NPIMap

Organization Active NPI

Southeast Health Center of Stoddard County, LLC

Doing business as Mercy Hospital Stoddard

  • Rural Health Clinic/Center
  • Dexter, MO
National Provider Identifier
1790828812
Registry record updated Sep 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Doing business as
Mercy Hospital Stoddard
Practice address
1200 N One Mile Rd
Dexter, MO 63841-1000
Phone
(573) 624-7575
NPI assigned
Feb 15, 2007
Last updated
Sep 16, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2025

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X MO Primary

Addresses

Primary practice location

1200 N One Mile Rd
Dexter, MO 63841-1000

Mailing address

1200 N One Mile Rd
Dexter, MO 63841-1015
Phone (573) 624-7575

Other names 1

  • MERCY HOSPITAL STODDARD Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130219000154 MO Part A Provider - Rural Health Clinic 7315192515 Practice locations: Dexter, MO
O20130605000128 MO Part B Supplier - Clinic/Group Practice 7315192515 Receives reassigned benefits from 108 practitioners
8 other NPIs on this enrollment
Practice locations: Dexter, MO; Sikeston, MO; Saint Louis, MO; Poplar Bluff, MO; New Madrid, MO; Malden, MO; Bloomfield, MO; Bernie, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790828812. Details of each certification follow.

Rural health clinic certification: CCN 268570

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
Jul 28, 2003
Last certification
Feb 15, 2023
Ownership / control type
2B
Most recent change of ownership
Jan 1, 2013 (3 total)
Organization structure
LLCNon-profit
Incorporated
Nov 30, 2012 in MO
Enrollment address
1200 N One Mile Rd
Dexter, MO 63841-1000
Related CCNs
260160

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

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory
Tax ID family
Southeast Health LLC9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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 17

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

NameRoleSinceShare
Carl E Ammons Individual Corporate OfficerCom Aug 1, 2025
Brian Robison Individual Corporate OfficerSecretary/Treasurer Jan 1, 2024
Krista Berry Individual Corporate DirectorCfo Dec 20, 2023
W-2 Managing EmployeeCfo Nov 2, 2018
Marissa Mills Individual Corporate DirectorVice Chair Jan 1, 2024
Mark Avery Individual Corporate Director Jan 1, 2024
Andrew Runge Individual Corporate DirectorBoard Member Aug 1, 2025
Stacie Farnam Individual W-2 Managing Employee Dec 20, 2023
Mercy Health Organization, Chesterfield, MO Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Dec 20, 2023 100%
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%
Greg Mathis Individual Corporate Director Oct 8, 2013
Michelle Aycock Individual Corporate Director Nov 11, 2014
Southeast Hospital Organization, Cape Girardeau, MO Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Jan 1, 2013 100%
Reza T Jalal Individual Corporate DirectorBoard Member Aug 1, 2025
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%
Ryan Adams Individual Corporate DirectorChairman Jan 1, 2024
Southeasthealth Hospital Holdings, LLC Organization, Cape Girardeau, MO LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 2, 2013 100%
Brian Day Individual Corporate OfficerSenior Vice President Aug 1, 2025

Owners & managing parties with NPI records 4

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 110

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 110

NPI Registry JSON

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

{
    "created_epoch": "1171497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757980800000",
    "number": "1790828812",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 N ONE MILE RD",
            "city": "DEXTER",
            "state": "MO",
            "postal_code": "638411015",
            "telephone_number": "573-624-7575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 N ONE MILE RD",
            "city": "DEXTER",
            "state": "MO",
            "postal_code": "638411000",
            "telephone_number": "573-624-7575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-15",
        "last_updated": "2025-09-16",
        "certification_date": "2025-09-16",
        "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": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MERCY HOSPITAL STODDARD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dexter, MO

Sources for this page

Verify at the official NPI Registry.