NPIMap

Organization Active NPI

Infinity Health

  • Federally Qualified Health Center (FQHC)
  • Corydon, IA
National Provider Identifier
1669697074
Registry record updated Feb 11, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
INFINITY HEALTH
Practice address
102-104 North Franklin St
Corydon, IA 50060
Phone
(641) 872-1750
Fax
(641) 872-1751
NPI assigned
Apr 13, 2007
Last updated
Feb 11, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2022

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

Authorized official

Name
Ms. Samantha Cannon
Title
Ceo
Phone
(641) 446-2383

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X IA
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

102-104 North Franklin St
Corydon, IA 50060

Mailing address

302 NE 14TH St
Leon, IA 50144-1206
Phone (641) 446-2383

Other identifiers 3

IdentifierTypeStateIssuer
0762930MedicaidIA
39014OtherWELLMARK BLUE CROSS/BLUE SHIELD
504921206MedicaidMO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20051024000374 IA Part B Supplier - Clinic/Group Practice 5597717496 Receives reassigned benefits from 27 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Albia, IA; Centerville, IA; Chariton, IA; Corydon, IA; Knoxville, IA; Lamoni, IA; Leon, IA; Mount Ayr, IA…
O20061012000688 IA Part A Provider - Federally Qualified Health Center (FQHC) 5597717496 1 other NPI on this enrollment
Practice locations: Corydon, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669697074. Details of each certification follow.

Federally qualified health center certification: CCN 161839

Legal name
INFINITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 6, 2006
Last certification
Dec 6, 2006
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2005 in IA
Enrollment address
102 N Franklin St
Corydon, IA 50060-1405

Other NPIs with the same Medicare PAC ID 11

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
Infinity Health13 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 9

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

NameRoleSinceShare
Brenda Fry Individual Corporate DirectorBoard Member Mar 1, 2022 11.11%
Shirley Kessel Individual Corporate DirectorBoard Chair Jan 1, 2005 11.11%
Pamela Burlin Individual Corporate DirectorBoard Member Nov 30, 2021 11.11%
William Weaver Individual Corporate DirectorBoard Member Apr 26, 2022 11.11%
Alan Wilson Individual Corporate Director Mar 23, 2010 11.11%
William Morain Individual Corporate DirectorBoard Secretary Jan 1, 2005 11.11%
Samantha Cannon Individual Corporate OfficerCeo Nov 27, 2012
Corporate DirectorCeo Nov 27, 2012
W-2 Managing EmployeeCeo Nov 27, 2012
Dien Judge Individual Corporate Director Oct 28, 2014 11.11%
Marvin McCann Individual Corporate DirectorBoard Chair Apr 27, 2021 11.11%

Practitioners & affiliated clinicians

Practitioners 8

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": "1176422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644537600000",
    "number": "1669697074",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "302 NE 14TH ST",
            "city": "LEON",
            "state": "IA",
            "postal_code": "501441206",
            "telephone_number": "641-446-2383",
            "fax_number": "641-446-2382"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102-104 NORTH FRANKLIN ST",
            "city": "CORYDON",
            "state": "IA",
            "postal_code": "50060",
            "telephone_number": "641-872-1750",
            "fax_number": "641-872-1751"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INFINITY HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-13",
        "last_updated": "2022-02-11",
        "certification_date": "2022-02-11",
        "status": "A",
        "authorized_official_last_name": "CANNON",
        "authorized_official_first_name": "SAMANTHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "641-446-2383",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0762930",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK BLUE CROSS/BLUE SHIELD",
            "identifier": "39014",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "504921206",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Corydon, IA

Sources for this page

Verify at the official NPI Registry.