Northeast Missouri Health Council, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Kirksville, MO
NPI 1104829498 · NPPES record last updated Jun 24, 2011
Key facts
- NPI
- 1104829498
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- NORTHEAST MISSOURI HEALTH COUNCIL, INC.
- Practice address
- 1416 Crown Drive
Kirksville, MO 63501-2548 - Phone
- (660) 627-5757
- Fax
- (660) 627-5802
- NPI assigned
- May 31, 2005
- Organization subpart
- No
Authorized official
- Name
- Andrew H. Grimm
- Title
- Executive Director
- Phone
- (660) 627-5757
Owned or controlled facilities with NPI records 4
Other NPIs on the same Medicare enrollment 9
Other NPIs with the same Medicare PAC ID 8
Practitioners 33
-
Alisa Beth Fajkus, CNM
-
Melanie S. Grgurich, D.O.
-
Heather R Martin, D.O.
-
Craig E McCoy, D.O.
-
Chante McKim, FNP
-
Joseph W Novinger, D.O.
-
Carolyn Allisa Snyder, R.D., L.D.
-
Brent D Speak, DO
-
Cassie Marie Tilton, NP-C
-
Amanda Dawn Wilford, FNP-BC
-
Margaret Wilson, DO
-
April Winkler, FNP-BC
-
Stacie Bevill, PNP
-
Jennifer Lynn Blacksmith, PH.D
-
Melissa I Dimmitt, LMSW
-
Shannon M Hatfield, FNP
-
Roxana Ionas, MD
-
Michelle Kenney, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (6 enrollments) in MO, WI
Federally qualified health center certification: CCN 261811
- Legal name
- NORTHEAST MISSOURI HEALTH COUNCIL INC
- Doing business as
- NORTHEAST PEDIATRICS AND OB/GYN SPECIALTY GROUP
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 1, 1992
- Last certification
- Jan 1, 1992
- Ownership / control type
- Non-profit – other
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 22, 1968 in MO
- Enrollment address
- 402W Jefferson
Suite a, Suite B, Suite C
Kirksville, MO 63501-3407
Federally qualified health center certification: CCN 261821
- Legal name
- NORTHEAST MISSOURI HEALTH COUNCIL INC
- Doing business as
- NORTHEAST MISSOURI FAMILY HEALTH CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 10, 1992
- Last certification
- Sep 10, 1992
- Ownership / control type
- Non-profit – other
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 22, 1968 in MO
- Enrollment address
- 104 E Jackson St
Edina, MO 63537-1335
Federally qualified health center certification: CCN 261848
- Legal name
- NORTHEAST MISSOURI HEALTH COUNCIL INC
- Doing business as
- NORTHEAST FAMILY & BEHAVIORAL HEALTH
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Oct 19, 1998
- Last certification
- Oct 19, 1998
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 22, 1968 in MO
- Enrollment address
- 1506 Crown Dr
Kirksville, MO 63501-2553
All disclosed owners & managing parties 16
| Name | Role | Since | Share |
|---|---|---|---|
| Chad Sawyer |
Corporate Director | Jan 23, 2020 | |
| Corporate Officer | Jan 29, 2020 | ||
| Tammi Propst |
W-2 Managing Employee |
May 23, 2005 | |
| W-2 Managing Employee |
May 23, 2005 | ||
| Jeffrey Doss |
Corporate Director | Nov 17, 2009 | |
| Corporate Director |
Apr 1, 2009 | ||
| Carolyn Ranee Brayton |
Corporate Director | Jan 23, 2020 | |
| Corporate Officer | Jan 23, 2020 | ||
| Walla Derosear |
Corporate Director |
Jan 26, 2012 | |
| Corporate Director | Mar 1, 2012 | ||
| Corporate Director |
Mar 1, 2012 | ||
| Ashley Hartman |
W-2 Managing Employee |
Jan 1, 2022 | |
| W-2 Managing Employee | Jan 1, 2014 | ||
| David Richard Rector |
Corporate Director |
Nov 17, 2009 | |
| Corporate Director | Nov 17, 2009 | ||
| Corporate Director |
Apr 1, 2009 | ||
| Karen Ann Lumley |
Corporate Director | Nov 1, 2009 | |
| Corporate Director |
Apr 1, 2009 | ||
| Tiffany Labeth |
Corporate Director | Aug 22, 2013 | |
| Corporate Director |
Aug 22, 2013 | ||
| Phil McIntosh |
Corporate Director | Jan 23, 2020 | |
| Corporate Officer | Jan 29, 2020 | ||
| Carolyn Primm |
Corporate Director | May 26, 2011 | |
| Corporate Director |
May 26, 2011 | ||
| Viola Morsbach |
Corporate Director | Jan 23, 2020 | |
| Richard Gooch |
Corporate Director |
May 26, 2011 | |
| Corporate Director | May 26, 2011 | ||
| Corporate Director |
May 26, 2011 | ||
| Pam Smith |
Corporate Director | Sep 26, 2013 | |
| Corporate Director |
Sep 26, 2013 | ||
