NPIMap

Organization Active NPI

Madison Medical Center Stockhoff Memorial Nursing Home

  • Rural Health Clinic/Center
  • Fredericktown, MO
National Provider Identifier
1467539031
Registry record updated Dec 5, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 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
Last updated
Dec 5, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 5, 2013

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
Rural Health Clinic/Center 261QR1300X 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 Medical Center RHC Other name

Medicare participation

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

Enrollment records 1

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467539031. Details of each certification follow.

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
GovernmentNon-profit
Enrollment address
611 W Main St
Fredericktown, MO 63645-1111
Related CCNs
261302

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
Madison Memorial Hospit9 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.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

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

611 W Main St
Ste D
Fredericktown, MO 63645

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
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 OfficerChief Executive Officer Jun 1, 2009
W-2 Managing Employee Dec 14, 2007

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Madison Medical Center RHC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Fredericktown, MO

Sources for this page

Verify at the official NPI Registry.