Healthcare Provider Details

I. General information

NPI: 1316460264
Provider Name (Legal Business Name): MADISON CO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N 3RD E STE 200
REXBURG ID
83440-1629
US

IV. Provider business mailing address

PO BOX 700
REXBURG ID
83440-0700
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6516
  • Fax:
Mailing address:
  • Phone: 208-359-6516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TROY CHRISTENSEN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 208-359-9802