MEDICARE: FORT MADISON HEALTH CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner		IA

General Provider Information

NPI Number	:	1063879203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT MADISON HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	1702 41ST ST
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-3269
Country	:	US
Telephone Number	:	319-372-8021
Fax Number	:	319-372-8163

Provider Business Practice Location Address
First Line	:	1702 41ST ST
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-3269
Country	:	US
Telephone Number	:	319-372-8021
Fax Number	:	319-372-8163

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CHRISOPHER L MCKAY
Credential	:
Telephone Number	:	319-372-8021

Provider Enumeration Date	:	01/19/2016
Last Update Date	:	01/19/2016

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