=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588725535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERIM HEALTHCARE OF MADISON, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 N BLACKHAWK AVE SUITE 215
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-238-0268
-----------------------------------------------------
Fax | 608-238-7308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 N BLACKHAWK AVE SUITE 215
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-238-0268
-----------------------------------------------------
Fax | 608-238-7308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DAVID E UTTER
-----------------------------------------------------
Credential | RN, MS
-----------------------------------------------------
Telephone | 608-238-0268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 206
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------