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Madison Medical Center Stockhoff Memorial Nursing Home

Organization Active NPI Rural Health Clinic/Center · Fredericktown, MO

NPI 1467539031 · NPPES record last updated Dec 5, 2013

Key facts

NPI
1467539031
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
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 1, 2006
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Other NPIs with the same Medicare PAC ID 2

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

Corporate family (same tax ID) 8

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

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

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 26

Medicare participation

Medicare fee-for-service enrollment
Enrolled in MO

Rural health clinic certification: CCN 268568

Legal name
MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Doing business as
MADISON MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 15, 2003
Last certification
Oct 21, 2019
Ownership / control type
Non-profit – church related
Organization structure
Government · Non-profit
Enrollment address
611 W Main St
Fredericktown, MO 63645-1111
Related CCNs
261302

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
Madison Medical Center Stockhoff Memorial Nursing Home
Organization · Fredericktown, MO 		5% Or Greater Direct Ownership Interest Apr 1, 2003 100%
Operational/Managerial Control Apr 1, 2003 100%
Lisa M Twidwell
Individual 		Corporate Officer
Chief Executive Officer		 Jun 1, 2009
W-2 Managing Employee Dec 14, 2007

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040805000502 MO Part a Provider - Rural Health Clinic 1355255886 Practice locations: Fredericktown, MO

National Provider Directory

Tax ID family
Madison Medical Center (9 organizations share this tax ID)

Locations

611 W Main St
Ste D
Fredericktown, MO 63645

611 W Main St
Ste C
Fredericktown, MO 63645
Phone (573) 783-4111

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Yes

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 identifiers

IdentifierTypeStateIssuer
590155107MedicaidMO

Other names

  • Madison Medical Center RHC Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 5, 2013.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1386201600000",
    "number": "1467539031",
    "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": "2006-11-01",
        "last_updated": "2013-12-05",
        "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": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "590155107",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Madison Medical Center RHC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Fredericktown, MO

All providers in Fredericktown, MO · Rural Health Clinic/Center in Missouri

Sources for this page

Verify at the official NPI Registry.