Healthcare Provider Details

I. General information

NPI: 1730602756
Provider Name (Legal Business Name): MADISON CO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440-1605
US

IV. Provider business mailing address

393 E 2ND N
REXBURG ID
83440-1605
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-5401
  • Fax: 208-356-3111
Mailing address:
  • Phone: 208-356-5401
  • Fax: 208-356-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RACHEL GONZALES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DM, RN, RODP
Phone: 208-359-6900