NPIMap

Organization Active NPI

Memorial Hospital Inc

Doing business as AdventHealth Pineville Clinic

  • Rural Health Clinic/Center
  • Pineville, KY
National Provider Identifier
1083499503
Registry record updated Aug 31, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MEMORIAL HOSPITAL INC
Doing business as
AdventHealth Pineville Clinic
Practice address
12904 Robert L Madon Byp Ste 2
Pineville, KY 40977-8063
Phone
(606) 598-4508
Fax
(606) 712-1200
NPI assigned
Aug 31, 2023
Last updated
Aug 31, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
MEMORIAL HOSPITAL INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 31, 2023

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

Authorized official

Name
Sissel Jacob
Title
Ceo
Phone
(606) 598-5104

Specialties & licenses 1

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

Addresses

Primary practice location

12904 Robert L Madon Byp Ste 2
Pineville, KY 40977-8063

Mailing address

11217 Highway 421 S
Tyner, KY 40486-8352
Phone (606) 598-5104

Other names 1

  • AdventHealth Pineville Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240220001121 KY Part A Provider - Rural Health Clinic 4486616141 Practice locations: Pineville, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083499503. Details of each certification follow.

Rural health clinic certification: CCN 188567

Legal name
MEMORIAL HOSPITAL, INC.
Doing business as
ADVENTHEALTH PINEVILLE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 20, 2024
Last certification
Jun 20, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 3, 1917 in KY
Enrollment address
12904 Robert L Madon Byp
Ste 2
Pineville, KY 40977-8063
Related CCNs
180043

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

Other NPIs with the same Medicare PAC ID 8

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

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
18D2291336Adventhealth Pineville Clinic12904 Robert L Madon Bypass Suite 2, Pineville, KY 40977Certificate of waiverOct 9, 2027

National Provider Directory

National Provider Directory
Tax ID family
Adventhealth Manchester8 organizations share this tax ID, including this one
Part of
Adventhealth Manchester

Other organizations with this tax ID 7

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

Locations

12904 Robert L Madon Byp
#2
Pineville, KY 40977
Phone (606) 598-4508

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Sandra K Johnson Individual OtherOperational Manager Aug 23, 2021
Alan Guyton, Jr Individual Corporate DirectorBoard Member Apr 30, 2020
James Phillips Individual Corporate Director Jan 1, 2018
Shane Gabbard Individual Corporate DirectorBoard Member Dec 30, 2020
Sissel Jacob Individual Corporate DirectorCeo Jul 12, 2022
W-2 Managing EmployeeCeo Jul 12, 2022
Lucas Shepherd Individual Corporate DirectorBoard Member Dec 30, 2020
Anita F Cornett Individual Corporate DirectorBoard Member Jan 1, 2018
Adventist Health System Sunbelt Healthcare Corporation Organization, Altamonte Springs, FL Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1982
John Dunzweiler Individual Corporate DirectorBoard Member Dec 30, 2020
Reecia Samples Individual Corporate DirectorBoard Member Jan 1, 2018
Marshall B House Individual Corporate DirectorBoard Member Jan 1, 2018
Michael Murrill Individual Corporate DirectorBoard Chairman Dec 31, 2020
Gregory C. Wilkens Individual Corporate DirectorBoard Member Dec 31, 2020
Charles Stone Individual Corporate DirectorBoard Member Jan 1, 2018

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 85

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

View all 85

NPI Registry JSON

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

{
    "created_epoch": "1693440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693440000000",
    "number": "1083499503",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11217 HIGHWAY 421 S",
            "city": "TYNER",
            "state": "KY",
            "postal_code": "404868352",
            "telephone_number": "606-598-5104",
            "fax_number": "606-712-1200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12904 ROBERT L MADON BYP STE 2",
            "city": "PINEVILLE",
            "state": "KY",
            "postal_code": "409778063",
            "telephone_number": "606-598-4508",
            "fax_number": "606-712-1200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEMORIAL HOSPITAL INC",
        "enumeration_date": "2023-08-31",
        "last_updated": "2023-08-31",
        "certification_date": "2023-08-31",
        "status": "A",
        "authorized_official_last_name": "JACOB",
        "authorized_official_first_name": "SISSEL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "606-598-5104"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AdventHealth Pineville Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pineville, KY

Sources for this page

Verify at the official NPI Registry.