Vanderbilt Bedford Hospital, LLC
Organization Active NPI Rural Health Clinic/Center · Wartrace, TN
NPI 1659970549 · NPPES record last updated Mar 31, 2022
Key facts
- NPI
- 1659970549
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- VANDERBILT BEDFORD HOSPITAL, LLC
- Practice address
- 507 Blackman Blvd W
Wartrace, TN 37183-2210 - Phone
- (931) 389-0600
- NPI assigned
- Oct 21, 2020
- Organization subpart
- No
Authorized official
- Name
- Angela L Simmons
- Title
- VP - Finance
- Phone
- (615) 936-8875
Owners & managing parties with NPI records 14
-
Jane E Freedman, M.D.
-
Makeba Williams, MD
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 5
Member of 1
Related certifications (CCN) 1
Change of ownership 1
Facilities with the same owner 19
Practitioners 12
-
Amber Archer, FNP-C
-
Sarah Beth Bridge, NP-C
-
Matthew Ryan Brock, D.O.
-
Nicole Campbell, PA-C
-
Gyu Chang Jo, FNP-BC
-
Karyn Elizabeth Jones, N.P.
-
Grahm Smith, PA-C
-
Sarah Tucker Allen, P.A.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D1088041 | Vanderbilt Bedford Hospital, LLC | Certificate of waiver | Aug 14, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Rural health clinic certification: CCN 443455
- Legal name
- VANDERBILT BEDFORD HOSPITAL LLC
- Doing business as
- VANDERBILT INTEGRATED PRIMARY CARE WARTRACE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 29, 2018
- Last certification
- Mar 29, 2018
- Ownership / control type
- 1B
- Organization structure
- LLC · Non-profit
- Enrollment address
- 507 Blackman Blvd W
Wartrace, TN 37183-2210 - Related CCNs
- 440137
All disclosed owners & managing parties 18
| Name | Role | Since | Share |
|---|---|---|---|
| John R Ingram |
Corporate Director |
Jul 1, 2022 | |
| Cecelia Moore |
Corporate Officer |
Oct 9, 2020 | |
| Gail Carr Williams |
Corporate Director |
Jul 1, 2023 | |
| John Frederick Stein |
Corporate Director |
Oct 9, 2020 | |
| Angela Simmons |
Corporate Director | Aug 1, 2021 | |
| Daniel Diermeier |
Corporate Director |
Oct 9, 2020 | |
| Gina Dudley |
W-2 Managing Employee | Mar 15, 2023 | |
| Edith Carell Johnson |
Corporate Director |
Oct 9, 2020 | |
| Makeba Williams |
Corporate Director |
Jul 1, 2022 | |
| Jane Freedman |
W-2 Managing Employee |
Jul 1, 2025 | |
| Colin Reed |
Corporate Director |
Jul 1, 2023 | |
| Vanderbilt University Medical Center |
5% Or Greater Direct Ownership Interest | Oct 9, 2020 | 100% |
| Operational/Managerial Control | Jan 1, 2021 | ||
| Kenneth W Rich |
Contracted Managing Employee |
Jan 1, 2021 | |
| Lucinda M Baier |
Corporate Director |
Jul 1, 2022 | |
| Sara Finley |
Corporate Director |
Jan 1, 2022 | |
| Marie Elizabeth Brock |
W-2 Managing Employee |
Aug 1, 2022 | |
| Raymond D Mefford |
Corporate Officer |
Jul 1, 2024 | |
| Jeffrey Balser |
Corporate Director |
Oct 9, 2020 |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| Jan 1, 2021 | Change of Ownership |
Tennova Family Care-Wartrace |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210108001145 | TN | Part a Provider - Rural Health Clinic | 4082026695 | Practice locations: Wartrace, TN |
National Provider Directory
- Tax ID family
- Vanderbilt Bedford Hospital LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
507 Blackman Blvd W
Wartrace, TN 37183-2210
Mailing address
3841 Green Hills Village Dr Ste 200
Nashville, TN 37215-2691
Other names
- Vanderbilt Integrated Primary Care Wartrace
Other providers in Wartrace, TN
- Shelbyville Hospital Company LLC
- Shelbyville Hospital Company LLC
- Shelbyville Hospital Corporation
- Shelbyville Hospital Corporation
- Shouthern Transport, LLC
- Wartrace Family Practice LLC
All providers in Wartrace, TN · Rural Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 31, 2022. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.