Merrick Medical Center
Organization Active NPI Rural Health Clinic/Center · Fullerton, NE
NPI 1124559901 · NPPES record last updated Jul 24, 2024
Key facts
- NPI
- 1124559901
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MERRICK MEDICAL CENTER
- Practice address
- 901 Broadway St
Fullerton, NE 68638-3151 - Phone
- (308) 536-2458
- NPI assigned
- Mar 23, 2017
- Organization subpart
- Yes
- Parent organization (as reported)
- MERRICK MEDICAL CENTER
Authorized official
- Name
- Jodi S Mohr
- Title
- Ceo
- Phone
- (402) 946-3015
Parent organization (reported in NPPES) 1
Owners & managing parties with NPI records 1
-
Blake Cover, M.D.
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 4
Related certifications (CCN) 1
Facilities with the same owner 17
Practitioners 17
-
Brian Keith Buhlke, D.O.
-
Blake Cover, M.D.
-
Traci A Dieckmann, D.O.
-
Brett Charles Hill, M.D.
-
Brandon Lee McLaughlin, P.A.
-
Natalie H Pearson, PA-C
-
Richard L Poppe, MD
-
Ryan Thomas Santin, M.D.
-
Cara E. Schiessler, APRN
-
Elisa Jean Zeiss, PA-C
-
Rhianna W Becker, PA-C
-
Timothy C Govaerts, M.D.
-
Shelby N Gowen, APRN
-
Douglas J Langemeier, PA-C
-
Swathi Lavudi, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 28D0886128 | Fullerton Medical Clinic | Certificate of waiver | Apr 30, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NE
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
- Corporation · Non-profit
- Incorporated
- Mar 15, 2017 in NE
- Enrollment address
- 901 Broadway St
Fullerton, NE 68638-3151 - Related CCNs
- 281328
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Nathan W Perry |
Corporate Officer | Feb 16, 2023 | |
| Corporate Director | Feb 16, 2023 | ||
| Shannon Hannappel |
Corporate Officer | Feb 18, 2021 | |
| Corporate Director | Dec 20, 2018 | ||
| Patrick D Ganyo |
Corporate Officer | Feb 16, 2023 | |
| Corporate Director | Feb 18, 2021 | ||
| Bryan Health |
Operational/Managerial Control | Mar 15, 2017 | |
| Blake a Cover |
Corporate Director | Jan 1, 2024 | |
| W-2 Managing Employee |
Sep 15, 2019 | ||
| Operational/Managerial Control |
Sep 15, 2019 | ||
| Richard Lloyd |
Corporate Director | Sep 1, 2023 | |
| Amy Martinez |
W-2 Managing Employee |
May 9, 2022 | |
| Operational/Managerial Control |
May 9, 2022 | ||
| Jodi S Mohr |
Corporate Officer |
Jun 17, 2024 | |
| Corporate Director |
Jun 17, 2024 | ||
| W-2 Managing Employee |
Jun 17, 2024 | ||
| Operational/Managerial Control |
Jun 17, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Part of
- Merrick Medical Center
Locations
2802 28th St
Ste 100
Central City, NE 68826
Phone (308) 946-3845
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes | ||
| Physician Assistant |
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
- FULLERTON MEDICAL CLINIC
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | direct@hisp.bryanhealth.org |
Other providers in Fullerton, NE
- Lincoln Behavioral Health Clinic, Inc
- Litzenberg Memorial Merrick County
- Lone Tree Medical Associates, P.C.
- Michele Mangus
- Melissa M Schock DDS LLC
- Nance County Family Chiropractic Center, LLC
- Nancetrans,Inc.
- Nikki Bauer Counseling, LLC
- Nathan W Olson
- Reimer Pharmacy LLC
All providers in Fullerton, NE · Rural Health Clinic/Center in Nebraska
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 24, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.