1902242647 NPI number — MADISON COUNTY COMMUNITY HEALTH CENTERS, INC.

Table of content: (NPI 1902242647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902242647 NPI number — MADISON COUNTY COMMUNITY HEALTH CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON COUNTY COMMUNITY HEALTH CENTERS, 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:
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:
1902242647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46015-0349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-641-0255
Provider Business Mailing Address Fax Number:
765-298-6001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1547 OHIO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46016-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-641-7499
Provider Business Practice Location Address Fax Number:
765-298-6001
Provider Enumeration Date:
05/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
765-641-0255

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  20042205A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200271310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200271310B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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