NPIMap

Organization Active NPI

Marshall County Hospital District

Doing business as Marshall County Surgical & Medical Group

  • Rural Health Clinic/Center
  • Benton, KY
National Provider Identifier
1962873109
Registry record updated Oct 14, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MARSHALL COUNTY HOSPITAL DISTRICT
Doing business as
Marshall County Surgical & Medical Group
Practice address
619 Old Symsonia Rd
Benton, KY 42025-5094
Phone
(270) 527-2411
Fax
(270) 527-8734
NPI assigned
Oct 14, 2015
Last updated
Oct 14, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 14, 2015

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

Authorized official

Name
David G Fuqua
Title
Ceo
Phone
(270) 527-4850

Specialties & licenses 1

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

Addresses

Primary practice location

619 Old Symsonia Rd
Benton, KY 42025-5094

Mailing address

619 Old Symsonia Rd
Benton, KY 42025-5094
Phone (270) 527-2411

Other names 1

  • Marshall County Surgical & Medical Group Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160108000040 KY Part A Provider - Rural Health Clinic 3375581986 Practice locations: Benton, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962873109. Details of each certification follow.

Rural health clinic certification: CCN 183492

Legal name
MARSHALL COUNTY HOSPITAL DISTRICT
Doing business as
MARSHALL COUNTY HOSPITAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 3, 2016
Last certification
Nov 3, 2016
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Oct 31, 1974 in KY
Enrollment address
617 Old Symsonia Rd
Benton, KY 42025-5042
Related CCNs
181327

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

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Marshall County Hospital District4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Locations

619 Old Symsonia Rd
Benton, KY 42025
Phone (270) 527-0880

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Jeff Smith Individual Corporate DirectorBoard Chairman Jun 1, 2016
Pamela Sirls Individual Corporate DirectorBoard Member Jun 1, 2017
Tiffany Tubbs Individual Corporate OfficerCco Jan 1, 2020
Janice Kelley Individual Corporate OfficerCfo Oct 9, 1995
Steven Luther Individual Corporate Officer Mar 1, 2026
W-2 Managing EmployeeChief Executive Officer Mar 1, 2026
Jerry Sells Individual Corporate Director Jun 1, 2020
James Wiseman Individual Corporate DirectorBoard Secretary Jun 1, 2017
Lauren Mann Individual Corporate DirectorBoard Member Jun 1, 2022

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Marshall County Hospital Home HealthBenton, KY, CCN 187161 Home health agency 5% Or Greater Direct Ownership Interest (25%) Jan 1, 2011

Owned or controlled facilities with NPI records 1

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

  • LHCG Xxiii, LLC

    dba Marshall County Hospital Home Health

    • Home Health Agency
    • Benton, KY
    • NPI 1376845834

    5% Or Greater Direct Ownership Interest

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1444780800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1444780800000",
    "number": "1962873109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "619 OLD SYMSONIA RD",
            "city": "BENTON",
            "state": "KY",
            "postal_code": "420255094",
            "telephone_number": "270-527-2411",
            "fax_number": "270-527-8734"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "619 OLD SYMSONIA RD",
            "city": "BENTON",
            "state": "KY",
            "postal_code": "420255094",
            "telephone_number": "270-527-2411",
            "fax_number": "270-527-8734"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARSHALL COUNTY HOSPITAL DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-14",
        "last_updated": "2015-10-14",
        "status": "A",
        "authorized_official_last_name": "FUQUA",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "270-527-4850"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marshall County Surgical & Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Benton, KY

Sources for this page

Verify at the official NPI Registry.