NPIMap

Organization Active NPI

Chiefland Medical Center LLC

  • Family Medicine Physician
  • Chiefland, FL
National Provider Identifier
1184674384
Registry record updated Sep 20, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
HCC4256 Issued in FL
Legal business name
CHIEFLAND MEDICAL CENTER LLC
Practice address
1113 NW 23Rd Ave
Chiefland, FL 32626-1911
Phone
(352) 493-9500
Fax
(352) 493-7070
NPI assigned
May 11, 2006
Last updated
Sep 20, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 20, 2007

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

Authorized official

Name
John L Connole II
Title
Exec Director
Phone
(352) 493-9500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X HCC4256 FL Primary

Addresses

Primary practice location

1113 NW 23Rd Ave
Chiefland, FL 32626-1911

Mailing address

1113 NW 23Rd Ave
Chiefland, FL 32626-1911
Phone (352) 493-9500

Other identifiers 1

IdentifierTypeStateIssuer
21419OtherFLBCBS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050302000024 FL Part A Provider - Rural Health Clinic 6406809433 Practice locations: Chiefland, FL
O20050321000655 FL Part B Supplier - Clinic/Group Practice 6406809433 Receives reassigned benefits from 4 practitioners
Practice locations: Chiefland, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1184674384. Details of each certification follow.

Rural health clinic certification: CCN 103932

Legal name
CHIEFLAND MEDICAL CENTER LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 15, 1996
Last certification
Feb 11, 2025
Ownership / control type
1B
Most recent change of ownership
May 1, 2005 (1 total)
Organization structure
CorporationProprietary
Incorporated
Jan 27, 2004 in FL
Enrollment address
1113 NW 23Rd Ave
Chiefland, FL 32626-1911

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
10D0913588Chiefland Medical Center LLC1113 NW 23Rd Ave, Chiefland, FL 32626Certificate of waiverJun 16, 2027

National Provider Directory

National Provider Directory

Locations

1113 NW 23rd Ave
Chiefland, FL 32626
Phone (352) 493-9500

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Stephen Minton Individual 5% Or Greater Direct Ownership Interest May 1, 2005
Corporate Director Jul 13, 2005
Elizabeth Schaefer Individual 5% Or Greater Direct Ownership Interest May 1, 2005
Corporate Director Jul 13, 2005
Gregory Washburn Individual 5% Or Greater Direct Ownership Interest May 1, 2005
Corporate Director Jul 13, 2005
Marie Minton Individual 5% Or Greater Direct Ownership Interest May 1, 2005
Corporate Director Jul 13, 2005
Operational/Managerial ControlPresident Jan 1, 2014 9%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1147305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1190246400000",
    "number": "1184674384",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1113 NW 23RD AVE",
            "city": "CHIEFLAND",
            "state": "FL",
            "postal_code": "326261911",
            "telephone_number": "352-493-9500",
            "fax_number": "352-493-7070"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1113 NW 23RD AVE",
            "city": "CHIEFLAND",
            "state": "FL",
            "postal_code": "326261911",
            "telephone_number": "352-493-9500",
            "fax_number": "352-493-7070"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHIEFLAND MEDICAL CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-11",
        "last_updated": "2007-09-20",
        "status": "A",
        "authorized_official_last_name": "CONNOLE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "EXEC DIRECTOR",
        "authorized_official_telephone_number": "352-493-9500",
        "authorized_official_name_suffix": "II"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "HCC4256",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "21419",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chiefland, FL

Sources for this page

Verify at the official NPI Registry.