NPIMap

Organization Active NPI

Northeast Missouri Health Council, Inc.

Doing business as Northeast Missouri Family Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Edina, MO
National Provider Identifier
1881730893
Registry record updated Nov 11, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Doing business as
Northeast Missouri Family Health Clinic
Practice address
104 E Jackson St
Edina, MO 63537-1335
Phone
(660) 397-3517
Fax
(660) 397-2307
NPI assigned
Jan 29, 2007
Last updated
Nov 11, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTHEAST MISSOURI HEALTH COUNCIL, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 11, 2015

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

Authorized official

Name
Andrew H. Grimm
Title
Executive Director
Phone
(660) 627-5757

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary
Family Medicine Physician 207Q00000X 107529 MO
Family Medicine Physician 207Q00000X R9D62 MO

Addresses

Primary practice location

104 E Jackson St
Edina, MO 63537-1335

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
503351819MedicaidMO

Other names 1

  • Northeast Missouri Family Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO, WI3 enrollments

Enrollment records 3

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
Practice locations: Memphis, MO; Edina, MO; Macon, MO
O20040112000061 MO Part B Supplier - Clinic/Group Practice 1658280805 Receives reassigned benefits from 27 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kirksville, MO
O20060918000511 WI Part A Provider - Federally Qualified Health Center (FQHC) 1658280805 1 other NPI on this enrollment
Practice locations: Edina, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881730893. Details of each certification follow.

Federally qualified health center certification: CCN 261821

Legal name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
NORTHEAST MISSOURI FAMILY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 10, 1992
Last certification
Sep 10, 1992
Ownership / control type
Non-profit – other
Organization structure
CorporationNon-profit
Incorporated
Apr 22, 1968 in MO
Enrollment address
104 E Jackson St
Edina, MO 63537-1335

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 9

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
26D0441634Northeast Missouri Family Health104 East Jackson, Edina, MO 63537Certificate of waiverMar 6, 2028

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

104 E Jackson St
Edina, MO 63537
Phone (660) 397-3517

209 N Missouri St
Macon, MO 63552
Phone (660) 385-4999

Ownership & related parties

All disclosed owners & managing parties 15

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 29, 2020
Tammi Propst Individual W-2 Managing EmployeeTeam Lead May 23, 2005
Jeffrey Doss Individual Corporate Director Nov 17, 2009
Carolyn Ranee Brayton Individual Corporate Officer Jan 23, 2020
Walla Derosear Individual Corporate Director Mar 1, 2012
Ashley Hartman Individual W-2 Managing Employee Jan 1, 2014
David Richard Rector Individual Corporate Director Nov 17, 2009
Karen Ann Lumley Individual Corporate Director Nov 1, 2009
Tiffany Labeth Individual Corporate DirectorBoard Member Aug 22, 2013
Phil McIntosh Individual Corporate Officer Jan 29, 2020
Carolyn Primm Individual Corporate Director May 26, 2011
Richard Gooch Individual Corporate Director May 26, 2011
Pam Smith Individual Corporate DirectorBoard Member Sep 26, 2013
John Thibaut Heard Individual Corporate Director Nov 17, 2009
Andrew Grimm Individual Corporate Director Nov 3, 2009
W-2 Managing Employee Nov 3, 2009

All facility ownership & control disclosures 4

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
Memphis Community Health CenterMemphis, MO, CCN 261932 Federally qualified health center Operational/Managerial Control Apr 21, 1968

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 14

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 14

NPI Registry JSON

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

{
    "created_epoch": "1170028800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447200000000",
    "number": "1881730893",
    "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": "104 E JACKSON ST",
            "city": "EDINA",
            "state": "MO",
            "postal_code": "635371335",
            "telephone_number": "660-397-3517",
            "fax_number": "660-397-2307"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MISSOURI HEALTH COUNCIL, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEAST MISSOURI HEALTH COUNCIL, INC.",
        "enumeration_date": "2007-01-29",
        "last_updated": "2015-11-11",
        "status": "A",
        "authorized_official_last_name": "GRIMM",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "660-627-5757"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "107529",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R9D62",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "503351819",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeast Missouri Family Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Edina, MO

Sources for this page

Verify at the official NPI Registry.