NPIMap

Organization Active NPI

SSM Regional Health Services

Doing business as SSM Health Medical Group - Family Medicine

  • Family Medicine Physician
  • Jefferson City, MO
National Provider Identifier
1396886065
Registry record updated Dec 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SSM REGIONAL HEALTH SERVICES
Doing business as
SSM Health Medical Group - Family Medicine
Practice address
2511 W Edgewood Dr Ste G
Jefferson City, MO 65109-5869
Phone
(573) 761-0458
Fax
(573) 634-3137
NPI assigned
Feb 8, 2007
Last updated
Dec 16, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
SSM REGIONAL HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 16, 2025

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

Authorized official

Name
Shasta Rene Manuel
Title
Regional Vice President Finance/Cfo
Phone
(405) 272-7282

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

2511 W Edgewood Dr Ste G
Jefferson City, MO 65109-5869

Mailing address

7655 Solutions Ctr
Chicago, IL 60677-7006
Phone (557) 203-1551

Other identifiers 1

IdentifierTypeStateIssuer
507008803MedicaidMO

Other names 1

  • SSM Health Medical Group - Family Medicine Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070316000022 MO Part B Supplier - Clinic/Group Practice 8921917352 Receives reassigned benefits from 17 practitioners
1 other NPI on this enrollment
Practice locations: Jefferson City, MO

Other NPIs with the same Medicare PAC ID 12

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
SSM Regional Health Ser14 organizations share this tax ID, including this one
Part of
SSM Regional Health Ser

Other organizations with this tax ID 13

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

View all 13

Ownership & related parties

All facility ownership & control disclosures 8

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

FacilityTypeRoleSince
SSM Health St Marys Hospital Jefferson CityJefferson City, MO, CCN 260011 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2000
SSM Health Good Samaritan Hospital - Mt. VernonMount Vernon, IL, CCN 140046 Hospital 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015
SSM Health St. Mary's Hospital-CentraliaCentralia, IL, CCN 14S034 Hospital 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015
SSM Health St. Mary's Hospital - CentraliaCentralia, IL, CCN 140034 Hospital 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015
SSM Health Good Samaritan Hospital - Mt VernonMount Vernon, IL, CCN 14T046 Hospital 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2015
SSM Health Medical GroupCentralia, IL, CCN 783803 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2008
SSM Health Medical Group Family MedicineBelle, MO, CCN 268678 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Nov 16, 2014
SSM Health Medical Group Family MedicineTipton, MO, CCN 268703 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Dec 22, 1999

Owned or controlled facilities with NPI records 8

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

Practitioners & affiliated clinicians

Practitioners 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1170892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765843200000",
    "number": "1396886065",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7655 SOLUTIONS CTR",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606777006",
            "telephone_number": "557-203-1551",
            "fax_number": "314-989-6721"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2511 W EDGEWOOD DR STE G",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651095869",
            "telephone_number": "573-761-0458",
            "fax_number": "573-634-3137"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SSM REGIONAL HEALTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SSM REGIONAL HEALTH SERVICES",
        "enumeration_date": "2007-02-08",
        "last_updated": "2025-12-16",
        "certification_date": "2025-12-16",
        "status": "A",
        "authorized_official_last_name": "MANUEL",
        "authorized_official_first_name": "SHASTA",
        "authorized_official_middle_name": "RENE",
        "authorized_official_title_or_position": "REGIONAL VICE PRESIDENT FINANCE/CFO",
        "authorized_official_telephone_number": "405-272-7282"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "507008803",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Medical Group - Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "SSM Health Medical Group - Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jefferson City, MO

Sources for this page

Verify at the official NPI Registry.