NPIMap

Organization Active NPI

Yalobusha General Hospital

Doing business as Odom Rural Health Clinic

  • Rural Health Clinic/Center
  • Water Valley, MS
National Provider Identifier
1356402002
Registry record updated Dec 10, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
YALOBUSHA GENERAL HOSPITAL
Doing business as
Odom Rural Health Clinic
Practice address
645 South Main Street
Water Valley, MS 38965
Phone
(662) 473-1311
NPI assigned
Dec 13, 2006
Last updated
Dec 10, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 10, 2007

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

Authorized official

Name
Terry L Varner
Title
Administrator
Phone
(662) 473-1411

Specialties & licenses 1

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

Addresses

Primary practice location

645 South Main Street
Water Valley, MS 38965

Mailing address

645 Hwy 7 South
Water Valley, MS 38965-0645
Phone (662) 473-1311

Other identifiers 1

IdentifierTypeStateIssuer
09013597MedicaidMS

Other names 1

  • ODOM RURAL HEALTH CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050331000530 MS Part B Supplier - Clinic/Group Practice 4486601648 Receives reassigned benefits from 37 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Water Valley, MS
O20070329000594 MS Part A Provider - Rural Health Clinic 4486601648 Practice locations: Water Valley, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356402002. Details of each certification follow.

Rural health clinic certification: CCN 258538

Legal name
YALOBUSHA GENERAL HOSPITAL
Doing business as
ODOM RURAL HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 1, 2007
Last certification
Mar 1, 2022
Ownership / control type
Non-profit – church related
Organization structure
GovernmentProprietary
Enrollment address
604 S Main St
Water Valley, MS 38965-3468
Related CCNs
250061

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 5

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
25D2002570Yalobusha General Hospital Odom Location604 S Main St, Water Valley, MS 38965ComplianceAug 13, 2027

National Provider Directory

National Provider Directory
Tax ID family
Yalobusha County Nursing Home Dba Yalobusha General Hospital16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

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

View all 15

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Stephanie S Burns Individual W-2 Managing Employee Mar 1, 2014
Jessica Embry Individual Corporate DirectorAdministrator Jan 26, 2020
W-2 Managing EmployeeAdministrator Jan 26, 2020
Yalobusha General Hospital Organization, Water Valley, MS 5% Or Greater Direct Ownership Interest Jan 1, 2007 100%

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Yalobusha General HospitalWater Valley, MS, CCN 250061 Hospital 5% Or Greater Direct Ownership Interest Sep 1, 1966
Yalobusha General Hospital Swing BedWater Valley, MS, CCN 25U061 Hospital 5% Or Greater Direct Ownership Interest Sep 12, 1985
Oakland Medical ClinicOakland, MS, CCN 258585 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2013
Arrington Medical ClinicCoffeeville, MS, CCN 258598 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 10, 2014

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 4

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

Practitioners & affiliated clinicians

Practitioners 12

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": "1165968000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1197244800000",
    "number": "1356402002",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "645 HWY 7 SOUTH",
            "city": "WATER VALLEY",
            "state": "MS",
            "postal_code": "389650645",
            "telephone_number": "662-473-1311",
            "fax_number": "662-473-4922"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "645 SOUTH MAIN STREET",
            "city": "WATER VALLEY",
            "state": "MS",
            "postal_code": "38965",
            "telephone_number": "662-473-1311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "YALOBUSHA GENERAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-13",
        "last_updated": "2007-12-10",
        "status": "A",
        "authorized_official_last_name": "VARNER",
        "authorized_official_first_name": "TERRY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "662-473-1411"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09013597",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ODOM RURAL HEALTH CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Water Valley, MS

Sources for this page

Verify at the official NPI Registry.