Healthcare Provider Details

I. General information

NPI: 1679673081
Provider Name (Legal Business Name): FORT MADISON COMMUNITY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 AVENUE O SUITE 114
FORT MADISON IA
52627-9611
US

IV. Provider business mailing address

5445 AVENUE O SUITE 114
FORT MADISON IA
52627-9611
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2166
  • Fax: 319-376-2167
Mailing address:
  • Phone: 319-376-2166
  • Fax: 319-376-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number560087H
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0163438E
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier167281
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerMEDICARE OSCAR CERTIFICATION

VIII. Authorized Official

Name: MS. SHELBY L BURCHETT
Title or Position: CEO
Credential:
Phone: 319-376-2124