NPIMap

Organization Active NPI

Mercy Hospital Booneville

  • Rural Health Clinic/Center
  • Magazine, AR
National Provider Identifier
1720417066
Registry record updated Sep 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MERCY HOSPITAL BOONEVILLE
Practice address
351 E Priddy St
Magazine, AR 72943-8503
Phone
(479) 969-8640
NPI assigned
Nov 7, 2013
Last updated
Sep 16, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2021

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

Authorized official

Name
Sherry Lynn Clouse Day
Title
VP Finance
Phone
(417) 820-8439

Specialties & licenses 1

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

Addresses

Primary practice location

351 E Priddy St
Magazine, AR 72943-8503

Mailing address

880 W Main St
Booneville, AR 72927-3443
Phone (479) 969-8640

Other identifiers 1

IdentifierTypeStateIssuer
205182729MedicaidAR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140206000589 AR Part A Provider - Rural Health Clinic 1951530385 Practice locations: Magazine, AR
O20170203001490 AR Part B Supplier - Clinic/Group Practice 1951530385 Receives reassigned benefits from 142 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Magazine, AR; Booneville, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720417066. Details of each certification follow.

Rural health clinic certification: CCN 048502

Legal name
MERCY HOSPITAL BOONEVILLE
Doing business as
MERCY HOSPITAL BOONEVILLE PRIMARY CARE-MAGAZINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 10, 2012
Last certification
Aug 29, 2024
Ownership / control type
2B
Most recent change of ownership
Dec 31, 2013 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Oct 10, 2013 in AR
Enrollment address
351 E Priddy St
Magazine, AR 72943-8503
Related CCNs
041318

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

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 3

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2035051Mercy Clinic Primary Care - Magazine351 E Priddy St, Magazine, AR 72943Certificate of waiverJan 9, 2028

National Provider Directory

National Provider Directory
Tax ID family
Mercy Hospital Booneville4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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.

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Jamie Wilke Individual Corporate OfficerSecretary Jul 1, 2024
Mercy Health Fort Smith Communities Organization, Ft Smith, AR Corporation, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2014 100%
Ryan Gehrig Individual Corporate OfficerPresident Jan 1, 2014
W-2 Managing EmployeePresident Jan 1, 2014
Elizabeth Maddox Individual Corporate DirectorBoard Member Jul 1, 2024
Yogya Regmi Individual W-2 Managing EmployeeDirector Aug 29, 2022
Michael Keith Gibbons Individual Corporate DirectorBoard Member Jul 1, 2022
Edward Melton Individual Corporate DirectorBoard Member Jul 1, 2024
Bret Cook Individual Corporate DirectorBoard Member Jul 1, 2022
Mercy Hospital Fort Smith Organization, Fort Smith, AR Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2014 100%
Martha Ullrich Individual Corporate DirectorBoard Member Jul 1, 2021
Allen Ray Individual Corporate DirectorBoard Member Jul 1, 2024
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office Operational/Managerial Control Jan 2, 2014 100%
Carol Corley Individual Corporate DirectorBoard Member Jul 1, 2021
Judith Marie Keith Individual Corporate DirectorBoard Member Jul 1, 2021
Sherry Clouse Day Individual Corporate OfficerTreasurer Jan 1, 2021
W-2 Managing EmployeeVP Finance Jan 1, 2021
Vicky Laird Individual Corporate DirectorBoard Member Jul 1, 2021

Owners & managing parties with NPI records 2

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

Facilities with the same owner 115

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

View all 115

Practitioners & affiliated clinicians

Practitioners 37

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.

View all 37

NPI Registry JSON

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

{
    "created_epoch": "1383782400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631750400000",
    "number": "1720417066",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "880 W MAIN ST",
            "city": "BOONEVILLE",
            "state": "AR",
            "postal_code": "729273443",
            "telephone_number": "479-969-8640"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "351 E PRIDDY ST",
            "city": "MAGAZINE",
            "state": "AR",
            "postal_code": "729438503",
            "telephone_number": "479-969-8640"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MERCY HOSPITAL BOONEVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-11-07",
        "last_updated": "2021-09-16",
        "certification_date": "2021-09-16",
        "status": "A",
        "authorized_official_last_name": "CLOUSE DAY",
        "authorized_official_first_name": "SHERRY",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "VP FINANCE",
        "authorized_official_telephone_number": "417-820-8439"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "205182729",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Magazine, AR

Sources for this page

Verify at the official NPI Registry.