Southeast Health Center of Stoddard County LLC
Organization Active NPI Rural Health Clinic/Center · Bernie, MO
NPI 1679820286 · NPPES record last updated Sep 16, 2025
Key facts
- NPI
- 1679820286
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
- Practice address
- 810 N Walnut St
Bernie, MO 63822-8901 - Phone
- (573) 293-5336
- NPI assigned
- Aug 14, 2012
- Organization subpart
- No
Authorized official
- Name
- Krista Berry
- Title
- Cfo
- Phone
- (573) 331-6028
Owners & managing parties with NPI records 4
-
Reza Jalal, MD
Other NPIs on the same Medicare enrollment 8
Other NPIs with the same Medicare PAC ID 9
Corporate family (same tax ID) 8
Member of 1
Related certifications (CCN) 1
Facilities with the same owner 117
Practitioners 42
-
Kimberly Essner, MS-PAC
-
Akeeb Adedokun, MD
-
Cara M Dillinger, NP-C
-
Tammy S Fowler, FNP
-
Ashley Marie Gantner, FNP-C
-
Lei Guan, MD
-
Leigh A Hampton, FNP
-
Saundra Marie Hickson, MSN, APRN, FNP-BC
-
Sierra Elaine Holiman, APRN
-
Melissa Elaine Hubbard, FNP-C
-
Reza Jalal, MD
-
Laurie Muriel Jibben, APN
-
Michael Lamb, MD
-
Judy Pedigo, FNP
-
Edward D Reese, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 26D2046362 | Southeast Health Center of Stoddard County | Certificate of waiver | Aug 30, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Rural health clinic certification: CCN 268683
- 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
- Dec 27, 2012
- Last certification
- Oct 22, 2019
- Ownership / control type
- 2B
- Most recent change of ownership
- Jan 1, 2013 (1 total)
- Organization structure
- LLC · Non-profit
- Enrollment address
- 810 N Walnut St
Bernie, MO 63822-8901 - Related CCNs
- 260160
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Carl E Ammons |
Corporate Officer |
Aug 1, 2025 | |
| Brian Robison |
Corporate Director |
Aug 1, 2025 | |
| Krista Berry |
Corporate Director |
Dec 20, 2023 | |
| W-2 Managing Employee |
Nov 2, 2018 | ||
| Marissa Mills |
Corporate Director |
Aug 1, 2025 | |
| Mark Avery |
Corporate Director |
Aug 1, 2025 | |
| Andrew Runge |
Corporate Director |
Aug 1, 2025 | |
| Stacie Farnam |
W-2 Managing Employee | Dec 20, 2023 | |
| Mercy Health |
5% Or Greater Indirect Ownership Interest | Dec 20, 2023 | 100% |
| Southeasthealth System Inc |
5% Or Greater Indirect Ownership Interest | Aug 30, 2013 | 100% |
| Greg Mathis |
Corporate Director |
Aug 1, 2025 | |
| Michelle Aycock |
Corporate Director |
Aug 1, 2025 | |
| Southeast Hospital |
5% Or Greater Indirect Ownership Interest | Jan 1, 2013 | 100% |
| Reza T Jalal |
Corporate Director |
Aug 1, 2025 | |
| Mercy Health East Communities |
5% Or Greater Indirect Ownership Interest | Dec 20, 2023 | 100% |
| Ryan Adams |
Corporate Director |
Aug 1, 2025 | |
| Southeasthealth Hospital Holdings, LLC |
5% Or Greater Direct Ownership Interest | Jan 2, 2013 | 100% |
| Brian Day |
Corporate Officer |
Aug 1, 2025 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20130913000717 | MO | Part a Provider - Rural Health Clinic | 7315192515 | Practice locations: Bernie, MO |
National Provider Directory
- Tax ID family
- Southeast Health Center of Stoddard County LLC
Locations
1300 N One Mile Rd
Ste 6
Dexter, MO 63841
Phone (573) 519-4830
607 Billington St
Kennett, MO 63857
Phone (573) 888-6600
500 N Douglass St
Malden, MO 63863
Phone (573) 276-2221
1707 N Douglass St
Malden, MO 63863
Phone (573) 276-6488
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
810 N Walnut St
Bernie, MO 63822-8901
Mailing address
810 N Walnut St
Bernie, MO 63822-8901
Phone (573) 293-5336
Other names
- MERCY HOSPITAL STODDARD
Other providers in Bernie, MO
- Karaline Alynn Keirsey
- Shelby Lawrence
- Katrina Leanne Miller
- Daley M Powers
- Ronna Reaves
- Southeast Missouri Health Network
- Southeast Missouri Health Network
- Brandi Sparks
- Super D Drugs Acquisition Co.
- Walgreen Co
All providers in Bernie, MO · Rural Health Clinic/Center in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 16, 2025. 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.