NPIMap

Organization Active NPI

Phelps County Regional Medical Center

Doing business as Phelps Health Medical Group Waynesville

  • Rural Health Clinic/Center
  • Waynesville, MO
National Provider Identifier
1447430574
Registry record updated Feb 2, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PHELPS COUNTY REGIONAL MEDICAL CENTER
Doing business as
Phelps Health Medical Group Waynesville
Practice address
1000 GW Lane
Waynesville, MO 65583-5401
Phone
(573) 774-2715
Fax
(573) 774-2792
NPI assigned
Nov 6, 2007
Last updated
Feb 2, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 2, 2023

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

Authorized official

Name
Jana Marie Cook
Title
Cfo/Sr. VP
Phone
(573) 458-7916

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X MO Primary
Pediatrics Physician 208000000X 2007024375 MO

Addresses

Primary practice location

1000 GW Lane
Waynesville, MO 65583-5401

Mailing address

PO Box 579
Rolla, MO 65402-0579
Phone (573) 426-2182

Other identifiers 1

IdentifierTypeStateIssuer
596499509MedicaidMO

Other names 1

  • Phelps Health Medical Group Waynesville Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230410000480 MO Part A Provider - Rural Health Clinic 2860391158 Practice locations: Waynesville, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1447430574. Details of each certification follow.

Rural health clinic certification: CCN 268796

Legal name
PHELPS COUNTY REGIONAL MEDICAL CENTER
Doing business as
PHELPS HEALTH WAYNESVILLE MEDICAL PLAZA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 1, 2023
Last certification
Oct 3, 2023
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
1000 GW LN
Waynesville, MO 65583-2339
Related CCNs
260017

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).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
26D1084926Phelps Health1000 GW Lane, Waynesville, MO 65583Provider-performed microscopyOct 17, 2026
26D2097292Phelps Health Waynesville1000 GW Lane Suite 115, Waynesville, MO 65583Certificate of waiverJun 10, 2027

National Provider Directory

National Provider Directory
Tax ID family
The Center Clinic10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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.

Locations

1050 W 10th St
Ste 510
Rolla, MO 65401
Phone (573) 426-2229

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Phelps County Clerk Organization, Rolla, MO Operational/Managerial Control Nov 12, 2007
Ben Tipton Individual Corporate DirectorDirector Apr 26, 2024
Jason Shenefield Individual Corporate DirectorCeo Jul 22, 2021
W-2 Managing EmployeeCeo Jul 22, 2021
Richard Elgin Individual Corporate DirectorDirector Apr 1, 2023
Kimberley Bruno Individual Corporate DirectorAssociate Vice President, Rev Cycle Aug 26, 2022
W-2 Managing EmployeeAssociate Vice President, Rev Cycle Aug 26, 2022
Brittany Roth Individual Corporate DirectorDirector, Contracting & Enrollment Aug 26, 2022
W-2 Managing EmployeeDirector, Contracting & Enrollment Aug 26, 2022
Jana M Cook Individual Corporate DirectorCfo/Sr. VP Jul 31, 2021
W-2 Managing EmployeeCfo/Sr. VP Jul 31, 2021
Janece Martin Individual Corporate DirectorBoard Member May 6, 2022
Mary V. Graham Individual Corporate DirectorDirector Apr 23, 2026
Annie Bass Individual Corporate DirectorBoard Member May 6, 2022

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Phelps Health Home Health & HospiceRolla, MO, CCN 267555 Home health agency 5% Or Greater Direct Ownership Interest (100%) Jun 11, 1998
Phelps Health Home Health & HospiceRolla, MO, CCN 261583 Hospice 5% Or Greater Direct Ownership Interest (100%) Jun 11, 1998
Phelps Health Medical Group ViennaVienna, MO, CCN 268908 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) May 1, 2007

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 6

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

Practitioners & affiliated clinicians

Practitioners 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1194307200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675296000000",
    "number": "1447430574",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 579",
            "city": "ROLLA",
            "state": "MO",
            "postal_code": "654020579",
            "telephone_number": "573-426-2182",
            "fax_number": "573-426-5341"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 GW LANE",
            "city": "WAYNESVILLE",
            "state": "MO",
            "postal_code": "655835401",
            "telephone_number": "573-774-2715",
            "fax_number": "573-774-2792"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHELPS COUNTY REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-06",
        "last_updated": "2023-02-02",
        "certification_date": "2023-02-02",
        "status": "A",
        "authorized_official_last_name": "COOK",
        "authorized_official_first_name": "JANA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CFO/SR. VP",
        "authorized_official_telephone_number": "573-458-7916"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": null,
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MO",
            "license": "2007024375",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "596499509",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Phelps Health Medical Group Waynesville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waynesville, MO

Sources for this page

Verify at the official NPI Registry.