Southeast Missouri Health Network
Organization Active NPI Federally Qualified Health Center (FQHC) · Bernie, MO
NPI 1194945154 · NPPES record last updated Apr 14, 2020
Key facts
- NPI
- 1194945154
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- SOUTHEAST MISSOURI HEALTH NETWORK
- Practice address
- 741 S Walnut St
Bernie, MO 63822-8900 - Phone
- (573) 748-7712
- Fax
- (573) 293-6838
- NPI assigned
- May 1, 2007
- Organization subpart
- No
Authorized official
- Name
- Sara Deane
- Title
- Chief Financial Officer
- Phone
- (573) 313-2500
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 9
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 13
Practitioners 19
-
Summer Alexander, NP
-
Autumn Lynnette Allgood, FNP-C
-
Taylor Rae Altenthal, APRN
-
Amanda Elaine Bader, FNP-BC
-
William Bradley, FNP
-
Daniel Domjan, MD
-
Samantha Anne Duffel, LCSW
-
Judith Haggard, FNP
-
Tia Heskett, APRN
-
Delayna Michele Hunter, FNP-C
-
Seth Tyler Koehler, D.O.
-
Nelson R Perez, MD
-
Amberly D Pritchard, LPC, NCC
-
Nathan Sprengel, DO
-
Sydney Justine Vangennip, MSN, APRN, FNP-C
-
Kristina Lynn Wadley, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Federally qualified health center certification: CCN 261862
- Legal name
- SOUTHEAST MISSOURI HEALTH NETWORK
- Doing business as
- BERNIE FAMILY AND DENTAL CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Mar 9, 2002
- Last certification
- Mar 9, 2002
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 1, 2001 in MO
- Enrollment address
- 741 S Walnut St
Bernie, MO 63822-8900
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Lance Crawford |
Corporate Officer |
Sep 1, 2016 | |
| Corporate Director |
Sep 1, 2016 | ||
| David Howard |
Corporate Officer |
Nov 17, 2014 | |
| Corporate Director |
Nov 17, 2014 | ||
| Scott Lawrence |
Corporate Officer |
Jan 15, 2019 | |
| Corporate Director |
Jan 15, 2019 | ||
| Mary Davis |
Corporate Officer |
Aug 20, 2007 | |
| Corporate Director |
Aug 20, 2007 | ||
| Christopher Jones |
Corporate Officer |
Dec 10, 2013 | |
| Don Miller |
Corporate Officer |
Aug 1, 2018 | |
| Corporate Director |
Aug 1, 2018 | ||
| Richard Rickman |
Corporate Director |
Dec 1, 2019 | |
| Teresa Richey |
Corporate Officer |
Jan 25, 2010 | |
| Corporate Director |
Jan 25, 2010 | ||
| Mallory Matthews |
W-2 Managing Employee |
Feb 1, 2019 | |
| Terunda L Farr |
W-2 Managing Employee | Aug 11, 2003 | |
| Catherine Bockhold |
Corporate Officer |
Mar 1, 2011 | |
| Corporate Director |
Mar 1, 2011 | ||
| Cynthia Sharp-Amick |
Corporate Officer |
Mar 17, 2014 | |
| Corporate Director |
Mar 17, 2014 | ||
| Sara Deane |
Corporate Officer |
Dec 8, 2014 | |
| Corporate Director |
Dec 8, 2014 |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Sikeston Alternative Education Center Clinic |
Federally qualified health center | Operational/Managerial Control | Nov 4, 2019 |
| NMCC School Based Health Center |
Federally qualified health center | Operational/Managerial Control | Nov 4, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050412000011 | MO | Part B Supplier - Clinic/Group Practice | 6507818044 |
Receives reassigned benefits from 20 practitioners 9 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Caruthersville, MO; Sikeston, MO; New Madrid, MO; Kennett, MO; Bernie, MO; Benton, MO |
| O20100625000422 | MO | Part a Provider - Federally Qualified Health Center (FQHC) | 6507818044 | Practice locations: Bernie, MO |
National Provider Directory
- Tax ID family
- Southeast Missouri Network
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
741 S Walnut St
Bernie, MO 63822-8900
Mailing address
6738 State Highway 77
Benton, MO 63736-8238
Phone (573) 313-2500
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500704051 | Medicaid | MO |
Other names
- Bernie Medical Center
Other providers in Bernie, MO
- Shelby Lawrence
- Katrina Leanne Miller
- Daley M Powers
- Ronna Reaves
- Southeast Health Center of Stoddard County LLC
- Southeast Missouri Health Network
- Brandi Sparks
- Super D Drugs Acquisition Co.
- Walgreen Co
- Mariah Walker
All providers in Bernie, MO · Federally Qualified Health Center (FQHC) in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 14, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.