Memorial Hospital Inc
Organization Active NPI Rural Health Clinic/Center · Pineville, KY
NPI 1083499503 · NPPES record last updated Aug 31, 2023
Key facts
- NPI
- 1083499503
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MEMORIAL HOSPITAL INC
- 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
- Organization subpart
- Yes
- Parent organization (as reported)
- MEMORIAL HOSPITAL INC
Authorized official
- Name
- Sissel Jacob
- Title
- Ceo
- Phone
- (606) 598-5104
Owners & managing parties with NPI records 2
-
Anita F Cornett, MD
-
Gregory Charles Wilkens, M.D.
Other NPIs with the same Medicare PAC ID 8
Corporate family (same tax ID) 7
Related certifications (CCN) 1
Facilities with the same owner 85
Practitioners 60
-
Elizabeth Lee Boggs, A R N P
-
Anita F Cornett, MD
-
April Michelle Couch, APRN
-
Johnnie Sue Dell, APRN
-
Kayla Gabbard, APRN
-
Melinda Dawn Garrett, LPCC
-
Rachael Ann Gilbert, APRN
-
Shawn R Gorden, M.D.
-
Giriraj Gupta, M.D.
-
Judy Hacker, APRN
-
Tammie Renee Hacker, APRN, FNP-C
-
Jeremie Hays, MD
-
Nina Hensley, APRN
-
Amber Henson, APRN
-
Kasi Hubbard Smith, APRN
-
Angela Hubbard, APRN
-
Sharon Melissa Kissel, LPCC
-
Megan Kunkel, APRN-CNP
-
Cynthia Surer Maggard, ARNP
-
Jackie D Maxey, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D2291336 | Adventhealth Pineville Clinic | Certificate of waiver | Oct 9, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in KY
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
- Corporation · Non-profit
- Incorporated
- May 3, 1917 in KY
- Enrollment address
- 12904 Robert L Madon Byp
Ste 2
Pineville, KY 40977-8063 - Related CCNs
- 180043
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Sandra K Johnson |
Other |
Aug 23, 2021 | |
| Alan Guyton, Jr |
Corporate Director |
Apr 30, 2020 | |
| James Phillips |
Corporate Director | Jan 1, 2018 | |
| Shane Gabbard |
Corporate Director |
Dec 30, 2020 | |
| Sissel Jacob |
Corporate Director |
Jul 12, 2022 | |
| W-2 Managing Employee |
Jul 12, 2022 | ||
| Lucas Shepherd |
Corporate Director |
Dec 30, 2020 | |
| Anita F Cornett |
Corporate Director |
Jan 1, 2018 | |
| Adventist Health System Sunbelt Healthcare Corporation |
5% Or Greater Direct Ownership Interest | Jan 1, 1982 | |
| John Dunzweiler |
Corporate Director |
Dec 30, 2020 | |
| Reecia Samples |
Corporate Director |
Jan 1, 2018 | |
| Marshall B House |
Corporate Director |
Jan 1, 2018 | |
| Michael Murrill |
Corporate Director |
Dec 31, 2020 | |
| Gregory C. Wilkens |
Corporate Director |
Dec 31, 2020 | |
| Charles Stone |
Corporate Director |
Jan 1, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240220001121 | KY | Part a Provider - Rural Health Clinic | 4486616141 | Practice locations: Pineville, KY |
National Provider Directory
- Tax ID family
- Red Bird Clinic
- Part of
- Red Bird Clinic
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
- AdventHealth Pineville Clinic
Other providers in Pineville, KY
- Maggies Enterprises LLC
- Samantha Maiden
- Martha Combs Woolum MD PLLC
- MC T'S Inc.
- Melissa Gale McDonald
- Middlesboro High School
- Middlesboro Intermediate School
- Middlesboro Middle School
- Middlesboro Primary School
- Andrea Kaye Miller
All providers in Pineville, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 31, 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.