Pediatric Rural Health Clinics, Inc
Organization Active NPI Pediatric Nurse Practitioner · Greenville, AL
NPI 1992742860 · NPPES record last updated Oct 11, 2012
Key facts
- NPI
- 1992742860
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatric Nurse Practitioner 363LP0200X
- License
- 1-065300 (AL)
- Legal business name
- PEDIATRIC RURAL HEALTH CLINICS, INC
- Practice address
- 46 L V Stabler Dr
Greenville, AL 36037-3804 - Phone
- (334) 382-9760
- Fax
- (334) 383-9331
- NPI assigned
- Jun 1, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Anne Keen, CRNP
- Title
- VP of Operations
- Phone
- (334) 382-9760
Practitioners 11
-
Melinda Faye Gibson, CRNP
-
Anne Harmon Keen, CRNP
-
Amelia S McNaughton, SLP
-
Tara Mollus, CRNP
-
Rachel Reynolds Moss, CRNP
-
Trina Simmons, CRNP
-
Lauren Smith, CRNP
-
Javier Lorenzo Tapia, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AL
Rural health clinic certification: CCN 013905
- Legal name
- PEDIATRIC RURAL HEALTH CLINICS, INC
- Doing business as
- GREENVILLE PEDIATRICS
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 16, 1998
- Last certification
- Jul 3, 2025
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Nov 25, 1997 in AL
- Enrollment address
- 46 L.V. Stabler Dr.
Greenville, AL 36037-3865
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Anne Keen |
5% Or Greater Direct Ownership Interest | Nov 25, 1997 | 25% |
| W-2 Managing Employee |
Nov 25, 1997 | 25% | |
| John Sumners |
5% Or Greater Direct Ownership Interest | Nov 25, 1997 | 37.5% |
| Corporate Officer |
Nov 25, 1997 | 37.5% | |
| William Sumners |
5% Or Greater Direct Ownership Interest | Nov 25, 1997 | 37.5% |
| Corporate Officer |
Nov 25, 1997 | 37.5% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060328000167 | AL | Part a Provider - Rural Health Clinic | 0042228496 | Practice locations: Greenville, AL |
National Provider Directory
Locations
46 L V Stabler Dr
Greenville, AL 36037
Phone (334) 382-9760
84 L V Stabler Dr
Greenville, AL 36037
Phone (334) 371-3232
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | 00006213 | AL | |
| Pediatrics Physician |
208000000X | 00024891 | AL | |
| Pediatrics Physician |
208000000X | 00006634 | AL | |
| Pediatric Nurse Practitioner |
363LP0200X | 1-065300 | AL | Yes |
| Pediatric Nurse Practitioner |
363LP0200X | 01-069655 | AL |
Addresses
Primary practice location
46 L V Stabler Dr
Greenville, AL 36037-3804
Mailing address
46 L V Stabler Dr
Greenville, AL 36037-3804
Phone (334) 382-9760
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 541003905 | Medicaid | AL | |
| 529800610 | Medicaid | AL |
Other names
- GREENVILLE PEDIATRICS
Other providers in Greenville, AL
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- Keldrian Pate
- Kanu J Patel
- Jason B Peavy
- Samara Dudley Perryman
- Pine Needle of Greenville
- Poised Counseling and Consulting, LLC
- Carol A Pope
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All providers in Greenville, AL · Pediatric Nurse Practitioner in Alabama
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 11, 2012. 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.