NPIMap

Organization Active NPI

Medstop One Inc

  • Clinic/Center
  • Cape Girardeau, MO
National Provider Identifier
1417959149
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
MEDSTOP ONE INC
Practice address
3065 William St
Suite 209
Cape Girardeau, MO 63703-6393
Phone
(573) 335-4100
Fax
(573) 339-7887
NPI assigned
Aug 12, 2005
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

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

Authorized official

Name
David J. Cantrell
Title
Business Manager
Phone
(573) 335-4100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X MO Primary

Addresses

Primary practice location

3065 William St
Suite 209
Cape Girardeau, MO 63703-6393

Mailing address

3065 William St
Ste 209
Cape Girardeau, MO 63703-6393
Phone (573) 335-4100

Other identifiers 3

IdentifierTypeStateIssuer
593915200MedicaidMO
175986OtherMOHEALTHLINK
218453OtherMOBLUE CROSS

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20030711000041 MO Part A Provider - Rural Health Clinic 6800706797 Practice locations: Cape Girardeau, MO
O20051201000775 MO Part B Supplier - Clinic/Group Practice 6800706797 Receives reassigned benefits from 5 practitioners
Practice locations: Cape Girardeau, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1417959149. Details of each certification follow.

Rural health clinic certification: CCN 263889

Legal name
MEDSTOP ONE INC
Doing business as
N/A
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 16, 1998
Last certification
Oct 23, 2024
Ownership / control type
1A
Organization structure
CorporationProprietary
Incorporated
Aug 12, 1997 in MO
Enrollment address
3065 William St
Ste 209
Cape Girardeau, MO 63703-6373

National Provider Directory

National Provider Directory

Locations

3065 William St
Ste 209
Cpe Girardeau, MO 63703
Phone (573) 335-1779

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
JSSD LLC Organization, Cape Girardeau, MO Created for acquisition, LLC 5% Or Greater Direct Ownership Interest Feb 4, 2008 100%
Stacey L Cantrell Individual 5% Or Greater Direct Ownership InterestBilling Administrator Apr 1, 2008 50%
W-2 Managing Employee Apr 1, 2008 50%
David Cantrell Individual 5% Or Greater Direct Ownership Interest Apr 11, 2008 50%
W-2 Managing EmployeeAd; Apr 11, 2008 50%

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1123804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1417959149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3065 WILLIAM ST",
            "address_2": "STE 209",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637036393",
            "telephone_number": "573-335-4100",
            "fax_number": "573-339-7887"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3065 WILLIAM ST",
            "address_2": "SUITE 209",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637036393",
            "telephone_number": "573-335-4100",
            "fax_number": "573-339-7887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDSTOP ONE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-12",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "CANTRELL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "573-335-4100"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "593915200",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHLINK",
            "identifier": "175986",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "218453",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cape Girardeau, MO

Sources for this page

Verify at the official NPI Registry.