NPIMap

Organization Active NPI

Mississippi County Hospital System

  • Rural Health Clinic/Center
  • Blytheville, AR
National Provider Identifier
1669089462
Registry record updated Sep 25, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MISSISSIPPI COUNTY HOSPITAL SYSTEM
Practice address
1522 N Division St
Blytheville, AR 72315-1448
Phone
(870) 838-7530
Fax
(870) 838-7539
NPI assigned
Sep 25, 2020
Last updated
Sep 25, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 25, 2020

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

Authorized official

Name
Chris Lee Raymer
Title
Ceo
Phone
(870) 838-7463

Specialties & licenses 1

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

Addresses

Primary practice location

1522 N Division St
Blytheville, AR 72315-1448

Mailing address

1520 N Division St
Blytheville, AR 72315-1448
Phone (870) 838-7000

Other names 1

  • Great River Family Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201023000853 AR Part A Provider - Rural Health Clinic 9739230723 Practice locations: Blytheville, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669089462. Details of each certification follow.

Rural health clinic certification: CCN 048527

Legal name
MISSISSIPPI COUNTY HOSPITAL SYSTEM
Doing business as
GREAT RIVER FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 19, 2021
Last certification
Mar 6, 2023
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
1522 N Division St
Blytheville, AR 72315-1448
Related CCNs
040069

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

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Mississippi County Primary Care Physicians9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
John Logan Individual Corporate DirectorBoard President Mar 13, 2009
Felicia Pierce Individual Corporate OfficerInterim Ceo Sep 25, 2024
W-2 Managing EmployeeInterim Ceo Sep 25, 2024
Van Parker Individual Corporate OfficerBoard Member Jan 4, 2010
Mississippi County Hospital System Organization, Blytheville, AR Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2016 100%

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mississippi County Primary Care Physicians ClinicOsceola, AR, CCN 048525 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2016

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

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": "1600992000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1600992000000",
    "number": "1669089462",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1520 N DIVISION ST",
            "city": "BLYTHEVILLE",
            "state": "AR",
            "postal_code": "723151448",
            "telephone_number": "870-838-7000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1522 N DIVISION ST",
            "city": "BLYTHEVILLE",
            "state": "AR",
            "postal_code": "723151448",
            "telephone_number": "870-838-7530",
            "fax_number": "870-838-7539"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSISSIPPI COUNTY HOSPITAL SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-25",
        "last_updated": "2020-09-25",
        "certification_date": "2020-09-23",
        "status": "A",
        "authorized_official_last_name": "RAYMER",
        "authorized_official_first_name": "CHRIS",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "870-838-7463"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great River Family Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Blytheville, AR

Sources for this page

Verify at the official NPI Registry.