NPIMap

Organization Active NPI

Northeast Missouri Health Council Inc

Doing business as Northeast Missouri Family Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Milan, MO
National Provider Identifier
1144366154
Registry record updated Jun 24, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
Northeast Missouri Family Health Clinic
Practice address
52334 Business Highway 5
Milan, MO 63556-3040
Phone
(660) 265-1042
Fax
(660) 265-1043
NPI assigned
Jan 29, 2007
Last updated
Jun 24, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2011

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

Authorized official

Name
Andrew H. Grimm
Title
Executive Director
Phone
(660) 627-5757

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary
Family Medicine Physician 207Q00000X 109328 MO
Obstetrics & Gynecology Physician 207V00000X 2009006697 MO

Addresses

Primary practice location

52334 Business Highway 5
Milan, MO 63556-3040

Mailing address

1416 Crown Dr
Kirksville, MO 63501-2548
Phone (660) 627-5757

Other identifiers 1

IdentifierTypeStateIssuer
503351850MedicaidMO

Other names 1

  • Northeast Missouri Family Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20030319000005 MO Part A Provider - Federally Qualified Health Center (FQHC) 1658280805 Practice locations: Milan, MO
O20040112000061 MO Part B Supplier - Clinic/Group Practice 1658280805 Receives reassigned benefits from 27 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kirksville, MO
O20040430000892 MO Part B Supplier - Clinic/Group Practice 1658280805 Receives reassigned benefits from 13 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Milan, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144366154. Details of each certification follow.

Federally qualified health center certification: CCN 261866

Legal name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
NORTHEAST FAMILY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 18, 2003
Last certification
Jun 18, 2003
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 22, 1968 in MO
Enrollment address
52334 Business Highway 5
Milan, MO 63556-3040

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 6

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
26D0985653Northeast Missouri Family Health52334 S Business Hwy 5, Milan, MO 63556Certificate of waiverApr 24, 2027

National Provider Directory

National Provider Directory
Tax ID family
Northeast Missouri Fami13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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

Locations

1410 Crown Dr
Kirksville, MO 63501
Phone (660) 627-3621

402 W Jefferson St
Kirksville, MO 63501
Phone (660) 665-2741

118 E Grand Ave
Memphis, MO 63555
Phone (660) 465-7522

52334 Business Highway 5
Milan, MO 63556
Phone (660) 265-1042

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Chad Sawyer Individual Corporate Director Jan 23, 2020
Tammi Propst Individual W-2 Managing Employee Jun 1, 2006
Jeffrey Doss Individual Corporate DirectorBoard Member Jun 15, 2009
Carolyn Ranee Brayton Individual Corporate Director Jan 23, 2023
Walla Derosear Individual Corporate DirectorBoard Member Mar 1, 2012
Ashley Hartman Individual W-2 Managing Employee Jan 1, 2014
David Richard Rector Individual Corporate DirectorBoard Vice President Apr 22, 2003
Karen Ann Lumley Individual Corporate DirectorBoard Member Apr 22, 2003
Tiffany Labeth Individual Corporate DirectorBoard Member Aug 22, 2013
Phil McIntosh Individual Corporate Director Jan 23, 2020
Carolyn Primm Individual Corporate DirectorBoard Member May 26, 2011
Richard Gooch Individual Corporate DirectorBoard Member Treasurer May 26, 2011
Pam Smith Individual Corporate DirectorBoard Member Sep 26, 2013
John Thibaut Heard Individual Corporate DirectorBoard President Apr 23, 2003
Andrew Grimm Individual Corporate OfficerCeo Sep 23, 2013
W-2 Managing Employee Apr 1, 2009

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Macon Family HealthMacon, MO, CCN 261116 Federally qualified health center Operational/Managerial Control (100%) Sep 2, 2015
Kahoka DentalKahoka, MO, CCN 261140 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011
Northeast Family Health AnnexKirksville, MO, CCN 261147 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011
Memphis Community Health CenterMemphis, MO, CCN 261932 Federally qualified health center Operational/Managerial Control Apr 21, 1968

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 10

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": "1170028800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1308873600000",
    "number": "1144366154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1416 CROWN DR",
            "city": "KIRKSVILLE",
            "state": "MO",
            "postal_code": "635012548",
            "telephone_number": "660-627-5757",
            "fax_number": "660-627-5802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "52334 BUSINESS HIGHWAY 5",
            "city": "MILAN",
            "state": "MO",
            "postal_code": "635563040",
            "telephone_number": "660-265-1042",
            "fax_number": "660-265-1043"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MISSOURI HEALTH COUNCIL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-29",
        "last_updated": "2011-06-24",
        "status": "A",
        "authorized_official_last_name": "GRIMM",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "660-627-5757"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "109328",
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "MO",
            "license": "2009006697",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "503351850",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeast Missouri Family Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Milan, MO

Sources for this page

Verify at the official NPI Registry.