NPIMap

Organization Active NPI

Mercy Clinic East Communities

  • Rural Health Clinic/Center
  • Bourbon, MO
National Provider Identifier
1235493776
Registry record updated Apr 28, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MERCY CLINIC EAST COMMUNITIES
Practice address
125 N Old Highway 66
Bourbon, MO 65441-6298
Phone
(573) 679-2006
NPI assigned
Jun 29, 2012
Last updated
Apr 28, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
MERCY HEALTH EAST COMMUNITIESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 28, 2025

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

Authorized official

Name
Kerry Dunger
Title
Executive Director - Finance
Phone
(314) 364-3707

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

125 N Old Highway 66
Bourbon, MO 65441-6298

Mailing address

125 N Old Highway 66
Bourbon, MO 65441-6298
Phone (573) 679-2006

Other identifiers 1

IdentifierTypeStateIssuer
596407106MedicaidMO

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070521000058 MO Part B Supplier - Clinic/Group Practice 7214827922 Receives reassigned benefits from 211 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Washington, MO; Warrenton, MO; Union, MO; Troy, MO; Sullivan, MO; Saint Clair, MO; Pacific, MO; New Haven, MO…
O20121010000452 MO Part A Provider - Rural Health Clinic 7214827922 Practice locations: Bourbon, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235493776. Details of each certification follow.

Rural health clinic certification: CCN 268984

Legal name
MERCY CLINIC EAST COMMUNITIES
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 10, 2008
Last certification
Feb 23, 2022
Ownership / control type
2B
Most recent change of ownership
Jul 1, 2012 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Feb 7, 1997 in MO
Enrollment address
125 North Old Highway 66
Bourbon, MO 65441-6298

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 7

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
26D1074778Mercy Clinic East Communities125 North Old Hwy 66, Bourbon, MO 65441Certificate of waiverOct 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mercy Clinic Communities6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

851 E 5th St
Ste 328
Washington, MO 63090
Phone (636) 239-1101

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
Jamie Wilke Individual Corporate OfficerSecretary Jul 1, 2024
Kerry Dunger Individual Corporate DirectorExecutive Director Apr 21, 2025
Paul H Young Individual Corporate Director Jul 1, 2020
James R Grimes Individual Corporate Director Jul 1, 2020
Jeffrey Peter Ciaramita Individual Corporate Director Jan 9, 2022
Andrew Runge Individual Corporate Officer Jul 1, 2020
Gary M Wasserman Individual Corporate Director Jul 1, 2020
Denise Scoffic Individual Corporate OfficerTreasurer Jul 1, 2021
Stacie Farnam Individual W-2 Managing EmployeeDirector Jul 8, 2022
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Jul 26, 2012 100%
David E Chalk Individual Corporate Director Jul 1, 2020
Mercy Health East Communities Organization, Saint Louis, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jul 26, 2012 100%
Brian Day Individual Corporate OfficerSVP Apr 21, 2025

Owners & managing parties with NPI records 4

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

Facilities with the same owner 116

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

View all 116

Practitioners & affiliated clinicians

Practitioners 8

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": "1340928000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1745798400000",
    "number": "1235493776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "125 N OLD HIGHWAY 66",
            "city": "BOURBON",
            "state": "MO",
            "postal_code": "654416298",
            "telephone_number": "573-679-2006"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "125 N OLD HIGHWAY 66",
            "city": "BOURBON",
            "state": "MO",
            "postal_code": "654416298",
            "telephone_number": "573-679-2006"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MERCY CLINIC EAST COMMUNITIES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MERCY HEALTH EAST COMMUNITIES",
        "enumeration_date": "2012-06-29",
        "last_updated": "2025-04-28",
        "certification_date": "2025-04-28",
        "status": "A",
        "authorized_official_last_name": "DUNGER",
        "authorized_official_first_name": "KERRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR - FINANCE",
        "authorized_official_telephone_number": "314-364-3707"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "596407106",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bourbon, MO

Sources for this page

Verify at the official NPI Registry.