NPIMap

Organization Active NPI

Jefferson Medical Group

  • Rural Health Clinic/Center
  • Brunswick, MO
National Provider Identifier
1104432806
Registry record updated May 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JEFFERSON MEDICAL GROUP
Practice address
807 E Broadway St
Brunswick, MO 65236-1468
Phone
(660) 542-1695
NPI assigned
Sep 17, 2020
Last updated
May 12, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 12, 2025

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

Authorized official

Name
Lesley Delaney
Title
Chief Financial Officer
Phone
(660) 542-1695

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

807 E Broadway St
Brunswick, MO 65236-1468

Mailing address

1502 N Jefferson St
Carrollton, MO 64633-1948
Phone (660) 542-1695

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address CCMHHIMDept@ccmhospital.cernerdirect.com Carroll County Memorial Hospital

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210630001113 MO Part A Provider - Rural Health Clinic 6800894379 Practice locations: Brunswick, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104432806. Details of each certification follow.

Rural health clinic certification: CCN 268808

Legal name
JEFFERSON MEDICAL GROUP
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 5, 2024
Last certification
Sep 5, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
807 E Broadway St
Brunswick, MO 65236-1468
Related CCNs
261332

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

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Carroll County Memorial Hospital3 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.

Locations

807 E Broadway St
Brunswick, MO 65236
Phone (660) 542-1695

1403 N Jefferson St
Carrollton, MO 64633
Phone (660) 542-9998

221 Elm St
Hale, MO 64643
Phone (660) 542-1695

105 E 2nd St
Norborne, MO 64668
Phone (660) 593-3623

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
Timothy N Reid Individual Corporate OfficerBoard Member Jan 1, 2021
Janice Burnside Individual Corporate OfficerBoard Member Oct 1, 2025
Jennifer Link Individual Corporate OfficerBoard Member Oct 1, 2025
Charles Riley Individual Corporate DirectorChief Operating Officer Oct 1, 2025
W-2 Managing EmployeeChief Operating Officer Oct 1, 2025
Carroll County Memorial Hospital Organization, Carrollton, MO Non-profit 5% Or Greater Direct Ownership Interest Jun 1, 2021 100%
Anna Barlow Individual Corporate OfficerBoard Member Jan 1, 2021
Jennifer R Poston Individual Corporate OfficerBoard Member Jan 1, 2021
Michael Schubach Individual Corporate DirectorChief Human Resources Officer Oct 1, 2025
W-2 Managing EmployeeChief Human Resources Officer Oct 1, 2025
Brittany Higgins Individual W-2 Managing EmployeeRevenue Integrity Analyst Jan 1, 2021
Kenneth Brown Individual Corporate OfficerBoard Member Oct 1, 2025
Matthew Lock Individual Corporate OfficerBoard Member Jan 1, 2021
Tracey Woodward Individual Corporate OfficerBoard Member Oct 1, 2025
George Thomas Burkhart Individual Corporate OfficerBoard Member Oct 1, 2025
Wade Mertensmeyer Individual Corporate OfficerBoard Member Jan 1, 2021

Owners & managing parties with NPI records 3

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

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1600300800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1104432806",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON ST",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-1695"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "807 E BROADWAY ST",
            "city": "BRUNSWICK",
            "state": "MO",
            "postal_code": "652361468",
            "telephone_number": "660-542-1695"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-17",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "status": "A",
        "authorized_official_last_name": "DELANEY",
        "authorized_official_first_name": "LESLEY",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "660-542-1695"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "CCMHHIMDept@ccmhospital.cernerdirect.com",
            "affiliation": "Y",
            "affiliationName": "Carroll County Memorial Hospital",
            "address_1": "1502 N Jefferson St",
            "city": "Carrollton",
            "state": "MO",
            "country_code": "US",
            "postal_code": "646331948",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Brunswick, MO

Sources for this page

Verify at the official NPI Registry.