Great Mines Health Center
Organization Active NPI Federally Qualified Health Center (FQHC) · Potosi, MO
NPI 1376536953 · NPPES record last updated Jun 23, 2009
Key facts
- NPI
- 1376536953
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- GREAT MINES HEALTH CENTER
- Practice address
- #1 Southtowne Drive
Potosi, MO 63664-1455 - Phone
- (573) 438-9355
- Fax
- (573) 438-7892
- NPI assigned
- Aug 29, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Michael L Johnson
- Title
- Ceo
- Phone
- (573) 438-9355
Other NPIs on the same Medicare enrollment 5
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 21
Practitioners 37
-
Rosalie Grimes Benz, APRN-BC, FNP
-
Casey Eaton, FNP-BC
-
Samantha Alanna Finley, FNP-C
-
John Joseph Grechus, M.D.
-
Brenda S Halton, PMHNP
-
Jessica Lynn Holland, FNP-C
-
Viktoriya V. Ivantsova, PMHNP-BC
-
Laura L Lukowski, LCSW
-
Heather Renee Mathieson, PLPC
-
Deirdre L Nivens, FAMILY NURSE PRACITI
-
Rozanne Lynn Rawson, LPC
-
Michael Yankowitz, DPM
-
Jennifer Gillam, PMHNP-BC
-
Bethany Renae Aubuchon, LCSW
-
Mary E Cooley, LPC
-
Brittany Gail Huys, LMSW
-
Shayne S Keddy, D.O.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 26D1009671 | Great Mines Health Center | Certificate of waiver | Oct 1, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Federally qualified health center certification: CCN 261878
- Legal name
- GREAT MINES HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jul 8, 2004
- Last certification
- Jul 8, 2004
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Oct 7, 2002 in MO
- Enrollment address
- 1 Southtowne Dr
Potosi, MO 63664-5729
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| John Casey |
Corporate Director |
Mar 26, 2018 | 11.11% |
| Brenda Eckhoff |
Corporate Officer |
Jan 1, 2017 | 11.11% |
| Mike G Doty |
Corporate Officer |
Apr 1, 2010 | 11.11% |
| Robert Rousan |
Corporate Director |
Dec 1, 2014 | 11.11% |
| Gregory a Roeback |
Corporate Officer |
Apr 1, 2012 | |
| Operational/Managerial Control |
Apr 1, 2012 | 100% | |
| Jennifer Sadler |
Corporate Officer |
Dec 1, 2016 | 11.11% |
| Stephen Johnson |
Corporate Director |
Mar 26, 2018 | 11.11% |
| Thomas R Dudley |
Corporate Officer |
Dec 1, 2015 | 11.11% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041004000035 | MO | Part B Supplier - Clinic/Group Practice | 3072598143 |
Receives reassigned benefits from 34 practitioners 5 other NPIs on this enrollment Practice locations: Cadet, MO; Farmington, MO; Mineral Point, MO; Potosi, MO; Richwoods, MO |
| O20061017000618 | MO | Part a Provider - Federally Qualified Health Center (FQHC) | 3072598143 | Practice locations: Potosi, MO |
National Provider Directory
- Tax ID family
- Great Mines Health Center
Locations (25 of 32)
10047 Diamond Rd
Rm 809
Cadet, MO 63630
Phone (573) 438-4982
10047 Diamond Rd
Ste 809
Cadet, MO 63630
608 Pine St
Ofc 2
Farmington, MO 63640
1040 Forster St
Rm E2A
Farmington, MO 63640
1 Black Knight Dr
Rm 1
Farmington, MO 63640
506 S Fleming St
Ofc A8
Farmington, MO 63640
1 Black Knight Dr
Ste 1
Farmington, MO 63640
9 Summit Dr
Farmington, MO 63640
Phone (573) 701-1360
103 Murphy Ave
Farmington, MO 63640
Phone (573) 701-1350
209 W College St
Farmington, MO 63640
Phone (573) 701-1370
1040 Forster St
Farmington, MO 63640
Phone (573) 701-1340
1101 Weber Rd
Ste 202
Farmington, MO 63640
Phone (573) 701-0102
506 S Fleming St
Farmington, MO 63640
708 S Fleming St
Farmington, MO 63640
Phone (573) 701-1340
1124 Main St
Ste 103
Leadwood, MO 63653
1124 Main St
Ste NB103
Leadwood, MO 63653
206 Church St
Leadwood, MO 63653
512 State St
Ste 101
Mineral Point, MO 63660
801 Columbia St
Rm 216
Park Hills, MO 63601
Phone (573) 431-2616
403 W Fite St
Ste 201
Park Hills, MO 63601
412 W Fite St
Rm 5
Park Hills, MO 63601
900 Saint Francois Ave
Ste A9
Park Hills, MO 63601
768 Highway M
Ste 113
Park Hills, MO 63601
625 Chariton Ave
Ste 103
Park Hills, MO 63601
801 Columbia St
Ste 216
Park Hills, MO 63601
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
#1 Southtowne Drive
Potosi, MO 63664-1455
Mailing address
#1 Southtowne Drive
Potosi, MO 63664-1455
Phone (573) 438-9355
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 26-1878 | Other | MO | UNITED GOVERNMENT SERVICE |
| 509215109 | Medicaid | MO |
Other providers in Potosi, MO
- Jennifer Gillam
- Allie Reshea Golden
- Gordon Goldman MD LLC
- Terra Renee Graves
- Kristie Lynn Gray
- Penny Kaye Grechus
- Greenlee Chiropractic Inc.
- Gary Lynn Greenlee Jr.
- Steven John Grouse
- Terry Guiley
All providers in Potosi, MO · Federally Qualified Health Center (FQHC) in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 23, 2009. 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.