NPIMap

Organization Active NPI

Crossett Health Foundation

Doing business as Ashley Family Clinic

  • Family Medicine Physician
  • Crossett, AR
National Provider Identifier
1134680242
Registry record updated Jun 11, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CROSSETT HEALTH FOUNDATION
Doing business as
Ashley Family Clinic
Practice address
124 Ray Lochala Rd
Crossett, AR 71635-4542
Phone
(870) 364-0590
Fax
(870) 364-1245
NPI assigned
Mar 29, 2019
Last updated
Jun 11, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 11, 2019

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

Authorized official

Name
Shirley White
Title
HR Director/Accounting Supervisor
Phone
(870) 364-1272

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

124 Ray Lochala Rd
Crossett, AR 71635-4542

Mailing address

PO Box 400
Crossett, AR 71635-0400
Phone (870) 364-0590

Other names 1

  • Ashley Family Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191221000059 AR Part A Provider - Rural Health Clinic 9133030117 Practice locations: Crossett, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1134680242. Details of each certification follow.

Rural health clinic certification: CCN 048522

Legal name
CROSSETT HEALTH FOUNDATION
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 1, 2020
Last certification
Apr 16, 2026
Ownership / control type
2B
Organization structure
OtherNon-profit
Incorporated
Oct 1, 1947 in AR
Enrollment address
124 Ray Lochala Rd
Crossett, AR 71635-4542
Related CCNs
041323

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

Other NPIs with the same Medicare PAC ID 8

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

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
04D2166125Ashley Family Clinic124 Ray Lochala Road, Crossett, AR 71635Certificate of waiverMay 12, 2027

National Provider Directory

National Provider Directory
Tax ID family
Ashley Memorial Hospita9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

124 Ray Lochala Rd
Crossett, AR 71635
Phone (870) 364-0590

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Sarah Cope Individual Corporate OfficerClinic Director Nov 2, 2023 100%
W-2 Managing EmployeeClinic Director Nov 1, 2023 100%
Phillip Gilmore Individual 5% Or Greater Indirect Ownership InterestCeo May 1, 2020 100%
Corporate OfficerCeo Jul 1, 2009 100%
Corporate DirectorCeo Jul 1, 2009 100%
W-2 Managing EmployeeCeo Jul 1, 2009
Operational/Managerial ControlCeo Jul 1, 2009 100%
Shirley White Individual Corporate OfficerHuman Resources Director/Acct Super Jan 1, 2011 100%
W-2 Managing EmployeeHuman Resources Dir/Accounting Supe Jan 1, 2011 100%

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Ashley County Medical CenterCrossett, AR, CCN 041323 Hospital 5% Or Greater Direct Ownership Interest Aug 1, 1945
Ashley County Medical CenterCrossett, AR, CCN 04Z323 Hospital 5% Or Greater Direct Ownership Interest (100%) Oct 1, 1998
Ashley Health ServicesCrossett, AR, CCN 043490 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control (100%)		 Dec 1, 2001
Dec 1, 2001
Hamburg Health ClinicHamburg, AR, CCN 048501 Rural health clinic Operational/Managerial Control (100%) Jan 1, 2012

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 4

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.

NPI Registry JSON

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

{
    "created_epoch": "1553817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1134680242",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 400",
            "city": "CROSSETT",
            "state": "AR",
            "postal_code": "716350400",
            "telephone_number": "870-364-0590",
            "fax_number": "870-364-1245"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 RAY LOCHALA RD",
            "city": "CROSSETT",
            "state": "AR",
            "postal_code": "716354542",
            "telephone_number": "870-364-0590",
            "fax_number": "870-364-1245"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROSSETT HEALTH FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-29",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "SHIRLEY",
        "authorized_official_title_or_position": "HR DIRECTOR/ACCOUNTING SUPERVISOR",
        "authorized_official_telephone_number": "870-364-1272"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ashley Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crossett, AR

Sources for this page

Verify at the official NPI Registry.