King'S Daughters Medical Center
Organization Active NPI Rural Health Clinic/Center · Brookhaven, MS
NPI 1013781731 · NPPES record last updated Nov 13, 2023
Key facts
- NPI
- 1013781731
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- KING'S DAUGHTERS MEDICAL CENTER
- Practice address
- 950 Brookway Blvd
Brookhaven, MS 39601-2644 - Phone
- (601) 833-7973
- NPI assigned
- Nov 13, 2023
- Organization subpart
- No
Authorized official
- Name
- Scott Christensen
- Title
- Ceo
- Phone
- (601) 835-9488
Owners & managing parties with NPI records 5
Owned or controlled facilities with NPI records 1
Other NPIs with the same Medicare PAC ID 5
Corporate family (same tax ID) 10
Related certifications (CCN) 1
Facilities with the same owner 1
Practitioners 75
-
Gerald Todd Adcock, CRNA
-
Amanda Leah Barry, ACNP
-
Leslie Lewis Barry, NP-C
-
Ellanie L Bessonette, AGACNP
-
Ryland Boehnke, DO
-
David Steven Braden, M.D.
-
Holly M Bridges, CFNP
-
Blaine Cooper Britt, M.D.
-
Robert B Britt, M.D
-
Stephen Jeffrey Brown, D.O.
-
William Graham Carter, FNP-C
-
Meghan Lynn Case, MD
-
Saloum Cisse, M.D.
-
Roger C Clapp Jr., M.D.
-
Candice Nicole Cliburn, NURSE PRACTITIONER
-
Simmons T Copeland, N.P.
-
Sean Maurice Debuysere, D.O.
-
Tammy Lofton Dixon, FNP
-
Paul G Dykes, MD
-
Justin Ross Estess, M.D.
-
Karla Adams Gerald, FNP
-
Cheryl Lynn Gladney, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D1039410 | King'S Daughters Medical Clinic | Compliance | Sep 9, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Rural health clinic certification: CCN 258676
- Legal name
- KINGS DAUGHTERS MEDICAL CENTER
- Doing business as
- KING'S DAUGHTERS MEDICAL CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 9, 2024
- Last certification
- Apr 9, 2024
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 3, 1966 in MS
- Enrollment address
- 950 Brookway Blvd
Brookhaven, MS 39601-2644 - Related CCNs
- 250057
All disclosed owners & managing parties 7
| Name | Role | Since | Share |
|---|---|---|---|
| Kings Daughters Medical Center |
5% Or Greater Direct Ownership Interest | Jan 1, 2024 | |
| Operational/Managerial Control | Jan 1, 2024 | ||
| Scott Christensen |
Corporate Officer |
Jan 1, 2024 | |
| Corporate Director |
Jan 1, 2024 | ||
| Operational/Managerial Control |
Jan 1, 2024 | ||
| Peggy King |
W-2 Managing Employee | Jan 1, 2024 | |
| Lori Palmer |
W-2 Managing Employee | Jan 1, 2024 | |
| Delton Jeffrey Richardson |
W-2 Managing Employee | Jan 1, 2024 | |
| Elizabeth Shann |
W-2 Managing Employee | Jan 1, 2024 | |
| Adam Moore |
Operational/Managerial Control |
Jan 1, 2024 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| King'S Daughters Primary Care Clinic |
Rural health clinic | 5% Or Greater Direct Ownership Interest Operational/Managerial Control |
Jan 1, 2024 Jan 1, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240108004421 | MS | Part a Provider - Rural Health Clinic | 3072575539 | Practice locations: Brookhaven, MS |
National Provider Directory
- Tax ID family
- King'S Daughters Medical Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
950 Brookway Blvd
Brookhaven, MS 39601-2644
Mailing address
427 Highway 51 N
Brookhaven, MS 39601-2350
Phone (601) 835-9275
Other names
- King's Daughters Medical Clinic
Other providers in Brookhaven, MS
- Jeremy Drew King
- Theresa Renee King
- King'S Daughters Medial Center
- King'S Daughters Medial Center
- King'S Daughters Medical Center
- King'S Daughters Medical Center
- King'S Daughters Medical Center
- King'S Daughters Medical Center
- King'S Daughters Medical Center
- King'S Daughters Medical Center
All providers in Brookhaven, MS · Rural Health Clinic/Center in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 13, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.