NPIMap

Organization Active NPI

Mosaic Medical Center - Maryville

Doing business as Mosaic Specialty Care - West

  • Rural Health Clinic/Center
  • Maryville, MO
National Provider Identifier
1821562265
Registry record updated Mar 1, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MOSAIC MEDICAL CENTER - MARYVILLE
Doing business as
Mosaic Specialty Care - West
Practice address
2016 S Main St
Maryville, MO 64468-2655
Phone
(660) 562-2525
Fax
(660) 526-4303
NPI assigned
Jan 18, 2019
Last updated
Mar 1, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 1, 2019

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

Authorized official

Name
Dwight R Carvell
Title
Director of Reimbursement
Phone
(816) 273-0473

Specialties & licenses 1

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

Addresses

Primary practice location

2016 S Main St
Maryville, MO 64468-2655

Mailing address

2016 S Main St
Maryville, MO 64468-2655
Phone (660) 562-2525

Other names 1

  • Mosaic Specialty Care - West Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190416000538 MO Part A Provider - Rural Health Clinic 3678813896 Practice locations: Maryville, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821562265. Details of each certification follow.

Rural health clinic certification: CCN 268540

Legal name
MOSAIC MEDICAL CENTER - MARYVILLE
Doing business as
MOSAIC SPECIALTY CARE - WEST
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 17, 2002
Last certification
Sep 25, 2024
Ownership / control type
2B
Most recent change of ownership
Apr 1, 2019 (1 total)
Organization structure
CorporationNon-profit
Enrollment address
2016 S Main St
Maryville, MO 64468-2655
Related CCNs
260050

Other NPIs with the same Medicare PAC ID 7

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

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
26D0964420Mosaic Specialty Care - West2016 S Main Street, Maryville, MO 64468Certificate of waiverAug 13, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mosaic Medical Center - Maryville4 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.

Locations

2701 W Edgewood Dr
Ste 101
Jefferson Cty, MO 65109
Phone (573) 634-5303

114 E South Hills Dr
Ste A
Maryville, MO 64468

2016 S Main St
#1
Maryville, MO 64468

2016 S Main St
Bldg 2
Maryville, MO 64468

4510 Frederick Ave
Saint Joseph, MO 64506
Phone (816) 233-1629

802 N Riverside Rd
Ste G60
Saint Joseph, MO 64507
Phone (816) 271-7465

301 E Price Ave
Ste A
Savannah, MO 64485
Phone (816) 324-5644

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Nathan James Blackford Individual Corporate OfficerPresident Feb 24, 2020
Davin G Turner Individual Corporate DirectorVice Chair Apr 1, 2019
Renee Hayes Individual W-2 Managing EmployeeSenior Net Revenue Analyst Sep 24, 2020
Dwight Carvell Individual Corporate DirectorDirector of Reimbursement Dec 28, 2021
Rachael Praiswater Individual W-2 Managing EmployeeProvider Enrollment Specialist Sep 28, 2020
Cynthia G Patterson Individual W-2 Managing EmployeeManaged Care Analyst Apr 1, 2019

Owners & managing parties with NPI records 1

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

Change-of-ownership history 1

DateEventCounterparty
Apr 1, 2019 Change of OwnershipThis provider was the buyer SSM Health Medical GroupCCN 268540, MO, NPI 1912965328

Practitioners & affiliated clinicians

Practitioners 53

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 53

NPI Registry JSON

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

{
    "created_epoch": "1547769600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1551398400000",
    "number": "1821562265",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2016 S MAIN ST",
            "city": "MARYVILLE",
            "state": "MO",
            "postal_code": "644682655",
            "telephone_number": "660-562-2525",
            "fax_number": "660-526-4303"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2016 S MAIN ST",
            "city": "MARYVILLE",
            "state": "MO",
            "postal_code": "644682655",
            "telephone_number": "660-562-2525",
            "fax_number": "660-526-4303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOSAIC MEDICAL CENTER - MARYVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-01-18",
        "last_updated": "2019-03-01",
        "status": "A",
        "authorized_official_last_name": "CARVELL",
        "authorized_official_first_name": "DWIGHT",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "DIRECTOR OF REIMBURSEMENT",
        "authorized_official_telephone_number": "816-273-0473"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mosaic Specialty Care - West",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maryville, MO

Sources for this page

Verify at the official NPI Registry.