NPIMap

Organization Active NPI

Southeast Health Center of Stoddard County, LLC

Doing business as Mercy Hospital Stoddard

  • Medicare Defined Swing Bed Hospital Unit
  • Dexter, MO
National Provider Identifier
1386802023
Registry record updated Jan 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
464-6 Issued in MO
Legal business name
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Doing business as
Mercy Hospital Stoddard
Practice address
1200 N One Mile Rd
Dexter, MO 63841-1000
Phone
(573) 624-5566
Fax
(573) 614-1966
NPI assigned
May 29, 2008
Last updated
Jan 13, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 13, 2024

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

Authorized official

Name
Krista Berry
Title
Cfo
Phone
(573) 331-6028

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 464-6 MO Primary

Addresses

Primary practice location

1200 N One Mile Rd
Dexter, MO 63841-1000

Mailing address

1200 N One Mile Rd
Dexter, MO 63841-1000
Phone (573) 624-5566

Other names 1

  • MERCY HOSPITAL STODDARD Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130226000036 MO Part A Provider - Hospital 7315192515 Practice locations: Dexter, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386802023. Details of each certification follow.

Hospital certification: CCN 26U160

Legal name
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
Doing business as
MERCY HOSPITAL STODDARD
Organization structure
LLCNon-profit
Incorporated
Nov 30, 2012 in MO
Enrollment address
1200 N One Mile Rd
Dexter, MO 63841-1000
Hospital Swing-Bed Unit
Hospital subgroups
Swing-bed approved

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

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Southeast Health County LLC9 organizations share this tax ID, including this one
Part of
Southeast Health County LLC

Other organizations with this tax ID 8

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Member organizations 3

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Carl E Ammons Individual Corporate OfficerCommunity President Jul 1, 2025
Brian Robison Individual Corporate OfficerSecretary Jul 30, 2025
Krista Berry Individual Corporate DirectorCfo Dec 20, 2023
W-2 Managing EmployeeCfo Jan 1, 2016
Marissa Mills Individual Corporate DirectorBoard Member Jul 1, 2025
Mark Avery Individual Corporate DirectorBoard Member Jul 1, 2025
Andrew Runge Individual Corporate DirectorBoard Member Jul 1, 2025
Stacie Farnam Individual W-2 Managing Employee Dec 20, 2023
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
Southeasthealth System Inc Organization, Cape Girardeau, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Aug 30, 2013 100%
Greg Mathis Individual Corporate DirectorBoard Member Jul 1, 2025
Michelle Aycock Individual Corporate DirectorBoard Member Jul 1, 2025
Southeast Hospital Organization, Cape Girardeau, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2013 100%
Reza T Jalal Individual Corporate DirectorBoard Member Jul 1, 2025
Mercy Health East Communities Organization, Saint Louis, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
Ryan Adams Individual Corporate DirectorBoard Member Jul 1, 2025
Southeasthealth Hospital Holdings, LLC Organization, Cape Girardeau, MO LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 2, 2013 100%
Brian Day Individual Corporate OfficerSenior Vice President Jul 30, 2025

Owners & managing parties with NPI records 4

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

Facilities with the same owner 117

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

View all 117

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1212019200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705104000000",
    "number": "1386802023",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 N ONE MILE RD",
            "city": "DEXTER",
            "state": "MO",
            "postal_code": "638411000",
            "telephone_number": "573-624-5566",
            "fax_number": "573-614-1966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 N ONE MILE RD",
            "city": "DEXTER",
            "state": "MO",
            "postal_code": "638411000",
            "telephone_number": "573-624-5566",
            "fax_number": "573-614-1966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC",
        "enumeration_date": "2008-05-29",
        "last_updated": "2024-01-13",
        "certification_date": "2024-01-13",
        "status": "A",
        "authorized_official_last_name": "BERRY",
        "authorized_official_first_name": "KRISTA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-331-6028"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "MO",
            "license": "464-6",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MERCY HOSPITAL STODDARD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dexter, MO

Sources for this page

Verify at the official NPI Registry.