NPIMap

Organization Active NPI

Carroll County Memorial Hospital

  • Critical Access Hospital
  • Carrollton, MO
National Provider Identifier
1528067113
Registry record updated Oct 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
210-45 Issued in MO
Legal business name
CARROLL COUNTY MEMORIAL HOSPITAL
Doing business as
Carroll County Memorial Hospital
Practice address
1502 N Jefferson St
Carrollton, MO 64633-1948
Phone
(660) 542-1695
Fax
(660) 542-0363
NPI assigned
Jul 18, 2005
Last updated
Oct 29, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2021

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

Authorized official

Name
Amy Danielle Ireland
Title
Cfo
Phone
(660) 329-6005

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 26Z332 MO
Medicare Defined Swing Bed Hospital Unit 275N00000X MO
Critical Access Hospital 282NC0060X 210-45 MO Primary

Addresses

Primary practice location

1502 N Jefferson St
Carrollton, MO 64633-1948

Mailing address

1502 N Jefferson
Carrollton, MO 64633-1948
Phone (660) 542-1695

Other identifiers 2

IdentifierTypeStateIssuer
010157907MedicaidMO
90017016OtherMOBCBS

Other names 1

  • Carroll County Memorial Hospital Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address CCMHHIMDept@ccmhospital.cernerdirect.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040407000120 MO Part B Supplier - Clinic/Group Practice 2860485638 Receives reassigned benefits from 84 practitioners
Practice locations: Carrollton, MO
O20061104000585 MO Part A Provider - Critical Access Hospital 2860485638 Receives reassigned benefits from 8 practitioners
Practice locations: Carrollton, MO
O20120419000092 MO Part A Provider - Critical Access Hospital 2860485638 Practice locations: Carrollton, MO

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1528067113. Details of each certification follow.

Hospital certification: CCN 261332

Legal name
CARROLL COUNTY MEMORIAL HOSPITAL
Doing business as
CARROLL COUNTY MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Nov 1, 2005
Last certification
Sep 13, 2023
Beds
25
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Enrollment address
1502 N Jefferson St
Carrollton, MO 64633-1948

Hospital certification: CCN 26Z332

Legal name
CARROLL COUNTY MEMORIAL HOSPITAL
Doing business as
CARROLL COUNTY MEMORIAL HOSPITAL
Organization structure
OtherNon-profit
Enrollment address
1502 N Jefferson St
Carrollton, MO 64633-1948

Facilities connected through Provider of Services related, parent or unit certification numbers.

Care Compare: Hospital

Medicare Care Compare
Listed as
Carroll County Memorial HospitalCCN 261332 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Member organizations 6

Organizations listed as members of this organization in the National Provider Directory.

Locations

1407 N Jefferson St
Carrollton, MO 64633
Phone (660) 542-1952

Interoperability endpoints

  • Direct secure messaging: tanyaland@ccmhospital.cernerdirect.com

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Timothy N Reid Individual Corporate OfficerBoard Member Jan 1, 2021
Janice Burnside Individual Corporate OfficerBoard Member Oct 1, 2025
Jennifer Link Individual Corporate OfficerBoard Member Oct 1, 2025
Charles Riley Individual Corporate DirectorChief Operating Officer Oct 1, 2025
W-2 Managing EmployeeChief Operating Officer Oct 1, 2025
Operational/Managerial ControlChief Operating Officer Oct 1, 2025
Anna Barlow Individual Corporate OfficerBoard Member Jan 1, 2021
Jennifer R Poston Individual Corporate OfficerBoard Member Jan 1, 2021
Michael Schubach Individual Corporate DirectorChief Human Resources Officer Oct 1, 2025
W-2 Managing EmployeeChief Human Resources Officer Oct 1, 2025
Operational/Managerial ControlChief Human Resources Officer Oct 1, 2025
Kenneth Brown Individual Corporate Officer Oct 1, 2025
Corporate OfficerBoard Member Oct 1, 2025
Matthew Lock Individual Corporate OfficerBoard Member Jan 1, 2021
Tracey Woodward Individual Corporate OfficerBoard Member Oct 1, 2025
George Thomas Burkhart Individual Corporate OfficerBoard Member Oct 1, 2025
Wade Mertensmeyer Individual Corporate OfficerBoard Member Jan 1, 2021
Carroll County Memorial Hospital Organization, Carrollton, MO 5% Or Greater Direct Ownership Interest May 10, 2011 100%

Owners & managing parties with NPI records 2

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
Jefferson Medical GroupCarrollton, MO, CCN 268666 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966
Jefferson Medical Group Hale ClinicHale, MO, CCN 268665 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966
Jefferson Medical GroupBrunswick, MO, CCN 268808 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2021

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 99

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 99

Affiliated clinicians 90

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 90

NPI Registry JSON

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

{
    "created_epoch": "1121644800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635465600000",
    "number": "1528067113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-1695",
            "fax_number": "660-542-0363"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON ST",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-1695",
            "fax_number": "660-542-0363"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CARROLL COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-18",
        "last_updated": "2021-10-29",
        "certification_date": "2021-10-29",
        "status": "A",
        "authorized_official_last_name": "IRELAND",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "DANIELLE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "660-329-6005"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "MO",
            "license": "26Z332",
            "primary": false
        },
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "MO",
            "license": null,
            "primary": false
        },
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "MO",
            "license": "210-45",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010157907",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "90017016",
            "state": "MO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "CCMHHIMDept@ccmhospital.cernerdirect.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1502 N Jefferson St",
            "city": "Carrollton",
            "state": "MO",
            "country_code": "US",
            "postal_code": "646331948",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Carroll County Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Carroll County Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Carrollton, MO

Sources for this page

Verify at the official NPI Registry.