NPIMap

Organization Active NPI

Coffey County Hospital

Doing business as Waverly Medical Clinic

  • Rural Health Clinic/Center
  • Waverly, KS
National Provider Identifier
1578645628
Registry record updated Jan 15, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COFFEY COUNTY HOSPITAL
Doing business as
Waverly Medical Clinic
Practice address
302 Pearson Ave
Waverly, KS 66871
Phone
(785) 733-2867
Fax
(785) 733-2143
NPI assigned
Oct 19, 2006
Last updated
Jan 15, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
COFFEY COUNTY HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 15, 2019

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

Authorized official

Name
Merri Michaels
Title
Billing Manager
Phone
(620) 364-2121

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X KS Primary

Addresses

Primary practice location

302 Pearson Ave
Waverly, KS 66871

Mailing address

PO Box 289
Burlington, KS 66839-0289
Phone (620) 364-5395

Other identifiers 1

IdentifierTypeStateIssuer
100098740DMedicaidKS

Other names 1

  • Waverly Medical Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070312000504 KS Part A Provider - Rural Health Clinic 4981598653 Practice locations: Waverly, KS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1578645628. Details of each certification follow.

Rural health clinic certification: CCN 173983

Legal name
COFFEY COUNTY HOSPITAL
Doing business as
WAVERLY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 16, 1991
Last certification
Feb 21, 2017
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Enrollment address
302 Pearson Ave
Waverly, KS 66871-9676
Related CCNs
170094

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Cusick Edward K DO9 organizations share this tax ID, including this one
Part of
Cusick Edward K DO

Other organizations with this tax ID 8

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.

  • County of Coffey

    dba Coffey Co Health Dept

    • State or Local Public Health Clinic/Center
    • Burlington, KS
    • NPI 1285731406

    Member Of

    NPD member

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Peter Allegre Individual Corporate DirectorBoard Secretary Jan 1, 2013
Operational/Managerial ControlBoard Secretary Jan 1, 2013
Perry Dale Chapman Individual Corporate DirectorBoard Treasurer Dec 19, 2022
Operational/Managerial ControlBoard Treasurer Dec 19, 2022
Stacy Nicole Augustyn Individual Corporate OfficerCoo Jul 1, 2022
W-2 Managing EmployeeCoo Jul 1, 2022
Jodi Lynn Thomas Individual Corporate DirectorBoard Member Jan 1, 2017
Operational/Managerial ControlBoard Member Jan 1, 2017
Michael Paul Abendroth Individual Corporate DirectorBoard Member Dec 27, 2023
Operational/Managerial ControlBoard Member Dec 27, 2023
Coffey County Hospital Organization, Burlington, KS Operational/Managerial Control Apr 16, 1991 100%
Stephen Craig Hopkins Individual Corporate DirectorBoard Chair Jan 1, 2014
Operational/Managerial ControlBoard Chair Jan 1, 2014
Eric Russell Ervin Individual Corporate DirectorBoard Member Jan 2, 2024
Operational/Managerial ControlBoard Member Jan 2, 2024
Joben Rieth Individual Corporate OfficerCeo Jan 29, 2022 100%
W-2 Managing EmployeeCeo Jan 29, 2022 100%
Jeff Blair Clark Individual Corporate DirectorBoard Vice Chair Jan 1, 2016
Operational/Managerial ControlBoard Member Jan 1, 2016
County of Coffey Organization, Burlington, KS 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%
John R Shell Individual Corporate OfficerChief Medical Officer Feb 1, 2014
W-2 Managing EmployeeChief Medical Officer Feb 7, 2014
Robert Melvin Fleming Individual Corporate DirectorBoard Member Jan 2, 2024
Operational/Managerial ControlBoard Member Jan 2, 2024
Arden Wayne Payer Individual Corporate DirectorBoard Member Jan 2, 2024
Operational/Managerial ControlBoard Member Jan 2, 2024

Owners & managing parties with NPI records 8

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Coffey County HospitalBurlington, KS, CCN 171385 Hospital Operational/Managerial Control (100%) Jan 1, 1966
Coffey County HospitalBurlington, KS, CCN 17Z385 Hospital Other (100%) Jan 1, 2017
Coffey County Medical Center RHCBurlington, KS, CCN 173982 Rural health clinic 5% Or Greater Direct Ownership Interest (75%) Jan 1, 1966
Yates Center Medical Center Rural Health ClinicYates Center, KS, CCN 178559 Rural health clinic Operational/Managerial Control (100%) Jul 18, 2018

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 4

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

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": "1161216000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547510400000",
    "number": "1578645628",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 289",
            "city": "BURLINGTON",
            "state": "KS",
            "postal_code": "668390289",
            "telephone_number": "620-364-5395",
            "fax_number": "620-364-8719"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "302 PEARSON AVE",
            "city": "WAVERLY",
            "state": "KS",
            "postal_code": "66871",
            "telephone_number": "785-733-2867",
            "fax_number": "785-733-2143"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COFFEY COUNTY HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COFFEY COUNTY HOSPITAL",
        "enumeration_date": "2006-10-19",
        "last_updated": "2019-01-15",
        "status": "A",
        "authorized_official_last_name": "MICHAELS",
        "authorized_official_first_name": "MERRI",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "620-364-2121"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "KS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100098740D",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waverly Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Waverly Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waverly, KS

Sources for this page

Verify at the official NPI Registry.