Dixon Family Practice and Internal Medicine, LLC
Organization Active NPI Rural Health Clinic/Center · Dixon, MO
NPI 1235135682 · NPPES record last updated Apr 29, 2008
Key facts
- NPI
- 1235135682
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 263875 (MO)
- Legal business name
- DIXON FAMILY PRACTICE AND INTERNAL MEDICINE, LLC
- Practice address
- 206 West 2ND Street
Dixon, MO 65459-0940 - Phone
- (573) 759-3030
- Fax
- (573) 759-3131
- NPI assigned
- Jun 21, 2005
- Organization subpart
- No
Authorized official
- Name
- Carlene S McMillian, FNP
- Title
- Owner
- Phone
- (573) 759-3030
Owners & managing parties with NPI records 1
-
Carlene S McMillian, F.N.P.
Practitioners 7
-
Whitney George, FNP
-
Bradley D. Jones, D.O.
-
Carlene S McMillian, F.N.P.
-
Jose A Atiles, MD
-
Tasaduq N Fazili, MD
-
Robert Mark Ross, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 26D0930428 | Dixon Family Practice Inc | Certificate of waiver | Jul 14, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Rural health clinic certification: CCN 263875
- Legal name
- DIXON FAMILY PRACTICE AND INTERNAL MEDICINE, LLC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Aug 27, 1997
- Last certification
- Oct 26, 2020
- Ownership / control type
- 1B
- Most recent change of ownership
- Jan 9, 2008 (1 total)
- Organization structure
- LLC · Proprietary
- Incorporated
- Jul 1, 1997 in MO
- Enrollment address
- 206 W 2ND St
Dixon, MO 65459-8048
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Carlene S McMillian |
5% Or Greater Direct Ownership Interest | Sep 11, 2010 | 100% |
| Corporate Director | Dec 19, 2007 | 100% | |
| W-2 Managing Employee | Dec 19, 2007 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080825000443 | MO | Part a Provider - Rural Health Clinic | 4486729563 | Practice locations: Dixon, MO |
| O20101123000397 | MO | Part B Supplier - Clinic/Group Practice | 4486729563 |
Receives reassigned benefits from 3 practitioners Practice locations: Dixon, MO |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | R6D44 | MO | |
| Rural Health Clinic/Center | 261QR1300X | 263875 | MO | Yes |
| Family Nurse Practitioner |
363LF0000X | 113217 | MO |
Addresses
Primary practice location
206 West 2ND Street
Dixon, MO 65459-0940
Mailing address
PO Box 9900
Dixon, MO 65459-0940
Phone (573) 759-3030
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 508937000 | Medicaid | MO | |
| 598937001 | Medicaid | MO |
Other providers in Dixon, MO
- William Edward Colyer
- Julia Clodius Cooke
- Dixon Ambulance District
- Dixon Reorganized Dist R1
- Daniel Draper
- Heidi Lynn Ellwood
- Jessica Janet Forlani
- Brenda Joy Fricke
All providers in Dixon, MO · Rural Health Clinic/Center 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 29, 2008. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.