NPIMap

Organization Active NPI

Panhandle Rural Health Incorporated

Doing business as Jay Medical Clinic

  • Rural Health Clinic/Center
  • Jay, FL
National Provider Identifier
1255398228
Registry record updated Jul 5, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PANHANDLE RURAL HEALTH INCORPORATED
Doing business as
Jay Medical Clinic
Practice address
14088 Alabama St
Jay, FL 32565-1036
Phone
(850) 675-4546
Fax
(850) 675-4548
NPI assigned
Apr 26, 2006
Last updated
Jul 5, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 5, 2012

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

Authorized official

Name
Dr. Cleatious David Smith I, MDNPI 1871546515
Title
Owner Supervising Physician
Phone
(850) 675-4546

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

14088 Alabama St
Jay, FL 32565-1036

Mailing address

PO Box 10
Jay, FL 32565-0010
Phone (850) 675-4546

Other identifiers 3

IdentifierTypeStateIssuer
660022100MedicaidFL
21333OtherFLBCBS OF FLORIDA GROUP NUMBER
660022102MedicaidFL

Other names 1

  • Jay Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040428000859 FL Part A Provider - Rural Health Clinic 1557358801 Practice locations: Jay, FL
O20121022000294 FL Part B Supplier - Clinic/Group Practice 1557358801 Receives reassigned benefits from 6 practitioners
Practice locations: Jay, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1255398228. Details of each certification follow.

Rural health clinic certification: CCN 103858

Legal name
PANHANDLE RURAL HEALTH INCORPORATED
Doing business as
JAY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 18, 1994
Last certification
Jun 10, 2019
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Feb 1, 1994 in FL
Enrollment address
14088 Alabama St
Jay, FL 32565-1036

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
10D0884275Jay Medical Clinic14088 Alabama Street, Jay, FL 32565Certificate of waiverJul 29, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Cleatious David Smith Individual 5% Or Greater Direct Ownership Interest Feb 1, 1994 100%
Rhonda Denise McLeod Individual W-2 Managing EmployeeAdministrator Jan 1, 2009

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 6

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": "1146009600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1341446400000",
    "number": "1255398228",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 10",
            "city": "JAY",
            "state": "FL",
            "postal_code": "325650010",
            "telephone_number": "850-675-4546",
            "fax_number": "850-675-4548"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14088 ALABAMA ST",
            "city": "JAY",
            "state": "FL",
            "postal_code": "325651036",
            "telephone_number": "850-675-4546",
            "fax_number": "850-675-4548"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PANHANDLE RURAL HEALTH INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-26",
        "last_updated": "2012-07-05",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "CLEATIOUS",
        "authorized_official_middle_name": "DAVID",
        "authorized_official_title_or_position": "OWNER SUPERVISING PHYSICIAN",
        "authorized_official_telephone_number": "850-675-4546",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "I",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660022100",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF FLORIDA GROUP NUMBER",
            "identifier": "21333",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660022102",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jay Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jay, FL

Sources for this page

Verify at the official NPI Registry.