NPIMap

Organization Active NPI

Northeast Missouri Health Council, Inc.

Doing business as Northeast Family Health Clinics

  • Federally Qualified Health Center (FQHC)
  • Kirksville, MO
National Provider Identifier
1104829498
Registry record updated Jun 24, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Doing business as
Northeast Family Health Clinics
Practice address
1416 Crown Drive
Kirksville, MO 63501-2548
Phone
(660) 627-5757
Fax
(660) 627-5802
NPI assigned
May 31, 2005
Last updated
Jun 24, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2011

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

Authorized official

Name
Andrew H. Grimm
Title
Executive Director
Phone
(660) 627-5757

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X 2003032101 MO
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 002241 MO
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X 2001012903 MO
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X 2006007559 MO
Dental HygienistGroup: 193200000X MULTI-SPECIALTY GROUP 124Q00000X 003847 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X R5E64 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 2001023603 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X R5C53 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X R9D62 MO
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X 2004027805 MO
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X 2006022612 MO
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X 2005037590 MO
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X 107529 MO
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 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 1

  • Northeast Family Health Clinics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO, WI6 enrollments

Enrollment records 6

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 3

The Medicare certification numbers (CCNs) connected to NPI 1104829498. Details of each certification follow.

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
CorporationNon-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
CorporationNon-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
CorporationNon-profit
Incorporated
Apr 22, 1968 in MO
Enrollment address
1506 Crown Dr
Kirksville, MO 63501-2553

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

1510 Crown Dr
Kirksville, MO 63501
Phone (660) 627-3621

402 W Jefferson St
Kirksville, MO 63501
Phone (660) 665-2741

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Chad Sawyer Individual Corporate Director Jan 23, 2020
Corporate Officer Jan 29, 2020
Tammi Propst Individual W-2 Managing EmployeeCredentialing May 23, 2005
W-2 Managing EmployeeTeam Lead May 23, 2005
Jeffrey Doss Individual Corporate Director Nov 17, 2009
Corporate DirectorBoard Member Apr 1, 2009
Carolyn Ranee Brayton Individual Corporate Director Jan 23, 2020
Corporate Officer Jan 23, 2020
Walla Derosear Individual Corporate DirectorBoard Member Jan 26, 2012
Corporate Director Mar 1, 2012
Corporate DirectorBoard Member Mar 1, 2012
Ashley Hartman Individual W-2 Managing EmployeeExecutive Secretary Jan 1, 2022
W-2 Managing Employee Jan 1, 2014
David Richard Rector Individual Corporate DirectorVice President Nov 17, 2009
Corporate Director Nov 17, 2009
Corporate DirectorBoard Vice President Apr 1, 2009
Karen Ann Lumley Individual Corporate Director Nov 1, 2009
Corporate DirectorBoard Member Apr 1, 2009
Tiffany Labeth Individual Corporate Director Aug 22, 2013
Corporate DirectorBoard Member Aug 22, 2013
Phil McIntosh Individual Corporate Director Jan 23, 2020
Corporate Officer Jan 29, 2020
Carolyn Primm Individual Corporate Director May 26, 2011
Corporate DirectorBoard Member May 26, 2011
Viola Morsbach Individual Corporate Director Jan 23, 2020
Richard Gooch Individual Corporate DirectorSecretary and Treasurer May 26, 2011
Corporate Director May 26, 2011
Corporate DirectorBoard Member Treasurer May 26, 2011
Pam Smith Individual Corporate Director Sep 26, 2013
Corporate DirectorBoard Member Sep 26, 2013
John Thibaut Heard Individual Corporate DirectorBoard President Nov 17, 2009
Corporate Director Nov 17, 2009
Corporate DirectorBoard President Apr 1, 2009
Andrew Grimm Individual Corporate DirectorCeo Apr 1, 2009
W-2 Managing EmployeeCeo Apr 1, 2009
Corporate Director Nov 3, 2009
W-2 Managing Employee Nov 3, 2009
Corporate OfficerCeo Apr 1, 2009
W-2 Managing Employee Feb 7, 2014

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Macon Family HealthMacon, MO, CCN 261116 Federally qualified health center Operational/Managerial Control (100%) Sep 2, 2015
Kahoka DentalKahoka, MO, CCN 261140 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011
Northeast Family Health AnnexKirksville, MO, CCN 261147 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011
Memphis Community Health CenterMemphis, MO, CCN 261932 Federally qualified health center Operational/Managerial Control Apr 21, 1968

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 33

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.

View all 33

NPI Registry JSON

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

{
    "created_epoch": "1117497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1308873600000",
    "number": "1104829498",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1416 CROWN DRIVE",
            "city": "KIRKSVILLE",
            "state": "MO",
            "postal_code": "635012548",
            "telephone_number": "660-627-5757",
            "fax_number": "660-627-5802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1416 CROWN DRIVE",
            "city": "KIRKSVILLE",
            "state": "MO",
            "postal_code": "635012548",
            "telephone_number": "660-627-5757",
            "fax_number": "660-627-5802"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MISSOURI HEALTH COUNCIL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-05-31",
        "last_updated": "2011-06-24",
        "status": "A",
        "authorized_official_last_name": "GRIMM",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "660-627-5757"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "MO",
            "license": "2003032101",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "002241",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "MO",
            "license": "2001012903",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "MO",
            "license": "2006007559",
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": "MO",
            "license": "003847",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R5E64",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "2001023603",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R5C53",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R9D62",
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "MO",
            "license": "2004027805",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "MO",
            "license": "2006022612",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "MO",
            "license": "2005037590",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "MO",
            "license": "107529",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MO",
            "license": "096968",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeast Family Health Clinics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kirksville, MO

Sources for this page

Verify at the official NPI Registry.