Waynesburg Clinic, PLLC
Organization Active NPI Rural Health Clinic/Center · Waynesburg, KY
NPI 1669670816 · NPPES record last updated Oct 4, 2023
Key facts
- NPI
- 1669670816
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 900205 (KY)
- Legal business name
- WAYNESBURG CLINIC, PLLC
- Practice address
- 14098 US Highway 27 S
Waynesburg, KY 40489-8253 - Phone
- (606) 379-6646
- Fax
- (606) 379-5707
- NPI assigned
- Jul 10, 2007
- Organization subpart
- No
Authorized official
- Name
- Dr. Christopher Duvall Sims, M.D.
- Title
- Medical Director
- Phone
- (606) 365-1547
Owners & managing parties with NPI records 2
Practitioners 11
-
Bria M Thompson, PA-C
-
Crystal D Brown, ARNP
-
Jeanne A Chase, FNP
-
Jody Coomer, APRN
-
Jesslyn Brianne Kelsey, APRN
-
Samantha Brooke Shell, APRN
-
Bethany Lee, PA-C
-
Tricia Harvey Jackson, APRN
-
Michelle Martin, PAC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D0979200 | Waynesburg Clinic | Provider-performed microscopy | Oct 16, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN 183954
- Legal name
- WAYNESBURG CLINIC, PLLC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Dec 10, 2007
- Last certification
- Mar 3, 2026
- Ownership / control type
- 1C
- Organization structure
- LLC · Proprietary
- Incorporated
- Jul 9, 2007 in KY
- Enrollment address
- 14098 Ky Highway 27 South
Waynesburg, KY 40489-0435
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| James a Miller |
5% Or Greater Direct Ownership Interest |
Sep 15, 2007 | 50% |
| General Partnership Interest | Jul 9, 2007 | ||
| Christopher D Sims |
5% Or Greater Direct Ownership Interest |
Sep 15, 2007 | 50% |
| General Partnership Interest | Aug 24, 2007 | ||
| Donna Rutherford |
W-2 Managing Employee |
Oct 1, 2014 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070829000132 | KY | Part B Supplier - Clinic/Group Practice | 3375635857 |
Receives reassigned benefits from 9 practitioners Practice locations: Waynesburg, KY |
| O20070913000044 | KY | Part a Provider - Rural Health Clinic | 3375635857 | Practice locations: Waynesburg, KY |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 900205 | KY | Yes |
Addresses
Primary practice location
14098 US Highway 27 S
Waynesburg, KY 40489-8253
Mailing address
PO Box 435
Waynesburg, KY 40489-0435
Phone (606) 379-6646
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7100019500 | Medicaid | KY | |
| 00361 | Other | KY | MEDICARE PART B |
| 183954 | Other | KY | MEDICARE PART A |
Other providers in Waynesburg, KY
- Lora Danielle Richardson
- Tracy Lynn Singleton
- Brittany Turpin
- Waynesburg Area Rescue Squad
- Waynesburg Clinic
All providers in Waynesburg, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 4, 2023. 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.