Healthcare Provider Details

I. General information

NPI: 1477122570
Provider Name (Legal Business Name): MADISON CO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440-1605
US

IV. Provider business mailing address

PO BOX 130
REXBURG ID
83440-0130
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6498
  • Fax: 208-448-4702
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAIME TANNER
Title or Position: AMBULATORY REVENUE MANAGER
Credential:
Phone: 208-359-7682