St. Croix Regional Medical Center
Organization Active NPI Rural Health Clinic/Center · Balsam Lake, WI
NPI 1013423219 · NPPES record last updated Jan 25, 2023
Key facts
- NPI
- 1013423219
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 1041 (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
- Organization subpart
- No
Authorized official
- Name
- Mike Youso
- Title
- Cfo
- Phone
- (715) 483-0553
Owners & managing parties with NPI records 1
-
Rebecca R Lyman, M.D.
Owned or controlled facilities with NPI records 2
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 2
Related certifications (CCN) 1
Practitioners 486
-
Sarah Marie Arnone, D.O.
-
Heather J Ash, NP
-
Penny Lynn Bearheart, LPC, SAC
-
Sarah A Bengtson, NP
-
Jeanine L Brunclik, M.D.
-
Dana Marie Burcar, PA-C
-
Carissa Marie Carlson, PA-C
-
Jonn B. Dinnies, PA-C
-
Colleen E Erb, PSY. D.
-
Nathan C Fritsch, CRNA
-
Faith A. Gustafson, PA-C
-
Jeffrey M Hall, M.D.
-
Melissa L Hall, M.D.
-
Inieke Mike Ikpe, M.D.
-
Leah B Jacobs, NP
-
Andrew Johnson, APNP
-
Jeanne M Johnson, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 52D0397078 | Unity Clinic | Accreditation | Jun 6, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
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
- Corporation · Non-profit
- Incorporated
- Mar 15, 1954 in WI
- Enrollment address
- 1504 190TH Ave
Balsam Lake, WI 54810-7102 - Related CCNs
- 521337
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Karen Hauer |
Corporate Director | Nov 30, 2021 | |
| Michael J Youso |
Corporate Officer |
Jun 28, 2022 | |
| Trudy Canine |
Corporate Director | Oct 27, 2020 | |
| Mark Burandt |
Corporate Director | Apr 23, 2024 | |
| William Ties |
Corporate Director | Oct 30, 2019 | |
| Kimberly J Ericson |
Corporate Officer |
Apr 17, 2023 | |
| Rebecca R Lyman |
Corporate Director |
Sep 1, 2018 | |
| Tanya K Mortel |
W-2 Managing Employee |
Jan 6, 1992 |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Adoray Home Health and Hospice |
Home health agency | 5% Or Greater Direct Ownership Interest (18.62%) | Sep 1, 2014 |
| Adoray Home Health and Hospice |
Hospice | 5% Or Greater Direct Ownership Interest (18.62%) | Sep 1, 2014 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180803001628 | WI | Part a Provider - Rural Health Clinic | 9335032184 | Practice locations: Balsam Lake, WI |
National Provider Directory
- Tax ID family
- St Croix Regional Medical
Locations
13185 Saint Croix Ave
Lindstrom, MN 55045
Phone (651) 257-4445
26425 Lakeland Ave S
Webster, WI 54893
Phone (715) 866-4271
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 1041 | WI | Yes |
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
- Unity Clinic
Other providers in Balsam Lake, WI
- Polk County-Dept of Administration
- Polk County-Dept of Administration
- Nicole A Ruetz
- Karen Rusch
- School District of Unity
- Corby Rae Stark
- Nancy Lee Stewart
- Tjzarn Ventures LLC
- Diane M Torres
- Unity Pharmacy, LLC
All providers in Balsam Lake, WI · Rural Health Clinic/Center in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 25, 2023. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.