NPIMap

Organization Active NPI

Merrick Medical Center

Doing business as Fullerton Medical Clinic

  • Rural Health Clinic/Center
  • Fullerton, NE
National Provider Identifier
1124559901
Registry record updated Jul 24, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MERRICK MEDICAL CENTER
Doing business as
Fullerton Medical Clinic
Practice address
901 Broadway St
Fullerton, NE 68638-3151
Phone
(308) 536-2458
NPI assigned
Mar 23, 2017
Last updated
Jul 24, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
MERRICK MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 24, 2024

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

Authorized official

Name
Jodi S Mohr
Title
Ceo
Phone
(402) 946-3015

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X

Addresses

Primary practice location

901 Broadway St
Fullerton, NE 68638-3151

Mailing address

PO Box 860874
Minneapolis, MN 55486-0874
Phone (308) 946-3015

Other names 1

  • FULLERTON MEDICAL CLINIC Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address direct@hisp.bryanhealth.org

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170424000272 NE Part A Provider - Rural Health Clinic 9537445812 Practice locations: Fullerton, NE
O20170512000681 NE Part B Supplier - Clinic/Group Practice 9537445812 Receives reassigned benefits from 17 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Central City, NE; Lincoln, NE

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124559901. Details of each certification follow.

Rural health clinic certification: CCN 288530

Legal name
MERRICK MEDICAL CENTER
Doing business as
FULLERTON MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 1, 2014
Last certification
Feb 20, 2024
Ownership / control type
2B
Most recent change of ownership
Jul 1, 2017 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Mar 15, 2017 in NE
Enrollment address
901 Broadway St
Fullerton, NE 68638-3151
Related CCNs
281328

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

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 2

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
28D0886128Fullerton Medical Clinic901 Broadway Street, Fullerton, NE 68638Certificate of waiverApr 30, 2028

National Provider Directory

National Provider Directory
Part of
Merrick Medical Center

Locations

2802 28th St
Ste 100
Central City, NE 68826
Phone (308) 946-3845

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Nathan W Perry Individual Corporate Officer Feb 16, 2023
Corporate Director Feb 16, 2023
Shannon Hannappel Individual Corporate Officer Feb 18, 2021
Corporate Director Dec 20, 2018
Patrick D Ganyo Individual Corporate Officer Feb 16, 2023
Corporate Director Feb 18, 2021
Bryan Health Organization, Lincoln, NE Corporation, Non-profit, Chain home office Operational/Managerial Control Mar 15, 2017
Blake a Cover Individual Corporate Director Jan 1, 2024
W-2 Managing EmployeeMD; Sep 15, 2019
Operational/Managerial ControlMedical Director Sep 15, 2019
Richard Lloyd Individual Corporate Director Sep 1, 2023
Amy Martinez Individual W-2 Managing EmployeeDirector of Ambulatory Services May 9, 2022
Operational/Managerial ControlDirector of Ambulatory Services May 9, 2022
Jodi S Mohr Individual Corporate OfficerCeo Jun 17, 2024
Corporate DirectorCeo Jun 17, 2024
W-2 Managing EmployeeCeo Jun 17, 2024
Operational/Managerial ControlCeo Jun 17, 2024

Owners & managing parties with NPI records 1

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

  • Blake Cover, M.D.
    • Family Medicine Physician
    • Omaha, NE
    • NPI 1225484934

    Corporate Director, Operational/Managerial Control, W-2 Managing Employee

    CMS ownership

Facilities with the same owner 17

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

View all 17

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 16

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 16

NPI Registry JSON

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

{
    "created_epoch": "1490227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721779200000",
    "number": "1124559901",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 860874",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554860874",
            "telephone_number": "308-946-3015",
            "fax_number": "308-946-5914"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 BROADWAY ST",
            "city": "FULLERTON",
            "state": "NE",
            "postal_code": "686383151",
            "telephone_number": "308-536-2458"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MERRICK MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MERRICK MEDICAL CENTER",
        "enumeration_date": "2017-03-23",
        "last_updated": "2024-07-24",
        "certification_date": "2024-07-24",
        "status": "A",
        "authorized_official_last_name": "MOHR",
        "authorized_official_first_name": "JODI",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "402-946-3015"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "direct@hisp.bryanhealth.org",
            "affiliation": "N",
            "address_1": "1600 S 48th St",
            "city": "Lincoln",
            "state": "NE",
            "country_code": "US",
            "postal_code": "685061299",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "FULLERTON MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fullerton, NE

Sources for this page

Verify at the official NPI Registry.