Madison Co Memorial Hospital
Organization Active NPI Family Medicine Physician · Rexburg, ID
NPI 1134592017 · NPPES record last updated Oct 23, 2023
Key facts
- NPI
- 1134592017
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 40 (ID)
- Legal business name
- MADISON CO MEMORIAL HOSPITAL
- Practice address
- 393 E 2ND N
Rexburg, ID 83440-1605 - Phone
- (208) 356-5401
- Fax
- (208) 356-3111
- NPI assigned
- Nov 2, 2015
- Organization subpart
- Yes
- Parent organization (as reported)
- MADISON CO MEMORIAL HOSPITAL
Authorized official
- Name
- Rachel Gonzales, DM, RN, RODP
- Title
- Chief Executive Officer
- Phone
- (208) 359-6900
Parent organization (reported in NPPES) 1
Owned or controlled facilities with NPI records 3
Other NPIs on the same Medicare enrollment 6
Other NPIs with the same Medicare PAC ID 2
Practitioners 45
-
Eric E. Barton, DPM
-
Brian Paul Beesley, M.D.
-
Erin Joanne Benson, NP-C
-
Colby Ray Brower, MD
-
Jack O. Clark, M.D.
-
Matheau Eysser, D.O.
-
Hayley Brooke Grover, FNP-C
-
Scott Russell Hardy, D.O.
-
Marie Horne, CNM
-
Michael J Larson, MD
-
Martin A Mangan, DO
-
James McCoy, MD
-
Rex Allen Meredith, PA-C
-
James Morris, MD
-
Michael M Packer, M.D.
-
Corey T Rammell, MD
-
Kylee E Schaat, FNP
-
Joseph Watson, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Madison Memorial Hospital |
Hospital | Other | Jul 1, 1966 |
| Madison Carriage Cove Short Term Rehabilitation |
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 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Part of
- Madison Co Memorial Hosp
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 40 | ID | Yes |
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
- Madison Memorial Rexburg Medical Clinic
Other providers in Rexburg, ID
- Kirk Lynn Mace
- Bree Anne Mackenzie
- Madison Anesthesia Services PA
- Madison Clinic Optometry, P.C.
- Madison Co Memorial Hospital
- Madison Co Memorial Hospital
- Madison Co Memorial Hospital
- Madison Co Memorial Hospital
- Madison Co Memorial Hospital
- Madison Co Memorial Hospital
All providers in Rexburg, ID · Family Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 23, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.