NPIMap

Organization Active NPI

Douglas County Public Health Services Group, Inc.

  • Family Medicine Physician
  • Licking, MO
National Provider Identifier
1629639109
Registry record updated Jun 25, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Practice address
135 College Ave.
Licking, MO 65542
Phone
(417) 683-4831
NPI assigned
Jun 25, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2019

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

Authorized official

Name
Jennifer Heinlein
Title
Coo
Phone
(417) 683-4831

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

135 College Ave.
Licking, MO 65542

Mailing address

PO Box 1359
Ava, MO 65608-1359
Phone (417) 683-4831

Other names 1

  • Missouri Ozarks Community Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050301000128 MO Part B Supplier - Clinic/Group Practice 3072423052 Receives reassigned benefits from 33 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ava, MO; Theodosia, MO; Mountain Grove, MO; Mansfield, MO; Licking, MO; Houston, MO; Gainesville, MO; Cabool, MO
O20191118001202 MO Part A Provider - Federally Qualified Health Center (FQHC) 3072423052 Practice locations: Licking, MO

Federally qualified health center certification: CCN 261189

Legal name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
MISSOURI OZARKS COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 14, 2019
Last certification
Nov 14, 2019
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
135 College Ave
Licking, MO 65542-9878

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 9

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

National Provider Directory

National Provider Directory
Tax ID family
Douglas County Public Health Services Group Inc13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

Organizations that report the same tax identification number in 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
Bart Ellison Individual Corporate DirectorBoard Member Sep 10, 2014 10%
Randall Gann Individual Corporate DirectorCeo Sep 1, 2024 100%
Operational/Managerial ControlCeo Sep 1, 2024 100%
Wesley Davis Individual Corporate DirectorBoard Member Sep 19, 2022 10%
Aaron Gerla Individual Corporate DirectorBoard Member Nov 20, 2024 10%
Aaron Dalton Individual Corporate DirectorBoard Member Apr 21, 2021 10%
Ronald Scheets Individual Corporate DirectorBoard Member Jun 1, 2013 10%
Rhonda Suter Individual Corporate DirectorBoard Chair Sep 19, 2001 10%
Carol Cunningham Individual Corporate DirectorBoard Member Feb 16, 1998 10%
Donald Pinckney Individual Corporate DirectorBoard Member Jan 30, 1997 10%
Ann Leonard Individual Corporate DirectorBoard Member Jul 15, 2020 10%
Jennifer D Heinlein Individual Corporate OfficerCoo Oct 12, 2021 50%
Angel Wells Individual Corporate DirectorBoard Member May 18, 2022 10%
Valerie Reece Individual Corporate DirectorBoard Member Aug 8, 2012 10%

Practitioners & affiliated clinicians

Practitioners 25

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 25

NPI Registry JSON

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

{
    "created_epoch": "1561420800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1561420800000",
    "number": "1629639109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1359",
            "city": "AVA",
            "state": "MO",
            "postal_code": "656081359",
            "telephone_number": "417-683-4831"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "135 COLLEGE AVE.",
            "city": "LICKING",
            "state": "MO",
            "postal_code": "65542",
            "telephone_number": "417-683-4831"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-25",
        "last_updated": "2019-06-25",
        "status": "A",
        "authorized_official_last_name": "HEINLEIN",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "417-683-4831"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Missouri Ozarks Community Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Licking, MO

Sources for this page

Verify at the official NPI Registry.