NPIMap

Organization Active NPI

Northeast Missouri Health Council Inc

Doing business as Northeast Family Health

  • Federally Qualified Health Center (FQHC)
  • Kirksville, MO
National Provider Identifier
1962548974
Registry record updated Jun 24, 2011
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 Family Health
Practice address
1506 Crown Drive
Kirksville, MO 63501
Phone
(660) 627-4493
Fax
(660) 627-4288
NPI assigned
Jan 29, 2007
Last updated
Jun 24, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2011

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 8

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 002241 MO
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 2006005622 MO
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 2005037424 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X R5E64 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X R5N07 MO
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 111208 MO
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X 096968 MO

Addresses

Primary practice location

1506 Crown Drive
Kirksville, MO 63501

Mailing address

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

Other names 1

  • Northeast Family Health Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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
O20060927000296 MO Part A Provider - Federally Qualified Health Center (FQHC) 1658280805 1 other NPI on this enrollment
Practice locations: Kirksville, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962548974. Details of each certification follow.

Federally qualified health center certification: CCN 261848

Legal name
NORTHEAST MISSOURI HEALTH COUNCIL INC
Doing business as
NORTHEAST FAMILY & BEHAVIORAL HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 19, 1998
Last certification
Oct 19, 1998
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 22, 1968 in MO
Enrollment address
1506 Crown Dr
Kirksville, MO 63501-2553

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 6

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
26D0953184Northeast Missouri Family Health1506 Crown Drive, Kirksville, MO 63501Certificate of waiverMay 8, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Jeffrey Doss Individual Corporate DirectorBoard Member Apr 1, 2009
Walla Derosear Individual Corporate DirectorBoard Member Mar 1, 2012
David Richard Rector Individual Corporate DirectorBoard Vice President Apr 1, 2009
Karen Ann Lumley Individual Corporate DirectorBoard Member Apr 1, 2009
Tiffany Labeth Individual Corporate DirectorBoard Member Aug 22, 2013
Carolyn Primm Individual Corporate DirectorBoard Member May 26, 2011
Richard Gooch Individual Corporate DirectorBoard Member Treasurer May 26, 2011
Pam Smith Individual Corporate DirectorBoard Member Sep 26, 2013
John Thibaut Heard Individual Corporate DirectorBoard President Apr 1, 2009
Andrew Grimm Individual Corporate OfficerCeo Apr 1, 2009
W-2 Managing Employee Feb 7, 2014

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 10

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.

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": "1308873600000",
    "number": "1962548974",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1416 CROWN DRIVE",
            "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": "1506 CROWN DRIVE",
            "city": "KIRKSVILLE",
            "state": "MO",
            "postal_code": "63501",
            "telephone_number": "660-627-4493",
            "fax_number": "660-627-4288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MISSOURI HEALTH COUNCIL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-29",
        "last_updated": "2011-06-24",
        "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": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "002241",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2006005622",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2005037424",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R5E64",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "R5N07",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "MO",
            "license": "111208",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MO",
            "license": "096968",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeast Family Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kirksville, MO

Sources for this page

Verify at the official NPI Registry.