Healthcare Provider Details

I. General information

NPI: 1720163025
Provider Name (Legal Business Name): MADISON MEDICAL CENTER STOCKHOFF MEMORIAL NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 06/25/2008
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 Code282NC0060X
TaxonomyCritical Access Hospital
License Number209-45
License Number StateMO

VIII. Authorized Official

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