NPIMap

Organization Active NPI

Mercy Hospital Waldron

  • Rural Health Clinic/Center
  • Waldron, AR
National Provider Identifier
1043268451
Registry record updated Feb 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MERCY HOSPITAL WALDRON
Practice address
1341 W 6TH St
Waldron, AR 72958-7642
Phone
(479) 637-2136
Fax
(479) 637-5411
NPI assigned
May 5, 2006
Last updated
Feb 17, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sherry Lynn Clouse Day
Title
VP Finance Mercy Cah
Phone
(417) 820-8439

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

1341 W 6TH St
Waldron, AR 72958-7642

Mailing address

5401 Ellsworth Rd
Fort Smith, AR 72903-3219
Phone (479) 314-1101

Other identifiers 3

IdentifierTypeStateIssuer
100698850CMedicaidOK
5B332OtherARBLUECROSS BLUESHIELD
146846729MedicaidAR

Other names 1

  • Mercy Family Medicine - Waldron Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040211000825 AR Part B Supplier - Clinic/Group Practice 5597658005 Receives reassigned benefits from 133 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Mansfield, AR; Waldron, AR
O20040426001879 AR Part A Provider - Rural Health Clinic 5597658005 Practice locations: Waldron, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043268451. Details of each certification follow.

Rural health clinic certification: CCN 043488

Legal name
MERCY HOSPITAL WALDRON
Doing business as
MERCY HOSPITAL WALDRON-WALDRON FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 3, 2002
Last certification
Sep 18, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 26, 1987 in AR
Enrollment address
1341 West 6TH Street
Waldron Family Medicine
Waldron, AR 72958-7642
Related CCNs
041305

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Community Service Clini3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jamie Wilke Individual Corporate OfficerSecretary Jul 1, 2024
Mercy Health Fort Smith Communities Organization, Fort Smith, AR Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Oct 11, 2007 100%
Ryan Gehrig Individual Corporate OfficerPresident May 12, 2014
Elizabeth Maddox Individual Corporate DirectorBoard Member Jul 1, 2024
Yogya Regmi Individual W-2 Managing EmployeeDirector Aug 29, 2022
Michael Keith Gibbons Individual Corporate DirectorBoard Member Jul 1, 2022
Edward Melton Individual Corporate DirectorBoard Member Jul 1, 2024
Bret Cook Individual Corporate DirectorBoard Member Jul 1, 2022
Mercy Hospital Fort Smith Organization, Fort Smith, AR Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Oct 11, 2007 100%
Martha Ullrich Individual Corporate DirectorBoard Member Jul 1, 2021
Allen Ray Individual Corporate DirectorBoard Member Jul 1, 2024
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Apr 27, 2012 100%
Carol Corley Individual Corporate DirectorBoard Member Jul 1, 2021
Judith Marie Keith Individual Corporate DirectorBoard Member Jul 1, 2022
Sherry Clouse Day Individual Corporate OfficerTreasurer Jan 1, 2021
W-2 Managing EmployeeDirector Jan 1, 2021
Vicky Laird Individual Corporate DirectorBoard Member Jul 1, 2022

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 115

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 115

Practitioners & affiliated clinicians

Practitioners 134

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 134

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613520000000",
    "number": "1043268451",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5401 ELLSWORTH RD",
            "city": "FORT SMITH",
            "state": "AR",
            "postal_code": "729033219",
            "telephone_number": "479-314-1101",
            "fax_number": "479-314-4704"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1341 W 6TH ST",
            "city": "WALDRON",
            "state": "AR",
            "postal_code": "729587642",
            "telephone_number": "479-637-2136",
            "fax_number": "479-637-5411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MERCY HOSPITAL WALDRON",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-05",
        "last_updated": "2021-02-17",
        "certification_date": "2021-02-17",
        "status": "A",
        "authorized_official_last_name": "CLOUSE DAY",
        "authorized_official_first_name": "SHERRY",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "VP FINANCE MERCY CAH",
        "authorized_official_telephone_number": "417-820-8439"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100698850C",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSS BLUESHIELD",
            "identifier": "5B332",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "146846729",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mercy Family Medicine - Waldron",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Mercy Family Medicine - Waldron",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Waldron, AR

Sources for this page

Verify at the official NPI Registry.