NPIMap

Organization Active NPI

Southeast Health Center of Stoddard County LLC

Doing business as Mercy Hospital Stoddard

  • Rural Health Clinic/Center
  • Sikeston, MO
National Provider Identifier
1679041040
Registry record updated Sep 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
Doing business as
Mercy Hospital Stoddard
Practice address
522 Virginia St
Sikeston, MO 63801-5812
Phone
(573) 624-1901
NPI assigned
Nov 5, 2018
Last updated
Sep 16, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2025

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

Authorized official

Name
Krista Berry
Title
Cfo
Phone
(573) 331-6028

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

522 Virginia St
Sikeston, MO 63801-5812

Mailing address

1200 N One Mile Rd
Dexter, MO 63841-1015
Phone (573) 614-1900

Other names 1

  • MERCY HOSPITAL STODDARD Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130605000128 MO Part B Supplier - Clinic/Group Practice 7315192515 Receives reassigned benefits from 108 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Dexter, MO; Sikeston, MO; Saint Louis, MO; Poplar Bluff, MO; New Madrid, MO; Malden, MO; Bloomfield, MO; Bernie, MO
O20190103001427 MO Part A Provider - Rural Health Clinic 7315192515 Practice locations: Sikeston, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679041040. Details of each certification follow.

Rural health clinic certification: CCN 268768

Legal name
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
Doing business as
MERCY HOSPITAL STODDARD
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 29, 2019
Last certification
Sep 10, 2024
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Dec 7, 2012 in MO
Enrollment address
522 Virginia St
Sikeston, MO 63801-5812
Related CCNs
260160

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

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory
Tax ID family
Southeast Health County LLC9 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.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

522 Virginia St
Sikeston, MO 63801
Phone (573) 472-2202

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Carl E Ammons Individual Corporate OfficerCommunity President Jul 30, 2025
Brian Robison Individual Corporate OfficerSecretary/Treasurer Jan 1, 2024
Krista Berry Individual Corporate DirectorCfo Dec 20, 2023
W-2 Managing EmployeeCfo Dec 20, 2023
Marissa Mills Individual Corporate DirectorBoard Member Jul 30, 2025
Mark Avery Individual Corporate OfficerBoard Member Jun 1, 2016
Andrew Runge Individual Corporate DirectorBoard Member Jul 30, 2025
Stacie Farnam Individual W-2 Managing Employee Dec 20, 2023
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
Southeasthealth System Inc Organization, Cape Girardeau, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Aug 30, 2013 100%
Greg Mathis Individual Corporate DirectorBoard Member Jan 1, 2024
Michelle Aycock Individual Corporate DirectorBoard Member Jan 1, 2024
Southeast Hospital Organization, Cape Girardeau, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2013 100%
Reza T Jalal Individual Corporate DirectorBoard Member Jul 30, 2025
Mercy Health East Communities Organization, Saint Louis, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
Ryan Adams Individual Corporate DirectorBoard Member Jul 30, 2025
Southeasthealth Hospital Holdings, LLC Organization, Cape Girardeau, MO LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2013 100%
Brian Day Individual Corporate OfficerSenior Vice President Jul 30, 2025

Owners & managing parties with NPI records 4

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

Facilities with the same owner 117

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 117

Practitioners & affiliated clinicians

Practitioners 1

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": "1541376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757980800000",
    "number": "1679041040",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 N ONE MILE RD",
            "city": "DEXTER",
            "state": "MO",
            "postal_code": "638411015",
            "telephone_number": "573-614-1900",
            "fax_number": "573-624-8895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "522 VIRGINIA ST",
            "city": "SIKESTON",
            "state": "MO",
            "postal_code": "638015812",
            "telephone_number": "573-624-1901"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-05",
        "last_updated": "2025-09-16",
        "certification_date": "2025-09-16",
        "status": "A",
        "authorized_official_last_name": "BERRY",
        "authorized_official_first_name": "KRISTA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-331-6028"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MERCY HOSPITAL STODDARD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sikeston, MO

Sources for this page

Verify at the official NPI Registry.