Jefferson Medical Group
Organization Active NPI Rural Health Clinic/Center · Carrollton, MO
NPI 1619276367 · NPPES record last updated Oct 29, 2021
Key facts
- NPI
- 1619276367
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 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
- Organization subpart
- No
Authorized official
- Name
- Amy Danielle Ireland
- Title
- Cfo
- Phone
- (660) 329-6005
Owners & managing parties with NPI records 3
-
Jennifer Rose Poston, O.D.
Other NPIs with the same Medicare PAC ID 3
Corporate family (same tax ID) 2
Member of 1
Related certifications (CCN) 1
Facilities with the same owner 3
Practitioners 10
-
Cynthia Lynne Cauble, LCSW
-
Andrew Douglas Horine, D.O.
-
Heidi L Leimkuehler, APRN, FNP-C
-
Trent Link, FNP
-
Pamela Lynn Ralls, M.D.
-
Richard Lee Smith, M.D.
-
Tara Lyrae Swan, APN
-
Marcanthony H Morgan, APRN FNP-C
-
Amy North, D.O.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
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
- Other · Non-profit
- Enrollment address
- 1502 N Jefferson St
Carrollton, MO 64633-1948 - Related CCNs
- 261332
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Timothy N Reid |
Corporate Officer |
Jan 1, 2021 | |
| Janice Burnside |
Corporate Officer |
Oct 1, 2025 | |
| Jennifer Link |
Corporate Officer |
Oct 1, 2025 | |
| Charles Riley |
Corporate Director |
Oct 1, 2025 | |
| W-2 Managing Employee |
Oct 1, 2025 | ||
| Carroll County Memorial Hospital |
5% Or Greater Direct Ownership Interest | Jan 1, 1966 | 100% |
| Anna Barlow |
Corporate Officer |
Jan 1, 2021 | |
| Jennifer R Poston |
Corporate Officer |
Jan 1, 2021 | |
| Michael Schubach |
Corporate Director |
Oct 1, 2025 | |
| W-2 Managing Employee |
Oct 1, 2025 | ||
| Kenneth Brown |
Corporate Officer |
Oct 1, 2025 | |
| Matthew Lock |
Corporate Officer |
Jan 1, 2021 | |
| Tracey Woodward |
Corporate Officer |
Oct 1, 2025 | |
| George Thomas Burkhart |
Corporate Officer |
Oct 1, 2025 | |
| Wade Mertensmeyer |
Corporate Officer |
Jan 1, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110512000274 | MO | Part a Provider - Rural Health Clinic | 6800894379 | Practice locations: Carrollton, MO |
National Provider Directory
- Tax ID family
- Carroll County Memorial Hospital
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 598993301 | Medicaid | MO |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | CCMHHIMDept@ccmhospital.cernerdirect.com | Carroll County Memorial Hospital |
Other providers in Carrollton, MO
- Tiffany M Horst
- Gregory William Hubbard
- Angela Imgarten
- James L Samples DDS ,PC
- Jefferson Medical Group
- Donald Leroy Kampschmidt
- Stefanie Leann Kissick
- Gay Lynn Korff
- Tanya Waddle Land
- Heidi L Leimkuehler
All providers in Carrollton, MO · Rural Health Clinic/Center in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 29, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.