NPIMap

Organization Active NPI

Samuel U. Rodgers Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Blue Springs, MO
National Provider Identifier
1174037519
Registry record updated Jun 11, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SAMUEL U. RODGERS HEALTH CENTER, INC.
Practice address
1501 NW Jefferson St
Blue Springs, MO 64015
Phone
(816) 224-1740
NPI assigned
Nov 21, 2017
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
Monique Proctor
Title
Credentialing Coordinator
Phone
(816) 889-1928

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary

Addresses

Primary practice location

1501 NW Jefferson St
Blue Springs, MO 64015

Mailing address

1501 NW Jefferson St
Blue Springs, MO 64015-7242
Phone (816) 224-1740

Other names 1

  • Samuel U. Rodgers Health Center Blue Springs School District Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031105000813 MO Part B Supplier - Clinic/Group Practice 9739092826 Receives reassigned benefits from 81 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Blue Springs, MO; Kansas City, MO; Liberty, MO
O20180122000185 MO Part A Provider - Federally Qualified Health Center (FQHC) 9739092826 Practice locations: Blue Springs, MO

Federally qualified health center certification: CCN 261154

Legal name
SAMUEL U RODGERS HEALTH CENTER INC
Doing business as
SAMUEL U. RODGERS HEALTH CENTER BLUE SPRINGS SCHOOL DISTRICT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 22, 2018
Last certification
Jan 22, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 20, 2017 in MO
Enrollment address
1501 NW Jefferson St
Blue Springs, MO 64015-7242

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 11

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

National Provider Directory

National Provider Directory
Tax ID family
Samuel Rodgers Comm Ctr11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

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

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Robert Theis Individual 5% Or Greater Indirect Ownership InterestCeo Nov 20, 2017 100%
Corporate OfficerCeo Nov 20, 2017
W-2 Managing EmployeeCeo Nov 20, 2017
Christopher Walker Individual Corporate OfficerCfo Nov 20, 2017

NPI Registry JSON

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

{
    "created_epoch": "1511222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1174037519",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1501 NW JEFFERSON ST",
            "city": "BLUE SPRINGS",
            "state": "MO",
            "postal_code": "640157242",
            "telephone_number": "816-224-1740"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1501 NW JEFFERSON ST",
            "city": "BLUE SPRINGS",
            "state": "MO",
            "postal_code": "64015",
            "telephone_number": "816-224-1740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAMUEL U. RODGERS HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-11-21",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "PROCTOR",
        "authorized_official_first_name": "MONIQUE",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "816-889-1928"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Samuel U. Rodgers Health Center Blue Springs School District",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Blue Springs, MO

Sources for this page

Verify at the official NPI Registry.