Deaconess Clinic Inc
Organization Active NPI Rural Health Clinic/Center · Morganfield, KY
NPI 1467027664 · NPPES record last updated Aug 21, 2023
Key facts
- NPI
- 1467027664
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- DEACONESS CLINIC INC
- Practice address
- 1284 US Highway 60 W
Morganfield, KY 42437-6236 - Phone
- (270) 389-2323
- Fax
- (270) 389-0526
- NPI assigned
- May 21, 2021
- Organization subpart
- No
Authorized official
- Name
- Cheryl Annette Wathen
- Title
- Cfo
- Phone
- (812) 450-3296
Owners & managing parties with NPI records 13
-
Garrett Chase Koon, D.O.
-
Chris E Chacko, MD
-
Mia Souheil Hindi, M.D
-
Gary J Keepes, M.D.
-
Majed A Koleilat, MD
-
Dhruvin N Mehta, MD
-
Snesha H Modi, M.D.
-
Jamie L Mull, MD
-
Barry S Phillips, M.D.
-
Ashley Lynn Richeson, M.D.
-
William Robert Smith, M.D.
-
Jason F White, MD
Other NPIs on the same Medicare enrollment 31
Other NPIs with the same Medicare PAC ID 9
Corporate family (same tax ID) 21
Member of 1
Facilities with the same owner 28
Practitioners 413
-
William H Clapp, M.D.
-
Macy Lura Thompson Clevidence, APRN FNP-C
-
Karen Goldie, FNP-C
-
Paul C Adjei, M.D.
-
Jamie Nathan Andrews, M.D.
-
Sarah M Bickett, PA-C
-
Jamie Bisel, PA-C
-
Sal Blake, PA-C
-
Linda Boarman, ARNP
-
Kelly Shawn Brauer, M.D.
-
Crystal Cheri Buchanan, APRN
-
Kimberly Ann Burrow, APRN
-
Karen R Canlas, MD
-
Rachel Marie Carter, APRN
-
Christina Cole Chumley, APRN
-
Kelly L Cole, D.O.
-
Heather T. Davis, APRN
-
Yvonne Maddela Davis, A.R.N.P.
-
Leslie L Dunn, NP
-
Victoria Edwards, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D0326658 | Deaconess Morganfield Clinic RHC | Certificate of waiver | Jun 30, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in KY
Rural health clinic certification: CCN 183968
- Legal name
- DEACONESS CLINIC INC
- Doing business as
- DEACONESS CLINIC MORGANFIELD
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 1, 2023
- Last certification
- Oct 3, 2013
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 1, 2008 in IN
- Enrollment address
- 1284 US Highway 60 W
Morganfield, KY 42437-6236
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Mia Souheil Hindi |
Corporate Director |
Oct 1, 2015 | |
| Majed a Koleilat |
Corporate Director |
Oct 1, 2012 | |
| Garrett C Koon |
Corporate Director |
Oct 1, 2020 | |
| Ashley Lynn Richeson |
Corporate Director |
Oct 1, 2020 | |
| Renee Michelle Galen |
Corporate Director |
Oct 1, 2012 | |
| Deaconess Health System Inc |
5% Or Greater Direct Ownership Interest | Jul 1, 2008 | 100% |
| Snesha Modi |
Corporate Director |
Oct 1, 2020 | |
| William R Smith |
Corporate Director |
Oct 1, 2015 | |
| Jason F White |
Corporate Director |
Oct 1, 2022 | |
| Barry S Phillips |
Corporate Director |
Oct 1, 2015 | |
| Jamie L Mull |
Corporate Director |
Oct 1, 2021 | |
| Cheryl Wathen |
Corporate Officer |
Oct 1, 2012 | |
| Stephen T Titzer |
Corporate Director |
Oct 1, 2012 | |
| Shawn W McCoy |
Operational/Managerial Control |
Jan 1, 2012 | |
| Chris E Chacko |
Corporate Director |
Oct 1, 2019 | |
| Gary J Keepes |
Corporate Director |
Oct 1, 2019 | |
| Dhruvin Mehta |
Corporate Director |
Oct 1, 2022 |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| Jan 1, 2023 | Change of Ownership |
Deaconess Union County Morganfield |
| Jan 1, 2023 | Change of Ownership |
Deaconess Clinic Morganfield |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20081017000259 | KY | Part B Supplier - Clinic/Group Practice | 3375610116 |
Receives reassigned benefits from 190 practitioners 28 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Sebree, KY; Philpot, KY; Owensboro, KY; Morganfield, KY; Madisonville, KY; Henderson, KY; Dixon, KY |
| O20210811002781 | KY | Part B Supplier - Clinic/Group Practice | 5799189866 |
Receives reassigned benefits from 15 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Dixon, KY; Morganfield, KY |
| O20230202003269 | KY | Part a Provider - Rural Health Clinic | 3375610116 | Practice locations: Morganfield, KY |
National Provider Directory
- Tax ID family
- Deaconess Clinc Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes | ||
| Physician Assistant |
363A00000X | |||
| Nurse Practitioner |
363L00000X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
1284 US Highway 60 W
Morganfield, KY 42437-6236
Mailing address
PO Box 638705
Cincinnati, OH 45263-8705
Phone (270) 389-2323
Other names
- Deaconess Clinic Morganfield
Other providers in Morganfield, KY
- Macy Lura Thompson Clevidence
- Peter Pruitt Cohron
- Rachel L Creighton
- Michelle Daugherty
- Sarah Marie Day
- Deaconess Clinic, Inc
- Deaconess Clinic, Inc
- Deaconess Health Kentucky Inc
- Deaconess Hospital, Inc
- Deaconess Speciality Physicians, Inc
All providers in Morganfield, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 21, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.