Healthcare Provider Details

I. General information

NPI: 1669514436
Provider Name (Legal Business Name): MADISON MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

IV. Provider business mailing address

611 W MAIN ST PO BOX 431
FREDERICKTOWN MO
63645-1111
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3341
  • Fax: 573-783-1096
Mailing address:
  • Phone: 573-783-3341
  • Fax: 573-783-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RODNEY D GROSS
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-783-3341