208) 356-5401
Fax
(208) 356-3111
NPI assigned
Nov 2, 2015
Last updated
Oct 23, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
MADISON CO MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 23, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Rachel Gonzales, DM, RN, RODP
Title
Chief Executive Officer
Phone
(208) 359-6900

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 40 ID Primary

Addresses

Primary practice location

393 E 2ND N
Rexburg, ID 83440-1605

Mailing address

393 E 2ND N
Rexburg, ID 83440-1605
Phone (208) 356-5401

Other names 1

  • Madison Memorial Rexburg Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040505000664 ID Part B Supplier - Clinic/Group Practice 8123016367 Receives reassigned benefits from 45 practitioners
7 other NPIs on this enrollment
Practice locations: Rexburg, ID; Rigby, ID

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Madison Co Memorial Hos

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Madison Memorial HospitalRexburg, ID, CCN 13S025 Hospital Other Jul 1, 1966
Madison Carriage Cove Short Term RehabilitationRexburg, ID, CCN 135140 Skilled nursing facility 5% Or Greater Direct Ownership Interest (50%)
General Partnership Interest (50%)
Operational/Managerial Control
Adp of the SNF
Direct Ownership Interest (50%)		 Oct 1, 2017
Oct 1, 2017
Oct 1, 2017
Oct 1, 2017
Oct 1, 2017

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 45

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 45

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1446422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698019200000",
    "number": "1134592017",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "393 E 2ND N",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834401605",
            "telephone_number": "208-356-5401",
            "fax_number": "208-356-3111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "393 E 2ND N",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834401605",
            "telephone_number": "208-356-5401",
            "fax_number": "208-356-3111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MADISON CO MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MADISON CO MEMORIAL HOSPITAL",
        "enumeration_date": "2015-11-02",
        "last_updated": "2023-10-23",
        "certification_date": "2023-10-23",
        "status": "A",
        "authorized_official_last_name": "GONZALES",
        "authorized_official_first_name": "RACHEL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "208-359-6900",
        "authorized_official_credential": "DM, RN, RODP"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "40",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Madison Memorial Rexburg Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Madison Memorial Rexburg Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rexburg, ID

Sources for this page

Verify at the official NPI Registry.