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DSH130025B MADISON MEMORIAL HOSPITAL (Active)
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Main Details
Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
MADISON MEMORIAL REXBURG MED CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130025B
Medicare Provider Number
130025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/9/2017
Participating Start Date
4/1/2017
Participating Approval Date
2/21/2017
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
393 E 2 ND N
MADISON MEMORIAL REXBURG MED CLINIC
REXBURG, ID 83440-1605
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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