NPIMap

Organization Active NPI

Hannibal Regional Healthcare System, Inc

Doing business as Canton/LaGrange Family Practice

  • Rural Health Clinic/Center
  • Canton, MO
National Provider Identifier
1063431575
Registry record updated May 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC
Doing business as
Canton/LaGrange Family Practice
Practice address
1802 Elm St
Canton, MO 63435-1694
Phone
(573) 655-4891
Fax
(573) 288-5361
NPI assigned
Jul 18, 2006
Last updated
May 25, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
HANNIBAL REGIONAL HEALTHCARE SYSTEM, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 25, 2021

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

Authorized official

Name
Rob Gasaway
Title
VP of Finance
Phone
(573) 406-1608

Specialties & licenses 1

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

Addresses

Primary practice location

1802 Elm St
Canton, MO 63435-1694

Mailing address

6500 Hospital Dr
Hannibal, MO 63401-6890
Phone (573) 221-3415

Other identifiers 1

IdentifierTypeStateIssuer
590416004MedicaidMO

Other names 1

  • Canton/LaGrange Family Practice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080118000508 MO Part A Provider - Rural Health Clinic 1254236300 Practice locations: Canton, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063431575. Details of each certification follow.

Rural health clinic certification: CCN 263984

Legal name
HANNIBAL REGIONAL HEALTHCARE SYSTEM INC
Doing business as
CANTON-LAGRANGE FAMILY PRACTICE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 3, 1992
Last certification
Oct 26, 2021
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Aug 6, 1965 in MO
Enrollment address
1802 Elm St
Canton, MO 63435-1694
Related CCNs
260025

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

Other NPIs with the same Medicare PAC ID 15

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

View all 15

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
26D0911257Canton Lagrange Family Practice1802 Elm, Canton, MO 63435Certificate of waiverDec 9, 2027

National Provider Directory

National Provider Directory
Tax ID family
Hannibal Regional Hosp33 organizations share this tax ID, including this one
Part of
Hannibal Regional Hosp

Other organizations with this tax ID 32

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

View all 32

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Hannibal Regional Healthcare System Inc Organization, Hannibal, MO Non-profit 5% Or Greater Direct Ownership Interest Apr 3, 1992 100%
Operational/Managerial Control Apr 30, 1992 100%
Robert N Gasaway Individual Corporate OfficerCfo Feb 6, 2017 100%
W-2 Managing EmployeeCfo Feb 6, 2017 100%
Christopher T Ahrens Individual Corporate OfficerPresident and Ceo Nov 19, 2016 100%
W-2 Managing EmployeePresident and Ceo Nov 19, 2016 100%

Owners & managing parties with NPI records 15

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

View all 15

All facility ownership & control disclosures 12

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Hannibal Regional HospitalHannibal, MO, CCN 260025 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Nov 20, 2014
Apr 1, 2014
Hannibal Regional Inpatient RehabilitationHannibal, MO, CCN 26T025 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Nov 20, 2014
Apr 1, 2014
Hannibal Regional Hospital Home Health AgencyHannibal, MO, CCN 267282 Home health agency 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Feb 22, 2012
Feb 6, 2017
Monroe City Family PracticeMonroe City, MO, CCN 268513 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2014
Apr 1, 2014
Shelbina Family PracticeShelbina, MO, CCN 268512 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2014
Apr 1, 2014
Pike Medical ClinicLouisiana, MO, CCN 268723 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2014
Apr 1, 2014
Hannibal Regional Medical Group-Bowling GreenBowling Green, MO, CCN 268724 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2014
Apr 1, 2014
Hannibal Regional Medical GroupHannibal, MO, CCN 268754 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2016
Express Care at WalmartHannibal, MO, CCN 268759 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Nov 1, 2016
Oct 1, 2012
Complete Family Medicine Lancaster RHCLancaster, MO, CCN 268757 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jul 3, 2017
Jul 3, 2017
Complete Family Medicine la Plata RHCLa Plata, MO, CCN 268756 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jul 3, 2017
Jul 3, 2017
Complete Family Medicine Kirksville RHCKirksville, MO, CCN 268758 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jul 3, 2017
Jul 3, 2017

Owned or controlled facilities with NPI records 12

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 12

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

NPI Registry JSON

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

{
    "created_epoch": "1153180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621900800000",
    "number": "1063431575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6500 HOSPITAL DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634016890",
            "telephone_number": "573-221-3415"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1802 ELM ST",
            "city": "CANTON",
            "state": "MO",
            "postal_code": "634351694",
            "telephone_number": "573-655-4891",
            "fax_number": "573-288-5361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC",
        "enumeration_date": "2006-07-18",
        "last_updated": "2021-05-25",
        "certification_date": "2021-05-25",
        "status": "A",
        "authorized_official_last_name": "GASAWAY",
        "authorized_official_first_name": "ROB",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "573-406-1608"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "590416004",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Canton/LaGrange Family Practice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Canton/LaGrange Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, MO

Sources for this page

Verify at the official NPI Registry.