Northeast Mississippi Health Care, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Mt. Pleasant, MS
NPI 1386792992 · NPPES record last updated Nov 17, 2010
Key facts
- NPI
- 1386792992
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- NORTHEAST MISSISSIPPI HEALTH CARE, INC.
- Practice address
- 154 Mt. Pleasant Road
Mt. Pleasant, MS 38649 - Phone
- (662) 851-7939
- Fax
- (662) 851-9053
- NPI assigned
- Jan 8, 2007
- Organization subpart
- No
Authorized official
- Name
- Mrs. Marjorie P. McKinney
- Title
- Executive Director
- Phone
- (662) 838-2163
Owners & managing parties with NPI records 1
-
Clifton Rodgers, M.D.
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 3
Related certifications (CCN) 1
Practitioners 13
-
Teresa Crockett, FNP
-
Ellouise Marie Knox, FNP
-
Nikisha Newsom, FNP
-
Raquel Janay Reed-Washington, FNP-C
-
Chassity W Greer, FNP-C
-
Clifton Rodgers, M.D.
-
Chrystal Williams-Davis, FNP-BC
-
Annabelle D. Cabe, M.D.
-
Mark Eason Gilbert, DDS
-
Jasmine Monique Mack, DDS
-
Joseph Hogue, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0884513 | Mt Pleasant Family Health Clinic | Certificate of waiver | Mar 31, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251848
- Legal name
- NORTHEAST MISSISSIPPI HEALTH CARE INC
- Doing business as
- MT. PLEASANT FAMILY HEALTH CLINC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Apr 1, 1995
- Last certification
- Apr 1, 1995
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 18, 1979 in MS
- Enrollment address
- 154 Old Mt Pleasant Rd
Mt Pleasant, MS 38635 - Related CCNs
- 251817
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Albert Lay |
Corporate Director | Dec 3, 2010 | |
| Adolphus Shipp |
Corporate Director | Dec 3, 2010 | |
| Lesley L Sigman |
Corporate Director | Dec 3, 2010 | |
| Terry H Sanderson |
Corporate Director | Dec 3, 2010 | |
| Annie M Jamison |
Corporate Director | Dec 3, 2010 | |
| William D Fitts |
Corporate Director | Dec 3, 2010 | |
| Janette W Jones |
Corporate Director | Dec 3, 2010 | |
| Felecia a Harvell |
Corporate Director | Dec 3, 2010 | |
| Lizzie J Blackmond |
Corporate Director | Dec 3, 2010 | |
| Bobby G Rice |
Corporate Director | Dec 3, 2010 | |
| Clifton Rodgers |
5% Or Greater Indirect Ownership Interest | Oct 1, 2011 | |
| Corporate Director |
Oct 1, 2011 | ||
| W-2 Managing Employee | Oct 1, 2011 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040602001469 | MS | Part B Supplier - Clinic/Group Practice | 5294717377 |
Receives reassigned benefits from 13 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Byhalia, MS; Mt Pleasant, MS; Southaven, MS |
| O20101201000541 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 5294717377 | Practice locations: Mt Pleasant, MS |
National Provider Directory
- Tax ID family
- NE Ms HLTH Care Flu Dem
Locations
7535 Airways Blvd
Ste 101
Southaven, MS 38671
Phone (662) 349-6220
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/HECABD
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
154 Mt. Pleasant Road
Mt. Pleasant, MS 38649
Mailing address
12 East Brunswick Ave.
P.O. Box 698
Byhalia, MS 38611
Phone (662) 851-7939
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9015490 | Medicaid | MS |
Other names
- Mt. Pleasant Family Health Clinic
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 17, 2010. 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.