NPIMap

Organization Active NPI

Pike County Memorial Hospital

Doing business as Medical Walk-In Clinic

  • Rural Health Clinic/Center
  • Bowling Green, MO
National Provider Identifier
1134633456
Registry record updated Nov 22, 2017
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
Medical Walk-In Clinic
Practice address
1420 S Business 61 Unit Fde
Bowling Green, MO 63334-5230
Phone
(573) 324-5562
NPI assigned
Nov 22, 2017
Last updated
Nov 22, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2017

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

Authorized official

Name
Annmary Tran
Title
Cfo
Phone
(573) 754-5531

Specialties & licenses 1

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

Addresses

Primary practice location

1420 S Business 61 Unit Fde
Bowling Green, MO 63334-5230

Mailing address

2305 Georgia St
Louisiana, MO 63353-2559
Phone (573) 754-5531

Other names 1

  • Medical Walk-In Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180227000146 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 1134633456. Details of each certification follow.

Rural health clinic certification: CCN 268767

Legal name
PIKE COUNTY MEMORIAL HOSPITAL
Doing business as
MEDICAL WALK-IN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 12, 2018
Last certification
Oct 18, 2024
Ownership / control type
2A
Organization structure
OtherNon-profit
Incorporated
Jan 1, 1990 in MO
Enrollment address
1420 S Business 61
Bowling Green, MO 63334-5230
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).

National Provider Directory

National Provider Directory
Tax ID family
Pike County Mem Hospital8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

425 N Galloway Rd
Vandalia, MO 63382
Phone (573) 594-2111

Ownership & related parties

All disclosed owners & managing parties 6

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 OfficerCeo of Practice Location Aug 1, 2018
Corporate DirectorCeo of Practice Location Aug 1, 2018 100%
W-2 Managing EmployeeCeo of Practice Location Aug 1, 2018 100%
Allen Lockard Individual Corporate DirectorBoard Member Apr 18, 1999 20%
Larry Chamberlain Individual Corporate DirectorBoard Member Apr 5, 2016 20%
Kevin Keely Individual Corporate OfficerVice Chairman of the Board Apr 18, 2013 20%
Margaret Goodin Individual Corporate DirectorSecretary of the Board Apr 18, 2012 20%
Robert Mustell Individual Corporate OfficerChairman of the Board Aug 1, 2013 20%

All facility ownership & control disclosures 2

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
PCMH ClinicBowling Green, MO, CCN 263468 Rural health clinic Operational/Managerial Control Dec 31, 1991

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 48

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 48

NPI Registry JSON

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

{
    "created_epoch": "1511308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1511308800000",
    "number": "1134633456",
    "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": "573-754-5531"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1420 S BUSINESS 61 UNIT FDE",
            "city": "BOWLING GREEN",
            "state": "MO",
            "postal_code": "633345230",
            "telephone_number": "573-324-5562"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PIKE COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-11-22",
        "last_updated": "2017-11-22",
        "status": "A",
        "authorized_official_last_name": "TRAN",
        "authorized_official_first_name": "ANNMARY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-754-5531"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Medical Walk-In Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bowling Green, MO

Sources for this page

Verify at the official NPI Registry.