NPIMap

Organization Active NPI

Southeast Missouri Hospital Physicians LLC

Doing business as Mercy Southeast Primary Care West

  • Rural Health Clinic/Center
  • Cape Girardeau, MO
National Provider Identifier
1699073122
Registry record updated Jan 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC
Doing business as
Mercy Southeast Primary Care West
Practice address
817 S Mount Auburn Rd
Cape Girardeau, MO 63703-6383
Phone
(573) 519-4500
NPI assigned
Mar 8, 2011
Last updated
Jan 13, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 13, 2024

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 1

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

Addresses

Primary practice location

817 S Mount Auburn Rd
Cape Girardeau, MO 63703-6383

Mailing address

817 S Mount Auburn Rd
Cape Girardeau, MO 63703-6383
Phone (573) 519-4500

Other names 1

  • MERCY SOUTHEAST PRIMARY CARE WEST Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100804000061 MO Part A Provider - Rural Health Clinic 9133024334 Practice locations: Cape Girardeau, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699073122. Details of each certification follow.

Rural health clinic certification: CCN 268657

Legal name
SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC
Doing business as
MERCY SOUTHEAST PRIMARY CARE WEST
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 1, 2011
Last certification
Jun 4, 2024
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Jan 18, 2001 in MO
Enrollment address
817 S Mount Auburn Rd
Cape Girardeau, MO 63703-6383
Related CCNs
260110

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

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Southeast Health5 organizations share this tax ID, including this one
Part of
Southeast Health

Other organizations with this tax ID 4

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

817 S Mount Auburn Rd
Cape Girardeau, MO 63703
Phone (573) 334-9637

817 S Mount Auburn Rd
Ste 100
Cape Girardeau, MO 63703
Phone (573) 519-4500

Ownership & related parties

All disclosed owners & managing parties 26

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

NameRoleSinceShare
Andrew J Moore Individual Corporate DirectorBoard Member Jan 1, 2024
Carl E Ammons Individual Corporate OfficerRegional President Jan 1, 2024
Kenneth Bateman Individual Corporate OfficerCeo Jan 19, 2015
W-2 Managing EmployeeCeo Jan 19, 2015
Stanley L Crader Individual Corporate OfficerTreasurer Jan 1, 2024
Corporate DirectorBoard Member Oct 1, 2013
Steven M Green Individual Corporate DirectorVice Chairman of the Board Jul 1, 2016
Thomas E Edelstein Individual Corporate DirectorBoard Member Jan 1, 2024
Christopher Wibbenmeyer Individual Corporate DirectorBoard Member Jan 1, 2024
Charles Kruse Individual Corporate OfficerSecretary Jan 1, 2024
Angie Umfleet Individual Corporate DirectorChair Jan 1, 2024
Krista Berry Individual Corporate Director Jan 1, 2017
W-2 Managing Employee Jan 1, 2017
Michael Kohlfeld Individual Corporate DirectorBoard Member Jan 1, 1992
Frank M Kinder Individual Corporate DirectorBoard Member Sep 1, 2009
Christine L Mackey-Ross Individual Corporate DirectorBoard Member Apr 1, 2013
Andrew Runge Individual Corporate DirectorChair Jan 1, 2024
Stacie Farnam Individual W-2 Managing Employee Dec 20, 2023
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
Benjamin F Lewis Individual Corporate DirectorBoard Member Apr 1, 1992
Curt Buchheit Individual Corporate DirectorVice Chair Jan 1, 2024
Naresh Agarwal Individual Corporate DirectorBoard Member Jan 1, 2024
Ryan Geib Individual Corporate OfficerPresident Dec 20, 2023
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%
Wade a Richey Individual Corporate DirectorBoard Member Jan 1, 2024
Fred Ducharme 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 Direct Ownership Interest Jan 1, 2001 100%
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%
James J Dufek Individual Corporate DirectorBoard Member Jan 1, 2006

Owners & managing parties with NPI records 6

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 5

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": "1299542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705104000000",
    "number": "1699073122",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "817 S MOUNT AUBURN RD",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637036383",
            "telephone_number": "573-519-4500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "817 S MOUNT AUBURN RD",
            "city": "CAPE GIRARDEAU",
            "state": "MO",
            "postal_code": "637036383",
            "telephone_number": "573-519-4500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC",
        "enumeration_date": "2011-03-08",
        "last_updated": "2024-01-13",
        "certification_date": "2024-01-13",
        "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": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MERCY SOUTHEAST PRIMARY CARE WEST",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cape Girardeau, MO

Sources for this page

Verify at the official NPI Registry.