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Organization Active NPI

Holzer Medical Center Jackson

  • Medicare Defined Swing Bed Hospital Unit
  • Jackson, OH
National Provider Identifier
1013058882
Registry record updated May 8, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
Legal business name
HOLZER MEDICAL CENTER JACKSON
Practice address
500 Burlington Rd
Jackson, OH 45640-9360
Phone
(740) 395-8500
Fax
(740) 395-8502
NPI assigned
Feb 12, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 8, 2018

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

Authorized official

Name
Michael R Canady, MDNPI 1396798948
Title
Ceo
Phone
(740) 446-5051

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X Primary
Clinical Medical Laboratory 291U00000X

Addresses

Primary practice location

500 Burlington Rd
Jackson, OH 45640-9360

Mailing address

500 Burlington Rd
Jackson, OH 45640-9360
Phone (740) 395-8500

Other identifiers 1

IdentifierTypeStateIssuer
2224195MedicaidOH

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220804002346 OH Part A Provider - Critical Access Hospital 0244147239 Practice locations: Jackson, OH

Hospital certification: CCN 36Z320

Legal name
HOLZER MEDICAL CENTER JACKSON
Organization structure
CorporationNon-profit
Incorporated
Aug 8, 2000 in OH
Enrollment address
500 Burlington Rd
Jackson, OH 45640-9360
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory

Locations

140 Jenkins Memorial Rd
Wellston, OH 45692
Phone (740) 384-2167

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Gerald Roach Individual Corporate DirectorChairman of the Board Jan 1, 2024
Lori Harrison Individual W-2 Managing EmployeeCredentialling Coordinator May 11, 2018
Shana R Booher Individual Corporate DirectorDirector of Credentialing Jan 1, 2020
Brent Saunders Individual Corporate DirectorBoard Member Jan 1, 2024
Brad Munn Individual Corporate DirectorBoard Member Oct 17, 2007
Craig Alan Mason Individual W-2 Managing EmployeeCredentialing Coordinator Sep 26, 2022
Rodney Barry Stout Individual Corporate OfficerChief Executive Officer Jan 1, 2024
Robert Grillo Individual Corporate DirectorBoard Member Oct 17, 2007
Larry Kidd Individual Corporate DirectorBoard Member Oct 21, 2009
Michael R Canady Individual Corporate DirectorBoard Member Jan 1, 2024
Holzer Health System Organization, Gallipolis, OH Corporation Operational/Managerial Control Aug 8, 2000
Nicolette M Jones Individual Corporate OfficerChief Medical Officer Jan 1, 2024

Owners & managing parties with NPI records 2

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

Facilities with the same owner 7

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

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1171238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1525737600000",
    "number": "1013058882",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 BURLINGTON RD",
            "city": "JACKSON",
            "state": "OH",
            "postal_code": "456409360",
            "telephone_number": "740-395-8500",
            "fax_number": "740-395-8502"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 BURLINGTON RD",
            "city": "JACKSON",
            "state": "OH",
            "postal_code": "456409360",
            "telephone_number": "740-395-8500",
            "fax_number": "740-395-8502"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOLZER MEDICAL CENTER JACKSON",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-12",
        "last_updated": "2018-05-08",
        "status": "A",
        "authorized_official_last_name": "CANADY",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "740-446-5051",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2224195",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jackson, OH

Sources for this page

Verify at the official NPI Registry.