NPIMap

Organization Active NPI

Jefferson Medical Group

  • Family Medicine Physician
  • Carrollton, MO
National Provider Identifier
1215030713
Registry record updated Oct 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
JEFFERSON MEDICAL GROUP
Practice address
1502 N Jefferson St
Carrollton, MO 64633-1948
Phone
(660) 542-9998
Fax
(660) 542-9880
NPI assigned
Sep 7, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2021

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

Authorized official

Name
Amy Danielle Ireland
Title
Cfo
Phone
(660) 329-6005

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

1502 N Jefferson St
Carrollton, MO 64633-1948

Mailing address

1502 N Jefferson St
Carrollton, MO 64633-1948
Phone (660) 542-9998

Other identifiers 1

IdentifierTypeStateIssuer
50899330MedicaidMO

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address himdept@ccmhospital.cernerdirect.com Direct Carroll County Memorial Hospital

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20061116000198 MO Part B Supplier - Clinic/Group Practice 6800894379 Receives reassigned benefits from 11 practitioners
1 other NPI on this enrollment
Practice locations: Brunswick, MO; Carrollton, MO; Hale, MO

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

807 E Broadway St
Brunswick, MO 65236
Phone (660) 542-1695

221 Elm St
Hale, MO 64643
Phone (660) 542-1695

Interoperability endpoints

  • Direct secure messaging: erinfinkeldei@ccmhospital.cernerdirect.com
  • Direct secure messaging: andrewhorine@ccmhospital.cernerdirect.com
  • Direct secure messaging: jonnarechterman@ccmhospital.cernerdirect.com
  • Direct secure messaging: gregstafford@ccmhospital.cernerdirect.com
  • Direct secure messaging: taraswan@ccmhospital.cernerdirect.com
  • Direct secure messaging: richardsmith@ccmhospital.cernerdirect.com
  • Direct secure messaging: timothyreid@ccmhospital.cernerdirect.com
  • Direct secure messaging: trentlink@ccmhospital.cernerdirect.com
  • Direct secure messaging: pamralls@ccmhospital.cernerdirect.com

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1157587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635465600000",
    "number": "1215030713",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON ST",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-9998",
            "fax_number": "660-542-9880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON ST",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-9998",
            "fax_number": "660-542-9880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-07",
        "last_updated": "2021-10-29",
        "certification_date": "2021-10-29",
        "status": "A",
        "authorized_official_last_name": "IRELAND",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "DANIELLE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "660-329-6005"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "50899330",
            "state": "MO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "himdept@ccmhospital.cernerdirect.com",
            "affiliation": "Y",
            "affiliationName": "Carroll County Memorial Hospital",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1502 N Jefferson St",
            "city": "Carrollton",
            "state": "MO",
            "country_code": "US",
            "postal_code": "646331948",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Carrollton, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.