NPIMap

Organization Active NPI

Northeast Missouri Health Council Inc

Doing business as Memphis Community Health Center

  • Internal Medicine Physician
  • Memphis, MO
National Provider Identifier
1881307155
Registry record updated Jan 3, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
Memphis Community Health Center
Practice address
118 E Grand Ave
Memphis, MO 63555
Phone
(660) 627-5757
NPI assigned
Jan 3, 2023
Last updated
Jan 3, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTHEAST MISSOURI HEALTH COUNCIL INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 3, 2023

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

Authorized official

Name
Andrew Grimm
Title
Ceo
Phone
(660) 627-5757

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NU Primary

Addresses

Primary practice location

118 E Grand Ave
Memphis, MO 63555

Mailing address

1416 Crown Dr
Kirksville, MO 63501-2548
Phone (660) 627-5757

Other names 1

  • Memphis Community Health Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040107000173 MO Part B Supplier - Clinic/Group Practice 1658280805 Receives reassigned benefits from 14 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Memphis, MO; Edina, MO; Macon, MO
O20230323001915 MO Part A Provider - Federally Qualified Health Center (FQHC) 1658280805 Practice locations: Memphis, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881307155. Details of each certification follow.

Federally qualified health center certification: CCN 261932

Legal name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
MEMPHIS COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 22, 2023
Last certification
Mar 22, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 21, 1968 in MO
Enrollment address
118 E Grand Ave
Memphis, MO 63555-1419

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 4

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

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
26D2275724Memphis Community Health Center118 East Grand Avenue, Memphis, MO 63555Certificate of waiverJan 25, 2027

National Provider Directory

National Provider Directory
Tax ID family
Northeast Missouri Fami13 organizations share this tax ID, including this one
Part of
Northeast Missouri Fami

Other organizations with this tax ID 12

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

Locations

22291 US Highway 136
Kahoka, MO 63445
Phone (660) 727-1500

1410 Crown Dr
Kirksville, MO 63501
Phone (660) 627-3621

402 W Jefferson St
Ste A
Kirksville, MO 63501
Phone (660) 627-2229

118 E Grand Ave
Memphis, MO 63555
Phone (660) 465-7522

52334 Business Highway 5
Milan, MO 63556
Phone (660) 265-1042

604 W Grant St
Princeton, MO 64673
Phone (660) 748-3720

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Chad Sawyer Individual Corporate Officer Jan 23, 2020
Tammi Propst Individual W-2 Managing EmployeeCredentialing Jul 1, 2005
Northeast Missouri Health Council Inc Organization, Kirksville, MO Non-profit Operational/Managerial Control Apr 21, 1968
Jeffrey Doss Individual Corporate Officer Nov 17, 2009
Carolyn Ranee Brayton Individual Corporate Officer Jan 23, 2020
Walla Derosear Individual Corporate Officer Jan 26, 2012
Ashley Hartman Individual W-2 Managing EmployeeExecutive Secretary Jan 1, 2014
David Richard Rector Individual Corporate OfficerVice President Nov 17, 2009
Karen Ann Lumley Individual Corporate Officer Nov 1, 2009
Tiffany Labeth Individual Corporate Officer Aug 22, 2013
Phil McIntosh Individual Corporate Officer Jan 23, 2020
Carolyn Primm Individual Corporate Officer May 26, 2011
Richard Gooch Individual Corporate OfficerSecretary/Treasurer May 26, 2011
Pam Smith Individual Corporate Officer Sep 26, 2003
John Thibaut Heard Individual Corporate OfficerBoard President Nov 17, 2009
Andrew Grimm Individual Corporate DirectorCeo Nov 3, 2009
W-2 Managing EmployeeCeo Nov 3, 2009

Owners & managing parties with NPI records 8

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Macon Family HealthMacon, MO, CCN 261116 Federally qualified health center Operational/Managerial Control (100%) Sep 2, 2015
Kahoka DentalKahoka, MO, CCN 261140 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011
Northeast Family Health AnnexKirksville, MO, CCN 261147 Federally qualified health center Operational/Managerial Control (100%) Aug 15, 2011

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 39

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 39

NPI Registry JSON

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

{
    "created_epoch": "1672704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1672704000000",
    "number": "1881307155",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1416 CROWN DR",
            "city": "KIRKSVILLE",
            "state": "MO",
            "postal_code": "635012548",
            "telephone_number": "660-627-5757",
            "fax_number": "660-627-5802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "118 E GRAND AVE",
            "city": "MEMPHIS",
            "state": "MO",
            "postal_code": "63555",
            "telephone_number": "660-627-5757"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MISSOURI HEALTH COUNCIL INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEAST MISSOURI HEALTH COUNCIL INC",
        "enumeration_date": "2023-01-03",
        "last_updated": "2023-01-03",
        "certification_date": "2022-12-30",
        "status": "A",
        "authorized_official_last_name": "GRIMM",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "660-627-5757"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Memphis Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Memphis, MO

Sources for this page

Verify at the official NPI Registry.