NPIMap

Organization Active NPI

Pike County Memorial Hospital

Doing business as PCMH Clinic

  • Rural Health Clinic/Center
  • Bowling Green, MO
National Provider Identifier
1124030424
Registry record updated Apr 5, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PIKE COUNTY MEMORIAL HOSPITAL
Doing business as
PCMH Clinic
Practice address
1015 W Adams St
Bowling Green, MO 63334-1974
Phone
(573) 324-5300
Fax
(573) 324-6059
NPI assigned
Aug 13, 2006
Last updated
Apr 5, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2016

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

Authorized official

Name
Justin Selle
Title
Ceo
Phone
(573) 754-5531

Specialties & licenses 1

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

Addresses

Primary practice location

1015 W Adams St
Bowling Green, MO 63334-1974

Mailing address

2305 Georgia St
Louisiana, MO 63353-2559
Phone (573) 754-4584

Other names 1

  • PCMH Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050407000376 MO Part B Supplier - Clinic/Group Practice 8123015518 Receives reassigned benefits from 31 practitioners
3 other NPIs on this enrollment
Practice locations: Vandalia, MO; Bowling Green, MO
O20090420000100 MO Part A Provider - Rural Health Clinic 8123015518 Practice locations: Bowling Green, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124030424. Details of each certification follow.

Rural health clinic certification: CCN 263468

Legal name
PIKE COUNTY MEMORIAL HOSPITAL
Doing business as
PCMH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 11, 1995
Last certification
Dec 31, 2019
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
1015 W Adams St
Bowling Green, MO 63334-1974
Related CCNs
261333

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Tylie Mills Individual Corporate Officer Aug 1, 2018
Corporate DirectorCeo Aug 1, 2018 100%
W-2 Managing EmployeeCeo Aug 1, 2018 100%
Allen Lockard Individual Corporate Director Apr 1, 2004
Larry Chamberlain Individual Corporate Director Apr 5, 2016
Kevin Keely Individual Corporate Director Apr 1, 2013
Pike County Memorial Hospital Organization, Louisiana, MO Operational/Managerial Control Dec 31, 1991
Margaret Goodin Individual Corporate Director Apr 1, 2012
Robert Mustell Individual Corporate Director Apr 1, 2005

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Pike County Memorial HospitalLouisiana, MO, CCN 26Z333 Hospital Operational/Managerial Control Dec 7, 2005

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 32

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 32

NPI Registry JSON

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

{
    "created_epoch": "1155427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1459814400000",
    "number": "1124030424",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2305 GEORGIA ST",
            "city": "LOUISIANA",
            "state": "MO",
            "postal_code": "633532559",
            "telephone_number": "573-754-4584",
            "fax_number": "573-754-5280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1015 W ADAMS ST",
            "city": "BOWLING GREEN",
            "state": "MO",
            "postal_code": "633341974",
            "telephone_number": "573-324-5300",
            "fax_number": "573-324-6059"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PIKE COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-13",
        "last_updated": "2016-04-05",
        "status": "A",
        "authorized_official_last_name": "SELLE",
        "authorized_official_first_name": "JUSTIN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "573-754-5531"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PCMH Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bowling Green, MO

Sources for this page

Verify at the official NPI Registry.