NPIMap

Organization Active NPI

Sid Peterson Memorial Hospital

Doing business as Peterson Hospice

  • Community Based Hospice Care Agency
  • Kerrville, TX
National Provider Identifier
1063584803
Registry record updated Jul 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
Legal business name
SID PETERSON MEMORIAL HOSPITAL
Doing business as
Peterson Hospice
Practice address
250 Cully Drive
Kerrville, TX 78028
Phone
(830) 258-7799
Fax
(830) 258-7009
NPI assigned
Nov 15, 2006
Last updated
Jul 27, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 27, 2022

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

Authorized official

Name
Lisa Medovich
Title
Chief Financial Officer
Phone
(830) 258-7632

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X TX Primary

Addresses

Primary practice location

250 Cully Drive
Kerrville, TX 78028

Mailing address

250 Cully Drive
Kerrville, TX 78028-5950
Phone (830) 258-7799

Other identifiers 1

IdentifierTypeStateIssuer
1016019MedicaidTX

Other names 1

  • Peterson Hospice Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070802000315 TX Part A Provider - Hospice 6002724887 Practice locations: Kerrville, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063584803. Details of each certification follow.

Hospice certification: CCN 671585

Legal name
SID PETERSON MEMORIAL HOSPITAL
Doing business as
PETERSON HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Feb 29, 2008
Last certification
May 21, 2016
Ownership / control type
Non-Profit - Private
Organization structure
CorporationNon-profit
Incorporated
Feb 13, 1989 in TX
Enrollment address
250 Cully Dr
Kerrville, TX 78028-5950

Other NPIs with the same Medicare PAC ID 4

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

Care Compare: Hospice

Medicare Care Compare
Listed as
Peterson HospiceCCN 671585 · All quality measures
Ownership
Non-Profit
Certified
Feb 29, 2008
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Peterson Home Care6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Gaye Avery Individual Corporate DirectorBoard Member Jul 1, 2024
Michael D Ross Individual Corporate DirectorBoard Member Jul 1, 2024
Norman Williams Individual Corporate DirectorBoard Director Jul 1, 2022
Toni Manchester Individual Corporate Director Jul 1, 2022
Rose Bradshaw Individual Corporate DirectorBoard Director Jul 1, 2022
James a Young Individual W-2 Managing EmployeeMD; Jul 1, 2020
Lisa M Medovich Individual Corporate OfficerCfo Jun 1, 2015
W-2 Managing EmployeeCfo Jun 1, 2015
Brian P Bowers Individual Corporate DirectorHospital Board Member Apr 1, 2017
Sid Peterson Memorial Hospital Organization, Kerrville, TX Corporation 5% Or Greater Direct Ownership Interest Apr 26, 2007 100%
Operational/Managerial Control Apr 26, 2007 100%
Amy F Ives Individual W-2 Managing EmployeeAd; Mar 3, 2025
Joseph Thomas Piszczor Individual Corporate OfficerCoo Jul 14, 2020
W-2 Managing Employee Jul 14, 2020
Jeremy Walther Individual Corporate DirectorBoard Member Jul 1, 2024
Kendall Davison Individual Corporate DirectorBoard Member Jul 1, 2023
Johnathan W McDonald Individual Corporate OfficerPresident/Ceo May 27, 2025
W-2 Managing EmployeePresident/Ceo May 27, 2025
Christopher Ballesteros Individual W-2 Managing EmployeeCompliance Officer Jul 1, 2020
Thomas Houdeshell Individual Corporate DirectorBoard Member Jul 1, 2020
Kristen McAlexander Individual Corporate DirectorBoard Member Jul 1, 2023

Owners & managing parties with NPI records 6

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Peterson Community Care Clinic RHCKerrville, TX, CCN 450007 Hospital 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 1990
Jan 1, 1990
Peterson Regional Medical CenterKerrville, TX, CCN 45T007 Hospital Operational/Managerial Control Jan 1, 1990
Peterson Home CareKerrville, TX, CCN 677052 Home health agency Operational/Managerial Control Feb 13, 2007
Peterson Community Care Clinic RHCKerrville, TX, CCN 678558 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 1990
Jan 1, 1990

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 4

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

Practitioners & affiliated clinicians

Affiliated clinicians 3

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": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658880000000",
    "number": "1063584803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "250 CULLY DRIVE",
            "city": "KERRVILLE",
            "state": "TX",
            "postal_code": "780285950",
            "telephone_number": "830-258-7799",
            "fax_number": "830-258-7009"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "250 CULLY DRIVE",
            "city": "KERRVILLE",
            "state": "TX",
            "postal_code": "78028",
            "telephone_number": "830-258-7799",
            "fax_number": "830-258-7009"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SID PETERSON MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2022-07-27",
        "certification_date": "2022-07-27",
        "status": "A",
        "authorized_official_last_name": "MEDOVICH",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "830-258-7632"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "TX",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1016019",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peterson Hospice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Peterson Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kerrville, TX

Sources for this page

Verify at the official NPI Registry.