1063879203 NPI number — FORT MADISON HEALTH CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063879203 NPI number — FORT MADISON HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT MADISON HEALTH CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063879203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1702 41ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MADISON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52627-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-372-8021
Provider Business Practice Location Address Fax Number:
319-372-8163
Provider Enumeration Date:
01/19/2016

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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