NPIMap

Organization Active NPI

St. Croix Regional Medical Center

  • Rural Health Clinic/Center
  • Balsam Lake, WI
National Provider Identifier
1013423219
Registry record updated Jan 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
1041 Issued in WI
Legal business name
ST. CROIX REGIONAL MEDICAL CENTER
Practice address
1504 190TH Ave
Balsam Lake, WI 54810-7102
Phone
(715) 825-3278
Fax
(715) 825-3433
NPI assigned
Dec 26, 2017
Last updated
Jan 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2023

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

Authorized official

Name
Mike Youso
Title
Cfo
Phone
(715) 483-0553

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 1041 WI Primary

Addresses

Primary practice location

1504 190TH Ave
Balsam Lake, WI 54810-7102

Mailing address

235 E State St
Saint Croix Falls, WI 54024-4117
Phone (715) 483-3221

Other names 1

  • Unity Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180803001628 WI Part A Provider - Rural Health Clinic 9335032184 Practice locations: Balsam Lake, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013423219. Details of each certification follow.

Rural health clinic certification: CCN 528605

Legal name
ST. CROIX REGIONAL MEDICAL CENTER
Doing business as
UNITY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 8, 2019
Last certification
May 27, 2026
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Mar 15, 1954 in WI
Enrollment address
1504 190TH Ave
Balsam Lake, WI 54810-7102
Related CCNs
521337

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

Other NPIs with the same Medicare PAC ID 4

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

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
52D0397078Unity Clinic1504 190TH Ave, Balsam Lake, WI 54810AccreditationJun 6, 2027

National Provider Directory

National Provider Directory
Tax ID family
St Croix Regional Med3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

13185 Saint Croix Ave
Lindstrom, MN 55045
Phone (651) 257-4445

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
Karen Hauer Individual Corporate Director Nov 30, 2021
Michael J Youso Individual Corporate OfficerCeo Jun 28, 2022
Trudy Canine Individual Corporate Director Oct 27, 2020
Mark Burandt Individual Corporate Director Apr 23, 2024
William Ties Individual Corporate Director Oct 30, 2019
Kimberly J Ericson Individual Corporate OfficerCfo Apr 17, 2023
Rebecca R Lyman Individual Corporate DirectorVP Medical Affairs Sep 1, 2018
Tanya K Mortel Individual W-2 Managing EmployeeCredentialing Supervisor Jan 6, 1992

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Adoray Home Health and HospiceBaldwin, WI, CCN 527137 Home health agency 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014
Adoray Home Health and HospiceBaldwin, WI, CCN 521521 Hospice 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 483

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 483

NPI Registry JSON

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

{
    "created_epoch": "1514246400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674604800000",
    "number": "1013423219",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "235 E STATE ST",
            "city": "SAINT CROIX FALLS",
            "state": "WI",
            "postal_code": "540244117",
            "telephone_number": "715-483-3221",
            "fax_number": "715-483-0507"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1504 190TH AVE",
            "city": "BALSAM LAKE",
            "state": "WI",
            "postal_code": "548107102",
            "telephone_number": "715-825-3278",
            "fax_number": "715-825-3433"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CROIX REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-12-26",
        "last_updated": "2023-01-25",
        "certification_date": "2023-01-25",
        "status": "A",
        "authorized_official_last_name": "YOUSO",
        "authorized_official_first_name": "MIKE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "715-483-0553"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WI",
            "license": "1041",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Unity Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Balsam Lake, WI

Sources for this page

Verify at the official NPI Registry.