NPIMap

Organization Active NPI

Pike County Memorial Hospital

  • 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
Practice address
1015 W Adams St
Bowling Green, MO 63334-1974
Phone
(573) 324-5300
Fax
(573) 324-6059
NPI assigned
Aug 13, 2006
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 5

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

Owned or controlled facilities with NPI records 1

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

Other NPIs on the same Medicare enrollment 3

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

Other NPIs with the same Medicare PAC ID 5

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

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

Facilities with the same owner 1

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

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 47

Medicare participation

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

Rural health clinic certification: CCN 263468

Medicare enrollment files
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

All disclosed owners & managing parties 7

Medicare enrollment files

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

All facility ownership & control disclosures 1

Medicare enrollment files

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

Medicare enrollment records 2

Medicare enrollment files
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

National Provider Directory

National Provider Directory

Specialties & licenses 1

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

Addresses

NPPES NPI Registry

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 identifiers 3

NPPES NPI Registry
IdentifierTypeStateIssuer
CK7206OtherMORAILROAD MEDICARE PIN
502663305OtherMOMEDICARE/MEDICAID PROF CROSSOVER 1500
598209203MedicaidMO

Other names 1

NPPES NPI Registry
  • PCMH Clinic Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Apr 5, 2016.

{
    "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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE PIN",
            "identifier": "CK7206",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE/MEDICAID PROF CROSSOVER 1500",
            "identifier": "502663305",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "598209203",
            "state": "MO"
        }
    ],
    "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.