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DSH130025K MADISON MEMORIAL HOSPITAL (Active)
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Main Details
Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
MADISON CO MEMORIAL HOSPITAL - Madison Foot and Ankle
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130025K
Medicare Provider Number
130025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/12/2024
Participating Start Date
4/1/2024
Participating Approval Date
1/23/2024
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
Madison Memorial Hospital
Rachel Gonzales, CEO
(208) 356-3691
Primary Contact
Madison Memorial Hospital
David A Kennedy, Pharmacy Director
(208) 359-6484
Addresses
Street Address
25 MADISON PROFESSIONAL PARK
REXBURG, ID 83440-2057
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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