Lake Regional Health System
Organization Active NPI Rural Health Clinic/Center · Iberia, MO
NPI 1891018784 · NPPES record last updated Oct 13, 2023
Key facts
- NPI
- 1891018784
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- LAKE REGIONAL HEALTH SYSTEM
- Practice address
- 2333 Highway 17
Iberia, MO 65486-9331 - Phone
- (573) 793-6900
- Fax
- (573) 793-6688
- NPI assigned
- Mar 5, 2010
- Organization subpart
- No
Authorized official
- Name
- Kevin McRoberts
- Title
- Ceo
- Phone
- (573) 348-8756
Owners & managing parties with NPI records 4
-
Kevin Gerard Byrne, D.O.
-
John C Patton, DO
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 15
Corporate family (same tax ID) 19
Related certifications (CCN) 2
Practitioners 132
-
Kayla Allison, FNP
-
Tara Nicole Andersen, PA-C
-
Julia G Ansari, M.D.
-
Evgeniya Banina, M.D.
-
Katherine Becker, NP
-
Kathy G. Beckner, PA-C
-
David N Bergthold, MSN-ACNP
-
Jason Wells Blair, D.O.
-
Miriam B. Borden, M.D.
-
John Carlyn Brand, D.O.
-
Joshua Palmer Brickner, D.O.
-
Mark P Bryer, MD
-
Kristina Kay Burton, FNP
-
Kevin Gerard Byrne, D.O.
-
Heidi C Calipjo, M.D.
-
Angela Cartwright, D.O.
-
Kimberly Collins, ANP
-
Reed Evans Cope, MD
-
Chelsie Deardeuff, FNP
-
Kaydie Ann Dial, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
Rural health clinic certification: CCN 268710
- Legal name
- LAKE REGIONAL HEALTH SYSTEM
- Doing business as
- LAKE REGIONAL CLINIC-IBERIA
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 1, 2014
- Last certification
- Oct 15, 2024
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 22, 1995 in MO
- Enrollment address
- 2333 Highway 17
Iberia, MO 65486-9331 - Related CCNs
- 260186
All disclosed owners & managing parties 19
| Name | Role | Since | Share |
|---|---|---|---|
| Dennis Michaelree |
Corporate Officer |
Jul 1, 2019 | |
| Corporate Director |
Oct 1, 2009 | ||
| John C Patton |
Corporate Director |
Jun 3, 2022 | |
| Karen K. Faiferlick |
Corporate Officer |
Jun 3, 2022 | |
| Corporate Director |
Jun 30, 2016 | ||
| Gregory D Anderson |
Corporate Director |
Oct 1, 1994 | |
| Kevin G McRoberts |
Corporate Officer |
Jan 3, 2022 | |
| Charles McElyea |
Corporate Officer |
Jun 30, 2016 | |
| Corporate Director |
Nov 1, 2014 | ||
| Mark Rector |
Corporate Director |
Jun 4, 2021 | |
| Warren T Cooper |
Corporate Director |
Jun 6, 2024 | |
| Alan W Mead |
Corporate Director |
Aug 4, 2015 | |
| Paula Littleton |
Corporate Officer |
Jul 22, 2024 | |
| Jason Hulett |
Corporate Officer |
Jun 3, 2022 | |
| Corporate Director |
Jun 4, 2021 | ||
| Jessica Hasty |
W-2 Managing Employee |
Feb 1, 2016 | |
| Corey M Tenbensel |
Corporate Director |
Jun 3, 2011 | |
| Larry Shields |
Corporate Director |
Oct 1, 1975 | |
| John Caine |
Corporate Director |
Jun 1, 1999 | |
| Kevin G Byrne |
Corporate Director |
Oct 1, 2004 | |
| Kristen L Prenger |
Operational/Managerial Control |
Jan 1, 2024 | |
| Wayne Compton |
Corporate Officer |
Jun 1, 2002 | |
| Corporate Director |
Jun 1, 2002 | ||
| James D. Judas |
Corporate Director |
Jun 7, 2013 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Lake Regional Health System |
Skilled nursing facility | 5% Or Greater Direct Ownership Interest (100%) Adp of the SNF Direct Ownership Interest (100%) |
Nov 23, 2006 Jan 3, 2025 Feb 23, 2006 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20140401000871 | MO | Part a Provider - Rural Health Clinic | 9133026776 |
1 other NPI on this enrollment Practice locations: Iberia, MO; Osage Beach, MO |
National Provider Directory
- Tax ID family
- Lake of the Ozarks Gene
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
2333 Highway 17
Iberia, MO 65486-9331
Mailing address
PO Box 801661
Kansas City, MO 64180-1661
Phone (573) 348-8000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891018784 | Medicaid | MO |
Other names
- Lake Regional Clinic - Iberia
Other providers in Iberia, MO
- Chelsie Deardeuff
- Heather Deskin
- Margaret C Hart
- Brian Herzog
- Iberia R-V School District
- Medley Pharmacy Inc.
- Kyle Nichols
- Steven Edwin Reenan
- Gary N Thomsen
All providers in Iberia, MO · Rural Health Clinic/Center in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 13, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.