NPIMap

Organization Active NPI

Deaconess Memorial Medical Center Inc

Doing business as Country Health Center

  • Rural Health Clinic/Center
  • Montgomery, IN
National Provider Identifier
1730420829
Registry record updated Mar 16, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
Country Health Center
Practice address
5066 N 900 E
Montgomery, IN 47558-5790
Phone
(812) 486-3396
Fax
(812) 486-3354
NPI assigned
Mar 14, 2013
Last updated
Mar 16, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
DEACONESS MEMORIAL MEDICAL CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 16, 2026

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

Authorized official

Name
Keith Miller
Title
Cao & Indiana Region President
Phone
(812) 996-0507

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X IN Primary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Family Medicine Physician 207Q00000X
Cardiovascular Disease Physician 207RC0000X
Pediatrics Physician 208000000X

Addresses

Primary practice location

5066 N 900 E
Montgomery, IN 47558-5790

Mailing address

PO Box 1028
Jasper, IN 47547-1028
Phone (812) 996-8478

Other names 1

  • Country Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031118000733 IN Part B Supplier - Clinic/Group Practice 4587578042 Receives reassigned benefits from 170 practitioners
36 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jasper, IN; Shoals, IN; Loogootee, IN; Montgomery, IN; Petersburg, IN; Santa Claus, IN; Washington, IN; Dale, IN…
O20110809000393 IN Part A Provider - Rural Health Clinic 4587578042 1 other NPI on this enrollment
Practice locations: Montgomery, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1730420829. Details of each certification follow.

Rural health clinic certification: CCN 153871

Legal name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
COUNTRY HEALTH CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 30, 2004
Last certification
Jun 28, 2022
Ownership / control type
2B
Most recent change of ownership
Jul 1, 2011 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jun 13, 1950 in IN
Enrollment address
5066 N 900 E
Montgomery, IN 47558-5790

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 36

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

View all 36

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
15D2055096Deaconess Memorial Center Country Health5066 N 900 E, Montgomery, IN 47558Certificate of waiverMar 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Memorial Hospital Healt27 organizations share this tax ID, including this one
Part of
Memorial Hospital Healt

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Tonya S Heim Individual Corporate DirectorBoard Member Jan 1, 2013
Kristi M Nord Individual Corporate DirectorBoard Member Jan 1, 2024
Renee Cunningham Individual Corporate DirectorBoard Member Jan 1, 2013
Sohail Qadir Individual Corporate DirectorBoard Member Jul 1, 2015
Shannon Ebenkamp Individual W-2 Managing EmployeeDirector of Finance Oct 8, 2024
James a Huebner Individual Corporate DirectorBoard Member Jan 1, 2014
Deaconess Health System Inc Organization, Evansville, IN Corporation, Chain home office 5% Or Greater Direct Ownership Interest Feb 1, 2024 100%
Lynn C Lingafelter Individual Corporate DirectorBoard Member Feb 1, 2024
Christian Blome Individual Corporate DirectorBoard Member Feb 1, 2024
Shawn W McCoy Individual 5% Or Greater Direct Ownership Interest Feb 1, 2024 100%
Operational/Managerial Control Feb 1, 2024
Keith Miller Individual Corporate OfficerCao & Indiana Region President Oct 8, 2024
W-2 Managing EmployeeAd; Oct 8, 2024
James Porter Individual Corporate DirectorBoard Member Feb 1, 2024
Donna Balka Individual Corporate DirectorBoard Member May 1, 2021
Nicholas a Werne Individual Corporate DirectorBoard Member Aug 5, 2022

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mission Behavioral Health HospitalHuntingburg, IN, CCN 154072 Hospital 5% Or Greater Direct Ownership Interest (50%) Apr 5, 2024
Dale Family MedicineDale, IN, CCN 153859 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 2, 2000

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 28

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

View all 28

Practitioners & affiliated clinicians

Practitioners 9

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": "1363219200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1773619200000",
    "number": "1730420829",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1028",
            "city": "JASPER",
            "state": "IN",
            "postal_code": "475471028",
            "telephone_number": "812-996-8478",
            "fax_number": "812-996-8497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5066 N 900 E",
            "city": "MONTGOMERY",
            "state": "IN",
            "postal_code": "475585790",
            "telephone_number": "812-486-3396",
            "fax_number": "812-486-3354"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "enumeration_date": "2013-03-14",
        "last_updated": "2026-03-16",
        "certification_date": "2026-03-16",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "KEITH",
        "authorized_official_title_or_position": "CAO & INDIANA REGION PRESIDENT",
        "authorized_official_telephone_number": "812-996-0507"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IN",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Montgomery, IN

Sources for this page

Verify at the official NPI Registry.