Basic Information
| Provider Information | |||||||||
| NPI: | 1639407125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON CARE CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROADFIELD CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25000 COUNTRY CLUB BLVD | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440705344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140160 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 7927 MIDDLE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440573023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404663702 | ||||||||
| FaxNumber: | 4404667287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | COLLERAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4406140160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0268 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2997753 | 05 | OH | MEDICAID |