NPIMap

Organization Active NPI

Douglas County Public Health Services Group, Inc.

Doing business as Missouri Ozarks Community Health

  • Federally Qualified Health Center (FQHC)
  • Mountain Grove, MO
National Provider Identifier
1518342153
Registry record updated Sep 2, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
Missouri Ozarks Community Health
Practice address
1604 C. North Main Street
Mountain Grove, MO 65711
Phone
(417) 926-1713
Fax
(417) 926-1209
NPI assigned
Jul 24, 2015
Last updated
Sep 2, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 2, 2015

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

Authorized official

Name
Tim Shryack
Title
Ceo
Phone
(417) 683-4831

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

1604 C. North Main Street
Mountain Grove, MO 65711

Mailing address

PO Box 1359
Ava, MO 65608-1359
Phone (417) 683-4831

Other names 1

  • Missouri Ozarks Community Health Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050301000128 MO Part B Supplier - Clinic/Group Practice 3072423052 Receives reassigned benefits from 33 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ava, MO; Theodosia, MO; Mountain Grove, MO; Mansfield, MO; Licking, MO; Houston, MO; Gainesville, MO; Cabool, MO
O20150828000981 MO Part A Provider - Federally Qualified Health Center (FQHC) 3072423052 Practice locations: Mountain Grove, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1518342153. Details of each certification follow.

Federally qualified health center certification: CCN 261110

Legal name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
MISSOURI OZARKS COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 2, 2015
Last certification
Sep 2, 2015
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
1604 C N Main St
Mountain Grove, MO 65711-1010

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 9

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

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
26D2099962Missouri Ozarks Community Health1604 C North Main Street, Mountain Grove, MO 65711Provider-performed microscopySep 30, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Bart Ellison Individual Corporate OfficerBoard Member Sep 17, 2014 8%
Aaron Dalton Individual Corporate OfficerBoard Member Apr 21, 2021 10%
Ronald Scheets Individual Corporate OfficerBoard Member Jun 12, 2013 8%
Rhonda Suter Individual Corporate OfficerBoard Chair Apr 9, 2001 8%
Carol Cunningham Individual Corporate OfficerBoard Member Feb 19, 1998 10%
Tim Shryack Individual Corporate DirectorCeo Jun 17, 2013 100%
Donald Pinckney Individual Corporate OfficerBoard Vice Chair Jan 30, 1997 10%
Ann Leonard Individual Corporate OfficerBoard Member Jul 15, 2020 10%
Jennifer D Heinlein Individual W-2 Managing EmployeeExect Assistant/Hro Jan 1, 2014 25%
Angel Wells Individual Corporate OfficerBoard Member May 18, 2022
Joe Golden Individual Corporate OfficerBoard Member Jul 21, 2021
Valerie Reece Individual Corporate OfficerBoard Secretary Aug 8, 2012 10%

Practitioners & affiliated clinicians

Practitioners 1

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": "1437696000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1441152000000",
    "number": "1518342153",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1359",
            "city": "AVA",
            "state": "MO",
            "postal_code": "656081359",
            "telephone_number": "417-683-4831"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1604 C. NORTH MAIN STREET",
            "city": "MOUNTAIN GROVE",
            "state": "MO",
            "postal_code": "65711",
            "telephone_number": "417-926-1713",
            "fax_number": "417-926-1209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-24",
        "last_updated": "2015-09-02",
        "status": "A",
        "authorized_official_last_name": "SHRYACK",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "417-683-4831"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Missouri Ozarks Community Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mountain Grove, MO

Sources for this page

Verify at the official NPI Registry.