Basic Information
| Provider Information | |||||||||
| NPI: | 1104821461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON COUNTY HOSPITAL HEALTH SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MADISON COUNTY MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 NW CRANE AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323401400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509732271 | ||||||||
| FaxNumber: | 8509732818 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 NW CRANE AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323401400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509732271 | ||||||||
| FaxNumber: | 8509732818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 8509732271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 4346 | FL | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 060090300 | 05 | FL | MEDICAID | 0101150-00 | 05 | FL | MEDICAID | 110 | 01 | FL | BLUE CROSS | OTHER | 020053100 | 05 | FL | MEDICAID |