NPIMap

Organization Active NPI

Southeast Missouri Health Network

Doing business as Bernie Medical Center

  • Federally Qualified Health Center (FQHC)
  • Bernie, MO
National Provider Identifier
1194945154
Registry record updated Apr 14, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHEAST MISSOURI HEALTH NETWORK
Doing business as
Bernie Medical Center
Practice address
741 S Walnut St
Bernie, MO 63822-8900
Phone
(573) 748-7712
Fax
(573) 293-6838
NPI assigned
May 1, 2007
Last updated
Apr 14, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2020

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

Authorized official

Name
Sara Deane
Title
Chief Financial Officer
Phone
(573) 313-2500

Specialties & licenses 1

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

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 names 1

  • Bernie Medical Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194945154. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Jun 1, 2001 in MO
Enrollment address
741 S Walnut St
Bernie, MO 63822-8900

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 9

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

National Provider Directory

National Provider Directory
Tax ID family
Southeast Missouri Network14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

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

View all 13

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Lance Crawford Individual Corporate OfficerVice President Sep 1, 2016
Corporate DirectorBoard Member Sep 1, 2016
David Howard Individual Corporate OfficerBoard Member Nov 17, 2014
Corporate DirectorBoard Member Nov 17, 2014
Scott Lawrence Individual Corporate OfficerCoo Jan 15, 2019
Corporate DirectorBoard Member Jan 15, 2019
Mary Davis Individual Corporate OfficerBoard Member Aug 20, 2007
Corporate DirectorBoard Member Aug 20, 2007
Christopher Jones Individual Corporate OfficerCeo Dec 10, 2013
Don Miller Individual Corporate OfficerPresident Aug 1, 2018
Corporate DirectorBoard Member Aug 1, 2018
Richard Rickman Individual Corporate DirectorBoard Member Dec 1, 2019
Teresa Richey Individual Corporate OfficerCno Jan 25, 2010
Corporate DirectorBoard Member Jan 25, 2010
Mallory Matthews Individual W-2 Managing EmployeeDirector of Clinical Operations Feb 1, 2019
Terunda L Farr Individual W-2 Managing Employee Aug 11, 2003
Catherine Bockhold Individual Corporate OfficerBoard Member Mar 1, 2011
Corporate DirectorBoard Member Mar 1, 2011
Cynthia Sharp-Amick Individual Corporate OfficerBoard Member Mar 17, 2014
Corporate DirectorBoard Member Mar 17, 2014
Sara Deane Individual Corporate OfficerCfo Dec 8, 2014
Corporate DirectorCfo Dec 8, 2014

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Sikeston Alternative Education Center ClinicSikeston, MO, CCN 261181 Federally qualified health center Operational/Managerial Control Nov 4, 2019
NMCC School Based Health CenterNew Madrid, MO, CCN 261989 Federally qualified health center Operational/Managerial Control Nov 4, 2019

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 2

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": "1177977600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1586822400000",
    "number": "1194945154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6738 STATE HIGHWAY 77",
            "city": "BENTON",
            "state": "MO",
            "postal_code": "637368238",
            "telephone_number": "573-313-2500",
            "fax_number": "573-313-2505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "741 S WALNUT ST",
            "city": "BERNIE",
            "state": "MO",
            "postal_code": "638228900",
            "telephone_number": "573-748-7712",
            "fax_number": "573-293-6838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST MISSOURI HEALTH NETWORK",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-01",
        "last_updated": "2020-04-14",
        "certification_date": "2020-04-14",
        "status": "A",
        "authorized_official_last_name": "DEANE",
        "authorized_official_first_name": "SARA",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "573-313-2500"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Bernie Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bernie, MO

Sources for this page

Verify at the official NPI Registry.