NPIMap

Organization Active NPI

Winston Medical Clinic LLC

  • Rural Health Clinic/Center
  • Louisville, MS
National Provider Identifier
1629417324
Registry record updated Jan 19, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
WINSTON MEDICAL CLINIC LLC
Practice address
923 S Church Ave
Louisville, MS 39339
Phone
(662) 773-3503
Fax
(662) 446-1039
NPI assigned
Jun 17, 2013
Last updated
Jan 19, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2017

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

Authorized official

Name
Debbie J Fryery
Title
Director of Clinic Operations
Phone
(662) 446-1972

Specialties & licenses 1

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

Addresses

Primary practice location

923 S Church Ave
Louisville, MS 39339

Mailing address

P O Box 470
Louisville, MS 39339
Phone (662) 773-3503

Other identifiers 1

IdentifierTypeStateIssuer
01689827MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130827000842 MS Part B Supplier - Clinic/Group Practice 7214170968 Receives reassigned benefits from 12 practitioners
2 other NPIs on this enrollment
Practice locations: Noxapater, MS; Louisville, MS
O20131216000061 MS Part A Provider - Rural Health Clinic 7214170968 1 other NPI on this enrollment
Practice locations: Louisville, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629417324. Details of each certification follow.

Rural health clinic certification: CCN 258593

Legal name
WINSTON MEDICAL CLINIC LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 22, 2014
Last certification
Sep 21, 2021
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Nov 6, 2012 in MS
Enrollment address
17540 E Main St
Louisville, MS 39339-2772
Related CCNs
250027

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

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 2

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

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
25D1007731Winston Medical Clinic LLC17540 E Main St, Louisville, MS 39339ComplianceJul 28, 2028

National Provider Directory

National Provider Directory
Tax ID family
Winston Medical Clinic LLC3 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.

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Debbie Fryery Individual W-2 Managing EmployeeDirector of Clinic Operations Jul 13, 2015
Paul S. Black Individual Corporate DirectorCfo Jul 5, 2011 100%
W-2 Managing EmployeeCfo Jul 5, 2011 100%
Operational/Managerial ControlCfo Jul 5, 2011 100%
Winston County Medical Foundation Organization, Louisville, MS Non-profit 5% Or Greater Direct Ownership Interest Nov 6, 2012 100%
Operational/Managerial Control Nov 6, 2012 100%

Owners & managing parties with NPI records 5

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

Facilities with the same owner 6

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

Subparts reporting this organization as parent 3

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 12

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": "1371427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1484784000000",
    "number": "1629417324",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P O BOX 470",
            "city": "LOUISVILLE",
            "state": "MS",
            "postal_code": "39339",
            "telephone_number": "662-773-3503",
            "fax_number": "662-446-1039"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "923 S CHURCH AVE",
            "city": "LOUISVILLE",
            "state": "MS",
            "postal_code": "39339",
            "telephone_number": "662-773-3503",
            "fax_number": "662-446-1039"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WINSTON MEDICAL CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-17",
        "last_updated": "2017-01-19",
        "status": "A",
        "authorized_official_last_name": "FRYERY",
        "authorized_official_first_name": "DEBBIE",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "DIRECTOR OF CLINIC OPERATIONS",
        "authorized_official_telephone_number": "662-446-1972"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01689827",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Louisville, MS

Sources for this page

Verify at the official NPI Registry.