NPIMap

Organization Active NPI

Community Hospital Association

Doing business as Community Hospital-Fairfax

  • Rural Health Clinic/Center
  • Rock Port, MO
National Provider Identifier
1396741302
Registry record updated Dec 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COMMUNITY HOSPITAL ASSOCIATION
Doing business as
Community Hospital-Fairfax
Rock Port Family Medicine
Practice address
100 E Cass St
Rock Port, MO 64482-1528
Phone
(660) 744-5361
Fax
(660) 744-2247
NPI assigned
Jun 23, 2005
Last updated
Dec 18, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2020

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

Authorized official

Name
Jon P Davis
Title
Cfo
Phone
(660) 686-2320

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X MO
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

100 E Cass St
Rock Port, MO 64482-1528

Mailing address

100 E Cass Street
Rock Port, MO 64482-1528
Phone (660) 744-5361

Other identifiers 2

IdentifierTypeStateIssuer
505428102MedicaidMO
29516017OtherMOBCBS KANSAS CITY MO

Other names 2

  • Community Hospital-Fairfax Doing business as
  • Rock Port Family Medicine Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050321000427 MO Part B Supplier - Clinic/Group Practice 1557316783 Receives reassigned benefits from 8 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fairfax, MO; Tarkio, MO; Rock Port, MO; Oregon, MO; Mound City, MO
O20190926001338 MO Part A Provider - Rural Health Clinic 1557316783 Practice locations: Rock Port, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396741302. Details of each certification follow.

Rural health clinic certification: CCN 268779

Legal name
COMMUNITY HOSPITAL ASSOCIATION
Doing business as
ROCK PORT FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 11, 2020
Last certification
May 11, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
100 E Cass St
Rock Port, MO 64482-1528
Related CCNs
261303

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

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 6

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

National Provider Directory

National Provider Directory
Tax ID family
Fairfax Community Hosp9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

26136 US Highway 59
#107
Fairfax, MO 64446
Phone (660) 686-2211

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Rebecca Ann Schlueter Individual Corporate OfficerCeo Oct 1, 2025
W-2 Managing EmployeeAd; Oct 1, 2025
Susan Noland Individual Corporate DirectorBoard Member Jul 1, 2018
Corey K. Herron Individual Corporate DirectorBoard Member Feb 25, 2014
Teresa Smith Individual Corporate DirectorBoard Member Jul 1, 2021
Virginia B Low Individual Corporate DirectorVice President Board of Directors Jul 1, 2012
Richard a Burke Individual Corporate DirectorChief of Medical Staff/Medical Dire Jul 1, 2007
Nebraska Medical Center Organization, Omaha, NE Corporation, Non-profit Operational/Managerial Control Jul 1, 2017
Timothy L Umbarger Individual Corporate DirectorChairman of the Board Jul 1, 2018
Tabitha F Wintz Individual Corporate DirectorDirector of Patient Financial Servi Sep 13, 2014
Rebekah Gebhards Individual Corporate DirectorBoard Member Jul 1, 2018
Garrett Wood Individual Corporate DirectorBoard Member Jul 1, 2018
Jon Phillip Davis Individual Corporate OfficerCfo Apr 1, 2015
Thomas Bullock Individual Corporate DirectorBoard Member Jul 1, 2021
Glenn R. Scott Individual Corporate DirectorBoard Member Jul 1, 2014

Owners & managing parties with NPI records 8

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
South Holt Family MedicineOregon, MO, CCN 268753 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jan 5, 2016
Jan 5, 2016
Mound City Family MedicineMound City, MO, CCN 268755 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jan 5, 2016
Jan 5, 2016
Tarkio Family MedicineTarkio, MO, CCN 268771 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jul 1, 2017
Jul 1, 2017
Fairfax Family MedicineFairfax, MO, CCN 268770 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Oct 3, 2018
Oct 3, 2018

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 8

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

Practitioners & affiliated clinicians

Practitioners 14

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.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1119484800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608249600000",
    "number": "1396741302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 E CASS STREET",
            "city": "ROCK PORT",
            "state": "MO",
            "postal_code": "644821528",
            "telephone_number": "660-744-5361",
            "fax_number": "660-744-2247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 E CASS ST",
            "city": "ROCK PORT",
            "state": "MO",
            "postal_code": "644821528",
            "telephone_number": "660-744-5361",
            "fax_number": "660-744-2247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HOSPITAL ASSOCIATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-23",
        "last_updated": "2020-12-18",
        "certification_date": "2020-12-18",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "660-686-2320"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "505428102",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS KANSAS CITY MO",
            "identifier": "29516017",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Hospital-Fairfax",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Community Hospital-Fairfax",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Rock Port Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rock Port, MO

Sources for this page

Verify at the official NPI Registry.