NPIMap

Organization Active NPI

Vanderbilt Bedford Hospital, LLC

Doing business as Vanderbilt Integrated Primary Care Shelbyville

  • Rural Health Clinic/Center
  • Shelbyville, TN
National Provider Identifier
1952900862
Registry record updated Mar 31, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
VANDERBILT BEDFORD HOSPITAL, LLC
Doing business as
Vanderbilt Integrated Primary Care Shelbyville
Practice address
1612 N Main St Ste B
Shelbyville, TN 37160-2392
Phone
(931) 685-2022
NPI assigned
Oct 21, 2020
Last updated
Mar 31, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 31, 2022

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

Authorized official

Name
Angela L Simmons
Title
VP - Finance
Phone
(615) 936-8875

Specialties & licenses 1

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

Addresses

Primary practice location

1612 N Main St Ste B
Shelbyville, TN 37160-2392

Mailing address

3841 Green Hills Village Dr Ste 200
Nashville, TN 37215-2691

Other names 1

  • Vanderbilt Integrated Primary Care Shelbyville Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210111000405 TN Part A Provider - Rural Health Clinic 4082026695 Practice locations: Shelbyville, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1952900862. Details of each certification follow.

Rural health clinic certification: CCN 443454

Legal name
VANDERBILT BEDFORD HOSPITAL LLC
Doing business as
VANDERBILT INTEGRATED PRIMARY CARE SHELBYVILLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 30, 2018
Last certification
Mar 30, 2018
Ownership / control type
1B
Organization structure
LLCNon-profit
Enrollment address
1612 N Main St
Ste B
Shelbyville, TN 37160-2392
Related CCNs
440137

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

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Vanderbilt Bedford Hospital6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 20

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

NameRoleSinceShare
John R Ingram Individual Corporate DirectorBoard Member Jul 1, 2022
Cecelia Moore Individual Corporate OfficerTreasurer Oct 9, 2020
Gail Carr Williams Individual Corporate DirectorBoard Member Jul 1, 2023
John Frederick Stein Individual Corporate DirectorGoverning Board Member Oct 9, 2020
Angela Simmons Individual Corporate Director Aug 1, 2021
Daniel Diermeier Individual Corporate DirectorGoverning Board Member Oct 9, 2020
Bruce Evans Individual Corporate DirectorGoverning Board Member Jul 1, 2025
Gina Dudley Individual W-2 Managing Employee Mar 15, 2023
Sheela Krishnasami Parrish Individual W-2 Managing EmployeeMedical Director Jun 1, 2023
Edith Carell Johnson Individual Corporate DirectorGoverning Board Member Oct 9, 2020
Makeba Williams Individual Corporate DirectorBoard Member Jul 1, 2022
Jane Freedman Individual W-2 Managing EmployeeChief Health System Officer Jul 1, 2025
Colin Reed Individual Corporate DirectorBoard Member Jul 1, 2023
Vanderbilt University Medical Center Organization, Nashville, TN Corporation, Non-profit, Chain home office 5% Or Greater Direct Ownership Interest Jan 1, 2021 100%
Operational/Managerial Control Jan 1, 2021
Kenneth W Rich Individual Contracted Managing EmployeePresident Jan 1, 2021
Lucinda M Baier Individual Corporate DirectorBoard Member Jul 1, 2022
Sara Finley Individual Corporate DirectorBoard Member Jan 1, 2022
William F. Carpenter Individual Corporate DirectorGoverning Board Member Jul 1, 2025
Raymond D Mefford Individual Corporate OfficerSecretary/General Counsel Jul 1, 2024
Jeffrey Balser Individual Corporate DirectorGoverning Board Member Oct 9, 2020

Owners & managing parties with NPI records 14

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

View all 14

Facilities with the same owner 19

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

View all 19

Change-of-ownership history 1

DateEventCounterparty
Jan 1, 2021 Change of OwnershipThis provider was the buyer Tennova Family Care-Main StreetCCN 443454, TN, NPI 1144748039

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

NPI Registry JSON

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

{
    "created_epoch": "1603238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648684800000",
    "number": "1952900862",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3841 GREEN HILLS VILLAGE DR STE 200",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372152691"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1612 N MAIN ST STE B",
            "city": "SHELBYVILLE",
            "state": "TN",
            "postal_code": "371602392",
            "telephone_number": "931-685-2022"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VANDERBILT BEDFORD HOSPITAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-21",
        "last_updated": "2022-03-31",
        "certification_date": "2022-03-31",
        "status": "A",
        "authorized_official_last_name": "SIMMONS",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "VP - FINANCE",
        "authorized_official_telephone_number": "615-936-8875"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Vanderbilt Integrated Primary Care Shelbyville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Vanderbilt Integrated Primary Care Shelbyville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shelbyville, TN

Sources for this page

Verify at the official NPI Registry.