Kenneth Jake Sample, MD

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

E-18299 Issued in AR

Practice address

1101 Jackson St SW
Gravette, AR 72736-9121

Phone

(479) 787-5221

Fax

(479) 787-5613

NPI assigned

May 4, 2021

Last updated

Aug 5, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in AR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Internal Medicine

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Sgoh Acquisition IncGroup PAC ID 5092616276, 95 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Enhabit Home Health Home health agency, Springdale, AR, CCN 047172
• Elite Home Health Home health agency, Springdale, AR, CCN 047346
• Ozarks Community Hospital of Gravette Hospital, Gravette, AR, CCN 041331
• Mercy Hospital Northwest Arkansas Hospital, Rogers, AR, CCN 040010
• Ozarks Community Hospital of Gravette Nursing home, CCN 04Z331

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Sgoh Acquisition Inc

  dba Ozarks Community Hospital of Gravette

  • Critical Access Hospital
  • Gravette, AR
  • NPI 1568643005
  Medicare reassignment Care Compare group NPD
• Sgoh Acquisition Inc

  dba Och Decatur Clinic

  • Rural Health Clinic/Center
  • Decatur, AR
  • NPI 1699513507
  NPD
• Sgoh Acquisition Inc

  • Clinic/Center
  • Springfield, MO
  • NPI 1114924768
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Ahm Action Home Health, LP

  dba Enhabit Home Health

  • Home Health Agency
  • Springdale, AR
  • NPI 1215314299
  Care Compare affiliation
• LHCG Xlii, LLC

  dba Elite Home Health

  • Home Health Agency
  • Springdale, AR
  • NPI 1043557788
  Care Compare affiliation
• Mercy Hospital Rogers

  dba Mercy Hospital Northwest Arkansas

  • General Acute Care Hospital
  • Rogers, AR
  • NPI 1316902414
  Care Compare affiliation
• Sgoh Acquisition Inc

  dba Ozarks Community Hospital of Gravette

  • Critical Access Hospital
  • Gravette, AR
  • NPI 1568643005
  Care Compare affiliation
• Sgoh Acquisition Inc

  dba Ozarks Community Hospital of Gravette

  • Medicare Defined Swing Bed Hospital Unit
  • Gravette, AR
  • NPI 1780943357

  Nursing home

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620086400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1722816000000",
    "number": "1699358960",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 JACKSON ST SW",
            "city": "GRAVETTE",
            "state": "AR",
            "postal_code": "727369121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 JACKSON ST SW",
            "city": "GRAVETTE",
            "state": "AR",
            "postal_code": "727369121",
            "telephone_number": "479-787-5221",
            "fax_number": "479-787-5613"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "346 N Main St",
            "address_purpose": "LOCATION",
            "city": "Decatur",
            "state": "AR",
            "postal_code": "727229732",
            "country_code": "US",
            "telephone_number": "479-752-3233",
            "fax_number": "479-752-3235",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "920 Madison Ave Ste 447",
            "address_purpose": "LOCATION",
            "city": "Memphis",
            "state": "TN",
            "postal_code": "381033438",
            "country_code": "US",
            "telephone_number": "901-448-5814",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SAMPLE",
        "first_name": "KENNETH",
        "middle_name": "JAKE",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-05-04",
        "last_updated": "2024-08-05",
        "certification_date": "2024-08-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "AR",
            "license": "E-18299",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Karen I Privett
• Mylynda Privett
• Debbie Query, LM, CPM
• Christopher Ray Rouse
• Ty D Russell, D.C.
• Sgoh Acquisition Inc (Ozarks Community Hospital of Gravette)
• Sgoh Acquisition Inc (Ozarks Community Hospital of Gravette)
• Sgoh Acquisition Inc (Ozarks Community Hospital of Gravette)
• Marva Shockley
• Lloyd Layton Spencer, M.D.

• Internal Medicine Physician in Gravette, AR
• Providers in Gravette, AR by specialty
• Internal Medicine Physician in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.