NPIMap

Organization Active NPI

Pcrmc Medical Group, Inc

Doing business as Phelps Health Medical Group Vienna

  • Rural Health Clinic/Center
  • Vienna, MO
National Provider Identifier
1114235041
Registry record updated Jan 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
2007024375 Issued in MO
Legal business name
PCRMC MEDICAL GROUP, INC
Doing business as
Phelps Health Medical Group Vienna
Practice address
606 Highway 63 S
Vienna, MO 65582-8101
Phone
(573) 422-3636
Fax
(573) 422-3434
NPI assigned
Sep 14, 2010
Last updated
Jan 17, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
PCRMC MEDICAL GROUP, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 17, 2019

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

Authorized official

Name
Jana M Cook
Title
VP, Chief Financial Officer
Phone
(573) 458-7916

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 2007024375 MO Primary

Addresses

Primary practice location

606 Highway 63 S
Vienna, MO 65582-8101

Mailing address

PO Box 579
Rolla, MO 65402
Phone (573) 426-2182

Other identifiers 1

IdentifierTypeStateIssuer
594328304MedicaidMO

Other names 1

  • Phelps Health Medical Group Vienna Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100701000579 MO Part A Provider - Rural Health Clinic 1557454063 1 other NPI on this enrollment
Practice locations: Vienna, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114235041. Details of each certification follow.

Rural health clinic certification: CCN 268908

Legal name
PCRMC MEDICAL GROUP INC
Doing business as
PHELPS HEALTH MEDICAL GROUP VIENNA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 4, 2010
Last certification
Oct 4, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
606 Highway 63 S
Ste a
Vienna, MO 65582-8101

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Pcrmc Medical Group Inc2 organizations share this tax ID, including this one
Part of
Pcrmc Medical Group Inc

Other organizations with this tax ID 1

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.

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Ben Tipton Individual Corporate OfficerDirector Apr 26, 2024
Jason Shenefield Individual Corporate OfficerCeo Jul 22, 2021
Corporate DirectorCeo Jul 22, 2021
W-2 Managing EmployeeCeo Jul 22, 2021
Richard Elgin Individual Corporate DirectorDirector Apr 1, 2023
Kimberley Bruno Individual Corporate OfficerAssociate VP of Revenue Cycle Aug 26, 2022
W-2 Managing EmployeeAssociate VP of Revenue Cycle Aug 26, 2022
Brittany Roth Individual Corporate DirectorDirector, Contracting & Enrollment Jul 11, 2022
W-2 Managing EmployeeDirector, Contracting & Enrollment Jul 11, 2022
Jana M Cook Individual Corporate OfficerCfo Jul 31, 2021
Corporate DirectorCfo Jul 31, 2021
W-2 Managing EmployeeCfo Jul 31, 2021
Phelps County Regional Medical Center Organization, Rolla, MO Non-profit 5% Or Greater Direct Ownership Interest May 1, 2007 100%
Janece Martin Individual Corporate DirectorDirector May 6, 2022
Mary V. Graham Individual Corporate DirectorDirector Apr 23, 2026
Annie Bass Individual Corporate OfficerBoard Member May 6, 2022

Owners & managing parties with NPI records 8

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 1

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": "1284422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547683200000",
    "number": "1114235041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 579",
            "city": "ROLLA",
            "state": "MO",
            "postal_code": "65402",
            "telephone_number": "573-426-2182",
            "fax_number": "573-426-5341"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "606 HIGHWAY 63 S",
            "city": "VIENNA",
            "state": "MO",
            "postal_code": "655828101",
            "telephone_number": "573-422-3636",
            "fax_number": "573-422-3434"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PCRMC MEDICAL GROUP, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PCRMC MEDICAL GROUP, INC",
        "enumeration_date": "2010-09-14",
        "last_updated": "2019-01-17",
        "status": "A",
        "authorized_official_last_name": "COOK",
        "authorized_official_first_name": "JANA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "VP, CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "573-458-7916"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": "2007024375",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "594328304",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Phelps Health Medical Group Vienna",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vienna, MO

Sources for this page

Verify at the official NPI Registry.