NPIMap

Organization Active NPI

Sullivan County Memorial Hospital

  • Rural Health Clinic/Center
  • Milan, MO
National Provider Identifier
1285775858
Registry record updated Jul 9, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
130-49 Issued in MO
Legal business name
SULLIVAN COUNTY MEMORIAL HOSPITAL
Practice address
630 W 3Rd St
Milan, MO 63556
Phone
(660) 265-4212
Fax
(660) 265-4898
NPI assigned
Feb 8, 2007
Last updated
Jul 9, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2018

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

Authorized official

Name
Amy Michael
Title
Coo
Phone
(660) 265-4212

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 130-49 MO Primary

Addresses

Primary practice location

630 W 3Rd St
Milan, MO 63556

Mailing address

630 W 3Rd St
Milan, MO 63556-1076
Phone (660) 265-4212

Other identifiers 1

IdentifierTypeStateIssuer
599995107MedicaidMO

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040626000444 MO Part B Supplier - Clinic/Group Practice 7810973252 Receives reassigned benefits from 20 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Milan, MO; Green City, MO
O20091012000272 MO Part A Provider - Rural Health Clinic 7810973252 Practice locations: Milan, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285775858. Details of each certification follow.

Rural health clinic certification: CCN 268520

Legal name
SULLIVAN COUNTY MEMORIAL HOSPITAL
Doing business as
SULLIVAN COUNTY MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 7, 1998
Last certification
Dec 7, 2021
Ownership / control type
2A
Organization structure
OtherNon-profit
Enrollment address
630 W 3Rd St
Milan, MO 63556-1076
Related CCNs
261306

Facilities connected through Provider of Services related, parent or unit certification numbers.

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 4

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

National Provider Directory

National Provider Directory
Tax ID family
Sullivan County Ambulan8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the 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
Martha Gragg Individual Corporate OfficerCeo Mar 26, 2023
W-2 Managing EmployeeCeo Mar 26, 2023
Operational/Managerial ControlCeo Mar 26, 2023
Amy Michael Individual Corporate OfficerCoo Feb 19, 2014 80%
Corporate DirectorCoo Sep 28, 2009 80%
W-2 Managing EmployeeCoo Feb 19, 2014 80%
Operational/Managerial ControlCoo Feb 19, 2014 80%

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Sullivan County Memorial Hospital Green City ClinicGreen City, MO, CCN 268718 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2013
Sullivan County Memorial Hospital Milan Family PracticeMilan, MO, CCN 268729 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 1, 2015

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 3

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": "1170892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531094400000",
    "number": "1285775858",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "630 W 3RD ST",
            "city": "MILAN",
            "state": "MO",
            "postal_code": "635561076",
            "telephone_number": "660-265-4212",
            "fax_number": "660-265-4898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "630 W 3RD ST",
            "city": "MILAN",
            "state": "MO",
            "postal_code": "63556",
            "telephone_number": "660-265-4212",
            "fax_number": "660-265-4898"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SULLIVAN COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-08",
        "last_updated": "2018-07-09",
        "status": "A",
        "authorized_official_last_name": "MICHAEL",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "660-265-4212"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": "130-49",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "599995107",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Milan, MO

Sources for this page

Verify at the official NPI Registry.