| John Thibaut Heard |
Corporate Director |
Nov 17, 2009 | |
| Corporate Director | Nov 17, 2009 | ||
| Corporate Director |
Apr 1, 2009 | ||
| Andrew Grimm |
Corporate Director |
Apr 1, 2009 | |
| W-2 Managing Employee |
Apr 1, 2009 | ||
| Corporate Director | Nov 3, 2009 | ||
| W-2 Managing Employee | Nov 3, 2009 | ||
| Corporate Officer |
Apr 1, 2009 | ||
| W-2 Managing Employee | Feb 7, 2014 |
All facility ownership & control disclosures 4
| Facility | Type | Role | Since |
|---|---|---|---|
| Macon Family Health |
Federally qualified health center | Operational/Managerial Control (100%) | Sep 2, 2015 |
| Kahoka Dental |
Federally qualified health center | Operational/Managerial Control (100%) | Aug 15, 2011 |
| Northeast Family Health Annex |
Federally qualified health center | Operational/Managerial Control (100%) | Aug 15, 2011 |
| Memphis Community Health Center |
Federally qualified health center | Operational/Managerial Control | Apr 21, 1968 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040107000173 | MO | Part B Supplier - Clinic/Group Practice | 1658280805 |
Receives reassigned benefits from 14 practitioners 4 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Memphis, MO; Edina, MO; Macon, MO |
| O20040112000061 | MO | Part B Supplier - Clinic/Group Practice | 1658280805 |
Receives reassigned benefits from 27 practitioners 6 other NPIs on this enrollment Practice locations: Kirksville, MO |
| O20040430000892 | MO | Part B Supplier - Clinic/Group Practice | 1658280805 |
Receives reassigned benefits from 13 practitioners 1 other NPI on this enrollment Practice locations: Milan, MO |
| O20060907000595 | MO | Part a Provider - Federally Qualified Health Center (FQHC) | 1658280805 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Kirksville, MO |
| O20060918000511 | WI | Part a Provider - Federally Qualified Health Center (FQHC) | 1658280805 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Edina, MO |
| O20060927000296 | MO | Part a Provider - Federally Qualified Health Center (FQHC) | 1658280805 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Kirksville, MO |
National Provider Directory
Locations
22291 US Highway 136
Kahoka, MO 63445
Phone (660) 727-1500
1506 Crown Dr
Kirksville, MO 63501
Phone (660) 627-4493
118 E Grand Ave
Memphis, MO 63555
Phone (660) 465-7522
52334 Business Highway 5
Milan, MO 63556
Phone (660) 265-1042
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor |
101YP2500X | 2003032101 | MO | |
| Clinical Social Worker |
1041C0700X | 002241 | MO | |
| Dentist |
122300000X | 2001012903 | MO | |
| Dentist |
122300000X | 2006007559 | MO | |
| Dental Hygienist |
124Q00000X | 003847 | MO | |
| Family Medicine Physician |
207Q00000X | R5E64 | MO | |
| Family Medicine Physician |
207Q00000X | 2001023603 | MO | |
| Family Medicine Physician |
207Q00000X | R5C53 | MO | |
| Family Medicine Physician |
207Q00000X | R9D62 | MO | |
| Obstetrics & Gynecology Physician |
207V00000X | 2004027805 | MO | |
| Pediatrics Physician |
208000000X | 2006022612 | MO | |
| Pediatrics Physician |
208000000X | 2005037590 | MO | |
| Federally Qualified Health Center (FQHC) | 261QF0400X | MO | Yes | |
| Nurse Practitioner |
363L00000X | 107529 | MO | |
| Family Nurse Practitioner |
363LF0000X | 096968 | MO |
Addresses
Primary practice location
1416 Crown Drive
Kirksville, MO 63501-2548
Mailing address
1416 Crown Drive
Kirksville, MO 63501-2548
Phone (660) 627-5757
Other names
- Northeast Family Health Clinics
Other providers in Kirksville, MO
- Northeast Missouri Health Council Inc
- Northeast Missouri Health Council, Inc
- Northeast Missouri Health Council, Inc
- Northeast Missouri Health Council, Inc
- Northeast Missouri Health Council, Inc.
- Northeast Missouri Health Council, Inc.
- Northeast Missouri Health Council, Inc.
- Northeast Missouri Health Council, Inc.
- Northeast Missouri Health Council, Inc.
- Northeast Missouri Health Council, Inc.
All providers in Kirksville, MO · Federally Qualified Health Center (FQHC) in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 24, 2011. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.