NPIMap

Organization Active NPI

Cross Trails Medical Center

  • Federally Qualified Health Center (FQHC)
  • Perryville, MO
National Provider Identifier
1215368402
Registry record updated Dec 12, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CROSS TRAILS MEDICAL CENTER
Practice address
1314 Brenda Ave
Perryville, MO 63775-2624
Phone
(573) 332-0808
Fax
(573) 339-7945
NPI assigned
Dec 12, 2013
Last updated
Dec 12, 2013By the provider in NPPES
Organization subpart
Yes
Parent organization
CROSS TRAILS MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 12, 2013

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

Authorized official

Name
Mona Wells
Title
Cfo
Phone
(573) 339-1196

Specialties & licenses 1

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

Addresses

Primary practice location

1314 Brenda Ave
Perryville, MO 63775-2624

Mailing address

1314 Brenda Ave
Perryville, MO 63775-2624
Phone (573) 332-0808

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031114000205 MO Part B Supplier - Clinic/Group Practice 8820902851 Receives reassigned benefits from 18 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Perryville, MO; Marble Hill, MO; Cape Girardeau, MO; Advance, MO
O20140102001443 MO Part A Provider - Federally Qualified Health Center (FQHC) 8820902851 Practice locations: Perryville, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1215368402. Details of each certification follow.

Federally qualified health center certification: CCN 261068

Legal name
CROSS TRAILS MEDICAL CENTER
Doing business as
CROSS TRAILS MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 25, 2014
Last certification
Feb 25, 2014
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Dec 1, 1995 in MO
Enrollment address
1314 Brenda Ave
Perryville, MO 63775-2303

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 4

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

National Provider Directory

National Provider Directory
Tax ID family
Cross Trails Medical Ce9 organizations share this tax ID, including this one
Part of
Cross Trails Medical Ce

Other organizations with this tax ID 8

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

Locations

937 Broadway St
Ste 202
Cape Girardeau, MO 63701
Phone (573) 332-0808

1314 Brenda Ave
Perryville, MO 63775
Phone (573) 332-0808

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Rebecca Garris Individual Corporate DirectorBoard Member Mar 1, 2024
Chrissy Warren Individual Corporate OfficerCoo Mar 1, 2014
Fran Seabaugh Individual Corporate DirectorBoard Member Mar 1, 2014
Amy Lanzotti Individual Corporate OfficerCfo Jul 1, 2024
Kathy Hotop-Raines Individual Corporate DirectorBoard Member Mar 1, 2014
Greg Nenninger Individual Corporate DirectorBoard Member Mar 1, 2014
Cathi Greer Individual Corporate DirectorBoard Member Mar 1, 2014
Laura Griffin Individual Corporate DirectorBoard Member Jul 1, 2016
Cindy Beussink Individual Corporate DirectorBoard Member Mar 1, 2014
Val Crader Individual Corporate DirectorBoard Member Aug 1, 2011
Rick Francis Individual Corporate OfficerCeo Apr 1, 2024
Glynda J Burford Individual Corporate DirectorBoard Member Jul 1, 2021
Cross Trails Medical Center Organization, Cape Girardeau, MO Non-profit Operational/Managerial Control Mar 1, 2014 100%
Sheila Pruitt Individual W-2 Managing EmployeeBilling Coordinator Mar 1, 2014

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Cross Trails Medical CenterCape Girardeau, MO, CCN 261936 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jun 19, 2023

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1386806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1386806400000",
    "number": "1215368402",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1314 BRENDA AVE",
            "city": "PERRYVILLE",
            "state": "MO",
            "postal_code": "637752624",
            "telephone_number": "573-332-0808",
            "fax_number": "573-339-7945"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1314 BRENDA AVE",
            "city": "PERRYVILLE",
            "state": "MO",
            "postal_code": "637752624",
            "telephone_number": "573-332-0808",
            "fax_number": "573-339-7945"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROSS TRAILS MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CROSS TRAILS MEDICAL CENTER",
        "enumeration_date": "2013-12-12",
        "last_updated": "2013-12-12",
        "status": "A",
        "authorized_official_last_name": "WELLS",
        "authorized_official_first_name": "MONA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-339-1196"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Perryville, MO

Sources for this page

Verify at the official NPI Registry.