Grande Ronde Hospital, Inc
Organization Active NPI Rural Health Clinic/Center · Elgin, OR
NPI 1043694342 · NPPES record last updated Apr 26, 2017
Key facts
- NPI
- 1043694342
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- GRANDE RONDE HOSPITAL, INC
- Practice address
- 570 8TH
Elgin, OR 97827 - Phone
- (541) 437-6321
- NPI assigned
- Jul 16, 2015
- Organization subpart
- No
Authorized official
- Name
- Mr. James A Mattes
- Title
- President/Ceo
- Phone
- (541) 963-1454
Owners & managing parties with NPI records 10
-
Blake Gornowicz, MD
-
Stephen McLean, DMD
Owned or controlled facilities with NPI records 6
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 10
Related certifications (CCN) 4
Facilities with the same owner 5
Practitioners 98
-
Maricela Elena Bandel-Ramirez, AGACNP
-
Andrew Dale Baum, DPM
-
Raffaella Sappe Betza, M.D.
-
Debora Brown-Cumpton, LCSW
-
Marcus Paul Carr, M.D.
-
Bradley Robert Close, CRNA
-
Aaron Randy Cooper, PA-C
-
Brooke Davis, DO
-
Gerry F Funk, MD
-
Geraldine Gardner, D.O.
-
Blake Gornowicz, MD
-
Jamie Jo Haddock, NP-C
-
Ellen Faye Hills, NP
-
Heather Holland, MSW, LCSW
-
Jared Johnathan Hulme, APRN, DNP, FNP-C
-
Leslie W Jackson, MD
-
Zachary Michael Jacobsen, CRNA
-
Jesse Jarnes, CRNA
-
John Karlin, ARNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 38D1089293 | Grande Ronde Hospital Elgin Clinic | Certificate of waiver | Aug 2, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
Rural health clinic certification: CCN 388524
- Legal name
- GRANDE RONDE HOSPITAL INC
- Doing business as
- GRANDE RONDE HOSPITAL ELGIN CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 29, 2016
- Last certification
- Apr 11, 2024
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 1, 1986 in OR
- Enrollment address
- 570 S 8TH Ave
Elgin, OR 97827-9726 - Related CCNs
- 381321
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Stephen M McLean |
Corporate Officer |
Jan 1, 2016 | |
| Grande Ronde Hospital Inc |
5% Or Greater Direct Ownership Interest | Nov 1, 2005 | 100% |
| Samuel H Kimball |
Corporate Officer |
Feb 22, 2017 | |
| Michael a Hetrick |
Corporate Officer |
Jan 1, 2016 | |
| Suzanne D Hopper |
Corporate Officer |
Jan 1, 2015 | |
| Blake a Gornowicz |
Corporate Officer |
Jan 1, 2022 | |
| Robert P Seymour |
Corporate Officer |
Nov 16, 2011 | |
| W-2 Managing Employee |
Nov 16, 2011 | ||
| Lara Kay Moore |
Corporate Officer |
Nov 16, 2016 | |
| John Garlitz |
Corporate Officer |
Jan 1, 2016 | |
| Nicholas Alvin Huelter |
Corporate Officer |
Jan 1, 2021 | |
| Jeremy P Davis |
Corporate Officer |
Nov 26, 2018 | |
| W-2 Managing Employee | Nov 26, 2018 | ||
| Teri S Champlin |
Corporate Officer |
Jan 1, 2014 | |
| Jared Cole Rogers |
Corporate Officer |
Dec 24, 2019 | |
| Robert Coulter |
Corporate Officer |
Jan 1, 2021 | |
| Michael E Billman |
Corporate Officer |
Jan 1, 2019 |
All facility ownership & control disclosures 5
| Facility | Type | Role | Since |
|---|---|---|---|
| Grande Ronde Hospital Inc |
Hospital | Operational/Managerial Control | May 31, 1966 |
| Grande Ronde Hospital Regional Medical Clinic |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) | Nov 1, 2005 |
| Grande Ronde Hospital Women'S & Children'S Clinic |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) | Nov 1, 1996 |
| Grande Ronde Hospital Union Clinic |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) | Nov 1, 2005 |
| Grande Ronde Hospital Urgent Care |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) | Sep 14, 2020 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150909002846 | OR | Part a Provider - Rural Health Clinic | 0547170789 | Practice locations: Elgin, OR |
National Provider Directory
- Tax ID family
- Robert Fuller MD
Locations
570 N 8th Ave
Elgin, OR 97827
Phone (541) 437-2273
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
570 8TH
Elgin, OR 97827
Mailing address
PO Box 3290
La Grande, OR 97850-7290
Phone (541) 963-1555
Other names
- GRANDE RONDE HOSPITAL ELGIN CLINIC
Other providers in Elgin, OR
- Melissa E Coe
- Elgin Family Dental LLC
- Elgin Health Center LLC
- Elisha Mayes, DDS, PC
- Ashley Nicole Gibbs
- Grande Ronde Hospital, Inc
- Kali Gray
- Jamie Jo Haddock
- Hope Mental Health Services, LLC
- Julia Lee Jones
All providers in Elgin, OR · Rural Health Clinic/Center in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 26, 2017. 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.