NPIMap

Organization Active NPI

Madison Medical Center Stockhoff Memorial Nursing Home

  • Medicare Defined Swing Bed Hospital Unit
  • Fredericktown, MO
National Provider Identifier
1316013139
Registry record updated Jul 30, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
20945 Issued in MO
Legal business name
MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Practice address
611 West Main Street
Fredericktown, MO 63645
Phone
(573) 783-3341
Fax
(573) 783-1096
NPI assigned
Nov 24, 2006
Last updated
Jul 30, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2008

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

Authorized official

Name
Mrs. Lisa Marie Twidwell
Title
Cfo
Phone
(573) 783-3341

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 20945 MO Primary

Addresses

Primary practice location

611 West Main Street
Fredericktown, MO 63645

Mailing address

611 W Main St
Fredericktown, MO 63645-1111
Phone (573) 783-3341

Other names 1

  • Madison Memorial Hospital Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080728000501 MO Part A Provider - Critical Access Hospital 1355255886 Practice locations: Fredericktown, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316013139. Details of each certification follow.

Hospital certification: CCN 26Z302

Legal name
MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Doing business as
MADISON MEDICAL CENTER
Organization structure
GovernmentNon-profit
Enrollment address
611 W Main St
Fredericktown, MO 63645-1111
Hospital Swing-Bed Unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Ajay K Upadhyay MD9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kent Marler Individual Corporate Director Jun 12, 2008
Lisa M Twidwell Individual Corporate OfficerCeo Jun 1, 2009 100%
W-2 Managing Employee Jun 12, 2008

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Madison Medical CenterFredericktown, MO, CCN 268568 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2003
Apr 1, 2003

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1164326400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1217376000000",
    "number": "1316013139",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 W MAIN ST",
            "city": "FREDERICKTOWN",
            "state": "MO",
            "postal_code": "636451111",
            "telephone_number": "573-783-3341",
            "fax_number": "573-783-1096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "611 WEST MAIN STREET",
            "city": "FREDERICKTOWN",
            "state": "MO",
            "postal_code": "63645",
            "telephone_number": "573-783-3341",
            "fax_number": "573-783-1096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-24",
        "last_updated": "2008-07-30",
        "status": "A",
        "authorized_official_last_name": "TWIDWELL",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-783-3341",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "MO",
            "license": "20945",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Madison Memorial Hospital",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Fredericktown, MO

Sources for this page

Verify at the official NPI Registry.