NPIMap

Organization Active NPI

Samuel U. Rodgers Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Liberty, MO
National Provider Identifier
1982931655
Registry record updated Jun 11, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SAMUEL U. RODGERS HEALTH CENTER, INC.
Practice address
800 Haines Drive
Liberty, MO 64068
Phone
(816) 792-1575
Fax
(816) 889-1803
NPI assigned
Nov 17, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 11, 2019

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

Authorized official

Name
Robert Theis
Title
Acting Ceo
Phone
(816) 474-4920

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary

Addresses

Primary practice location

800 Haines Drive
Liberty, MO 64068

Mailing address

825 Euclid Ave
Kansas City, MO 64124-2323
Phone (816) 474-4920

Other identifiers 1

IdentifierTypeStateIssuer
504119702MedicaidMO

Other names 1

  • Samuel U. Rodgers Health Center Clay County Family Medicine & Dental Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031105000813 MO Part B Supplier - Clinic/Group Practice 9739092826 Receives reassigned benefits from 81 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Blue Springs, MO; Kansas City, MO; Liberty, MO
O20101015001306 MO Part A Provider - Federally Qualified Health Center (FQHC) 9739092826 Practice locations: Liberty, MO

Federally qualified health center certification: CCN 261043

Legal name
SAMUEL U RODGERS HEALTH CENTER INC
Doing business as
SAMUEL U. RODGERS HEALTH CENTER CLAY COUNTY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 19, 2010
Last certification
Nov 19, 2010
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 21, 1968 in MO
Enrollment address
800 Haines
Liberty, MO 64068-1006

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Samuel Rodgers Comm Ctr11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

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

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Sidney King Individual Corporate DirectorBoard of Director, Chair Dec 20, 2013
Monique Jones Individual W-2 Managing EmployeeCredentialing Co-Ordinator May 28, 2018
Robert Theis Individual Corporate OfficerActing Ceo and Coo Feb 2, 2009
Christopher Walker Individual Corporate OfficerCfo Oct 9, 2017
Elizabeth Bordenave Individual Corporate OfficerBoard of Director, Chair Jan 1, 2024

NPI Registry JSON

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

{
    "created_epoch": "1258416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1982931655",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "825 EUCLID AVE",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641242323",
            "telephone_number": "816-474-4920",
            "fax_number": "816-889-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 HAINES DRIVE",
            "city": "LIBERTY",
            "state": "MO",
            "postal_code": "64068",
            "telephone_number": "816-792-1575",
            "fax_number": "816-889-1803"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAMUEL U. RODGERS HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-17",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "THEIS",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "ACTING CEO",
        "authorized_official_telephone_number": "816-474-4920"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "504119702",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Samuel U. Rodgers Health Center Clay County Family Medicine & Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Liberty, MO

Sources for this page

Verify at the official NPI Registry.