NPIMap

Organization Active NPI

Jefferson Medical Group

  • Rural Health Clinic/Center
  • Carrollton, MO
National Provider Identifier
1619276367
Registry record updated Oct 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JEFFERSON MEDICAL GROUP
Practice address
1502 N Jefferson St
Carrollton, MO 64633-1948
Phone
(660) 542-9998
Fax
(660) 542-9880
NPI assigned
Mar 21, 2011
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 1

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

Addresses

Primary practice location

1502 N Jefferson St
Carrollton, MO 64633-1948

Mailing address

1502 N Jefferson St
Carrollton, MO 64633-1948
Phone (660) 542-9998

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address CCMHHIMDept@ccmhospital.cernerdirect.com Carroll County Memorial Hospital

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110512000274 MO Part A Provider - Rural Health Clinic 6800894379 Practice locations: Carrollton, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619276367. Details of each certification follow.

Rural health clinic certification: CCN 268666

Legal name
JEFFERSON MEDICAL GROUP
Doing business as
JEFFERSON MEDICAL GROUP
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 27, 2011
Last certification
Sep 16, 2024
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
1502 N Jefferson St
Carrollton, MO 64633-1948
Related CCNs
261332

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

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Carroll County Memorial Hospital3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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.

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
Carroll County Memorial Hospital Organization, Carrollton, MO Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%
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
Kenneth Brown Individual 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

Owners & managing parties with NPI records 3

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

Facilities with the same owner 3

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

NPI Registry JSON

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

{
    "created_epoch": "1300665600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635465600000",
    "number": "1619276367",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1502 N JEFFERSON ST",
            "city": "CARROLLTON",
            "state": "MO",
            "postal_code": "646331948",
            "telephone_number": "660-542-9998",
            "fax_number": "660-542-9880"
        },
        {
            "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": "660-542-9998",
            "fax_number": "660-542-9880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-21",
        "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": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "CCMHHIMDept@ccmhospital.cernerdirect.com",
            "affiliation": "Y",
            "affiliationName": "Carroll County Memorial Hospital",
            "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": []
}

Other providers in Carrollton, MO

Sources for this page

Verify at the official NPI Registry.