NPIMap

Organization Active NPI

Mosaic Medical Center - Maryville

Doing business as Mosaic Specialty Care - East

  • Rural Health Clinic/Center
  • Maryville, MO
National Provider Identifier
1598239790
Registry record updated Jun 10, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MOSAIC MEDICAL CENTER - MARYVILLE
Doing business as
Mosaic Specialty Care - East
Practice address
114 E South Hills Dr
Maryville, MO 64468-2659
Phone
(660) 562-2525
Fax
(660) 562-4303
NPI assigned
Jan 22, 2019
Last updated
Jun 10, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2019

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

Authorized official

Name
Dwight R Carvell
Title
Director of Reimburement
Phone
(816) 273-0473

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Nurse Practitioner 363LF0000X NU
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU
Pediatrics Physician 208000000X NU
Psychiatry Physician 2084P0800X NU

Addresses

Primary practice location

114 E South Hills Dr
Maryville, MO 64468-2659

Mailing address

114 E South Hills Dr
Maryville, MO 64468-2659
Phone (660) 562-2525

Other names 1

  • Mosaic Specialty Care - East Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190402000695 MO Part A Provider - Rural Health Clinic 3678813896 Practice locations: Maryville, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1598239790. Details of each certification follow.

Rural health clinic certification: CCN 268542

Legal name
MOSAIC MEDICAL CENTER - MARYVILLE
Doing business as
MOSAIC SPECIALTY CARE - EAST
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 17, 2002
Last certification
Dec 6, 2023
Ownership / control type
2B
Most recent change of ownership
Apr 1, 2019 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Oct 12, 2018 in MO
Enrollment address
114 E South Hills Dr
Maryville, MO 64468-2659
Related CCNs
260050

Other NPIs with the same Medicare PAC ID 7

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

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
26D0444865Mosaic Specialty Care - East114 East South Hills Drive, Maryville, MO 64468Certificate of waiverAug 13, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mosaic Medical Center - Maryville4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

5325 Faraon St
Ste A
Saint Joseph, MO 64506

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Nathan James Blackford Individual Corporate OfficerPresident Feb 24, 2020
Davin G Turner Individual Corporate DirectorVice Chair Apr 1, 2019
Renee Hayes Individual W-2 Managing EmployeeSenior Net Revenue Analyst Sep 24, 2020
Dwight Carvell Individual Corporate DirectorDirector of Reimbursement Dec 28, 2021
Rachael Praiswater Individual W-2 Managing EmployeeProvider Enrollment Specialist Sep 28, 2020
Mosaic Health System Organization, Saint Joseph, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Apr 1, 2019 100%
Cynthia G Patterson Individual W-2 Managing EmployeeManaged Care Analyst Apr 1, 2019
Serena Naylor Individual Corporate DirectorBoard Member Apr 1, 2019

Owners & managing parties with NPI records 1

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

Facilities with the same owner 15

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

View all 15

Change-of-ownership history 1

DateEventCounterparty
Apr 1, 2019 Change of OwnershipThis provider was the buyer SSM Health Medical GroupCCN 268542, MO, NPI 1942267547

NPI Registry JSON

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

{
    "created_epoch": "1548115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560124800000",
    "number": "1598239790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "114 E SOUTH HILLS DR",
            "city": "MARYVILLE",
            "state": "MO",
            "postal_code": "644682659",
            "telephone_number": "660-562-2525",
            "fax_number": "660-562-4303"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "114 E SOUTH HILLS DR",
            "city": "MARYVILLE",
            "state": "MO",
            "postal_code": "644682659",
            "telephone_number": "660-562-2525",
            "fax_number": "660-562-4303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOSAIC MEDICAL CENTER - MARYVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-01-22",
        "last_updated": "2019-06-10",
        "status": "A",
        "authorized_official_last_name": "CARVELL",
        "authorized_official_first_name": "DWIGHT",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "DIRECTOR OF REIMBUREMENT",
        "authorized_official_telephone_number": "816-273-0473"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mosaic Specialty Care - East",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maryville, MO

Sources for this page

Verify at the official NPI Registry.