NPIMap

Organization Active NPI

Community Health Centers of Southeastern Iowa, Inc

Doing business as Tri-State Medical Group Inc

  • Federally Qualified Health Center (FQHC)
  • Keokuk, IA
National Provider Identifier
1558340968
Registry record updated Jul 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA, INC
Doing business as
Tri-State Medical Group Inc
Practice address
400 N 17TH St
Keokuk, IA 52632-3452
Phone
(319) 524-5734
Fax
(319) 524-5758
NPI assigned
Jan 13, 2006
Last updated
Jul 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 15, 2024

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

Authorized official

Name
Mr. Antonio Flores, CEO
Title
Ceo
Phone
(319) 768-5858

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

400 N 17TH St
Keokuk, IA 52632-3452

Mailing address

1706 West Agency Road
West Burlington, IA 52655
Phone (319) 768-5858

Other practice location 1

1618 Main St
Keokuk, IA 52632-3928
Phone (319) 524-5734

Other identifiers 3

IdentifierTypeStateIssuer
506089408MedicaidMO
33624OtherIABLUE CROSS BLUE SHIELD
0278374MedicaidIA

Other names 1

  • Tri-State Medical Group Inc Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20021216000023 IA Part A Provider - Federally Qualified Health Center (FQHC) 4486562527 Practice locations: Keokuk, IA
O20040219000446 IA Part B Supplier - Clinic/Group Practice 4486562527 Receives reassigned benefits from 40 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Burlington, IA; Columbus City, IA; Keokuk, IA; West Burlington, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558340968. Details of each certification follow.

Federally qualified health center certification: CCN 161816

Legal name
COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 23, 2002
Last certification
Dec 23, 2002
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 29, 2001 in IA
Enrollment address
400 N 17TH St
Keokuk, IA 52632-3452

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory

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
Suzanne Sorensen Individual Corporate DirectorBoard Member May 28, 2020
William Staats Individual Corporate Director Jul 1, 2004
David Haden Individual Corporate DirectorBoard Member Jan 26, 2023
Joseph Douglas Individual Corporate DirectorBoard Member Apr 25, 2024
Julie a Schilling Individual Corporate Director Nov 1, 2011
Delaney Richards Individual Corporate DirectorBoard Member Jan 26, 2023
Misty Cale Individual Corporate DirectorBoard Member Dec 18, 2025
Dennis Fitzgibbon Individual Corporate DirectorBoard Member Jun 26, 2025
David Selmon Individual Corporate DirectorBoard Member Sep 27, 2021
William Grimm Individual Corporate OfficerCeo Aug 1, 2024
W-2 Managing EmployeeCeo Aug 1, 2024
Operational/Managerial ControlCeo Aug 1, 2024
Samuel Klein Individual Corporate DirectorBoard Member Jun 26, 2025
Jeffrey Strause Individual Corporate Director Jan 25, 2018
Chuck Griffin Individual Corporate Director Aug 22, 2013

Practitioners & affiliated clinicians

Practitioners 3

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": "1137110400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721001600000",
    "number": "1558340968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1706 WEST AGENCY ROAD",
            "city": "WEST BURLINGTON",
            "state": "IA",
            "postal_code": "52655",
            "telephone_number": "319-768-5858",
            "fax_number": "319-753-2301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 N 17TH ST",
            "city": "KEOKUK",
            "state": "IA",
            "postal_code": "526323452",
            "telephone_number": "319-524-5734",
            "fax_number": "319-524-5758"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1618 Main St",
            "address_purpose": "LOCATION",
            "city": "Keokuk",
            "state": "IA",
            "postal_code": "526323928",
            "country_code": "US",
            "telephone_number": "319-524-5734",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-13",
        "last_updated": "2024-07-15",
        "certification_date": "2024-07-15",
        "status": "A",
        "authorized_official_last_name": "FLORES",
        "authorized_official_first_name": "ANTONIO",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "319-768-5858",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "506089408",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "33624",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0278374",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri-State Medical Group Inc",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Tri-State Medical Group Inc",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Keokuk, IA

Sources for this page

Verify at the official NPI Registry.