NPIMap

Organization Active NPI

County of Clay

  • Rural Health Clinic/Center
  • Clay City, IL
National Provider Identifier
1871950550
Registry record updated Sep 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COUNTY OF CLAY
Practice address
800 Kelly Dr SW
Clay City, IL 62824-1155
Phone
(618) 662-2191
Fax
(618) 662-1482
NPI assigned
Jan 26, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 17, 2021

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

Authorized official

Name
Carrie Miller
Title
Chief Nursing Officer
Phone
(618) 662-2131

Specialties & licenses 1

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

Addresses

Primary practice location

800 Kelly Dr SW
Clay City, IL 62824-1155

Mailing address

PO Box 280
Flora, IL 62839-0280
Phone (618) 662-2131

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160315002731 IL Part A Provider - Rural Health Clinic 0042101982 Practice locations: Clay City, IL

Rural health clinic certification: CCN 148558

Legal name
COUNTY OF CLAY
Doing business as
CLAY CITY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 2, 2016
Last certification
Sep 2, 2016
Ownership / control type
Non-profit – church related
Organization structure
GovernmentProprietary
Enrollment address
939 Sunset Rd SW
Clay City, IL 62824-1113
Related CCNs
141351

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

Other NPIs with the same Medicare PAC ID 5

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
14D2110284Clay County Hospital Clay City Med Clinic939 Sunset Rd SW, Clay City, IL 62824Certificate of waiverMar 10, 2028

National Provider Directory

National Provider Directory
Tax ID family
Clay County Hospital9 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.

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
County of Clay Organization, Flora, IL 5% Or Greater Direct Ownership Interest Mar 1, 2016 100%
Ariane Souder Individual W-2 Managing EmployeeChief of Clinic Operations Mar 26, 2018
Jody Gillum Individual Corporate OfficerChief Nursing Officer Oct 13, 2022
W-2 Managing EmployeeChief Nursing Officer Oct 13, 2022

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Clay County HospitalFlora, IL, CCN 141351 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966
Clay County HospitalFlora, IL, CCN 14Z351 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966
Louisville Medical ClinicLouisville, IL, CCN 143487 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2006
CCH Medical ClinicFlora, IL, CCN 143458 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2010

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 4

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

Practitioners & affiliated clinicians

Practitioners 88

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 88

NPI Registry JSON

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

{
    "created_epoch": "1453766400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631836800000",
    "number": "1871950550",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 280",
            "city": "FLORA",
            "state": "IL",
            "postal_code": "628390280",
            "telephone_number": "618-662-2131",
            "fax_number": "618-662-1482"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 KELLY DR SW",
            "city": "CLAY CITY",
            "state": "IL",
            "postal_code": "628241155",
            "telephone_number": "618-662-2191",
            "fax_number": "618-662-1482"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTY OF CLAY",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-26",
        "last_updated": "2021-09-17",
        "certification_date": "2021-09-17",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "CARRIE",
        "authorized_official_title_or_position": "CHIEF NURSING OFFICER",
        "authorized_official_telephone_number": "618-662-2131"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Clay City, IL

Sources for this page

Verify at the official NPI Registry.