Southeast Health Center of Stoddard County, LLC
Organization Active NPI Rural Health Clinic/Center · Poplar Bluff, MO
NPI 1780927871 · NPPES record last updated Sep 16, 2025
Key facts
- NPI
- 1780927871
- 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
- 2002 Kanell Blvd
Poplar Bluff, MO 63901-4045 - Phone
- (573) 727-9130
- Fax
- (573) 727-9128
- NPI assigned
- Mar 27, 2013
- Organization subpart
- No
Authorized official
- Name
- Krista Berry
- Title
- Cfo
- Phone
- (573) 331-6028
Owners & managing parties with NPI records 1
-
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
Related certifications (CCN) 1
Facilities with the same owner 116
Practitioners 40
-
Akeeb Adedokun, MD
-
Cara M Dillinger, NP-C
-
Kimberly Essner, MS-PAC
-
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.
-
Rodney T. Rubi, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Rural health clinic certification: CCN 268736
- 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
- May 11, 2016
- Last certification
- May 10, 2023
- Ownership / control type
- 2B
- Organization structure
- LLC · Non-profit
- Enrollment address
- 2002 Kanell Blvd
Poplar Bluff, MO 63901-1000 - 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 |
Jan 1, 2024 | |
| Krista Berry |
Corporate Director |
Dec 20, 2023 | |
| W-2 Managing Employee |
Dec 20, 2023 | ||
| Marissa Mills |
Corporate Director |
Jan 1, 2024 | |
| Mark Avery |
Corporate Director | Jun 1, 2016 | |
| Andrew Runge |
Corporate Director |
Aug 1, 2025 | |
| Stacie Farnam |
W-2 Managing Employee | Dec 20, 2023 | |
| Southeast Hospital |
5% Or Greater Indirect Ownership Interest | Jan 1, 2013 | 100% |
| 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 | Oct 8, 2013 | |
| Michelle Aycock |
Corporate Director |
Nov 1, 2014 | |
| 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 |
Jan 1, 2024 | |
| Southeasthealth Hospital Holdings, LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 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 |
| O20151211000859 | MO | Part a Provider - Rural Health Clinic | 7315192515 | Practice locations: Poplar Bluff, MO |
National Provider Directory
- Tax ID family
- Southeast Health Center of Stoddard County LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
2002 Kanell Blvd
Poplar Bluff, MO 63901-4045
Mailing address
1200 N One Mile Rd
Dexter, MO 63841-1015
Phone (573) 614-1938
Other names
- MERCY HOSPITAL STODDARD
Other providers in Poplar Bluff, MO
- Son Shine Home Inc
- Sonshine Home Inc
- Jennifer Ilene Sopko
- Pamella Joanne Soto
- Sound Imaging Inc LLC
- Southeast Health Pharmacy LLC
- Southeast Missouri Anesthesia Partners LLC
- Southeast Missouri Behavioral Health
- Southeast Missouri Community Treatment Center Inc
- Southeast Missouri Community Treatment Center, Inc.
All providers in Poplar Bluff, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.