Healthcare Provider Details

I. General information

NPI: 1316013139
Provider Name (Legal Business Name): MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 WEST MAIN STREET
FREDERICKTOWN MO
63645
US

IV. Provider business mailing address

611 W MAIN ST
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 Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number20945
License Number StateMO

VIII. Authorized Official

Name: MRS. LISA MARIE TWIDWELL
Title or Position: CFO
Credential:
Phone: 573-783-3341