NPIMap

Organization Active NPI

Allina Health System

Doing business as Allina Health Faribault Medical Center Professional Services

  • Emergency Medicine Physician
  • Faribault, MN
National Provider Identifier
1063832475
Registry record updated Feb 24, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
Legal business name
ALLINA HEALTH SYSTEM
Doing business as
Allina Health Faribault Medical Center Professional Services
Practice address
200 State Ave
Faribault, MN 55021-6339
Phone
(507) 334-6451
NPI assigned
Apr 24, 2014
Last updated
Feb 24, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2025

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

Authorized official

Name
Dominica Tallarico
Title
Coo
Phone
(612) 222-2222

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Group Psychotherapy Psychologist 103TP2701X
Anesthesiology Physician 207L00000X
Emergency Medicine Physician 207P00000X Primary
Psychiatry Physician 2084P0800X

Addresses

Primary practice location

200 State Ave
Faribault, MN 55021-6339

Mailing address

PO Box 43
Mail Route 10585
Minneapolis, MN 55440-0043
Phone (612) 262-1166

Other names 1

  • Allina Health Faribault Medical Center Professional Services Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.cioxhealth.com:8291/Gateway/DocumentSubmission/1_1/NhinService/XDRRequest_Service Other Ciox Health

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040319000460 MN Part B Supplier - Clinic/Group Practice 4587573613 Receives reassigned benefits from 4,246 practitioners
This NPI is an additional NPI on the enrollment
O20141013002446 MN Part A Provider - Hospital 4587573613 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Faribault, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063832475. Details of each certification follow.

Hospital certification: CCN 240071

Legal name
ALLINA HEALTH SYSTEM
Doing business as
ALLINA HEALTH FARIBAULT MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Sep 12, 2015
Beds
99
Ownership / control type
Private (not for profit)
Most recent change of ownership
Jan 1, 2015 (3 total)
Organization structure
CorporationNon-profit
Incorporated
Sep 28, 1983 in MN
Enrollment address
200 State Ave
Faribault, MN 55021-6339
Main/Primary Hospital Location
Hospital subgroups
Acute care

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Allina Health Faribault Medical CenterCCN 240071 · All quality measures
Overall star rating
3 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Locations

825 Nicollet Mall
Ste 300
Minneapolis, MN 55402
Phone (612) 333-8883

255 Smith Ave N
Ste 100
Saint Paul, MN 55102
Phone (651) 241-5000

Ownership & related parties

All disclosed owners & managing parties 28

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

NameRoleSinceShare
Challis Lowe Individual Corporate Director Jun 8, 2022
John Richard Church Individual Corporate DirectorBoard Member Sep 9, 2021
Laura Jean Gillund Individual Corporate DirectorBoard Member Jun 10, 2015
Amy L Ronneberg Individual Corporate DirectorBoard Member Dec 1, 2020
Daniel Thomas O'Laughlin Individual Corporate Director Jan 1, 2022
Maykao Y Hang Individual Corporate DirectorBoard Member Jun 13, 2019
Brian McGrane Individual Corporate DirectorBoard Member Jun 14, 2024
Marna Borgstrom Individual Corporate DirectorBoard Member Jun 13, 2025
Jennifer Soo Alstad Individual Corporate DirectorBoard Member Jun 10, 2016
Shari L Ballard Individual Corporate DirectorBoard Member Jun 10, 2020
Matthew T Wille Individual Corporate OfficerPresident Jun 1, 2026
Timothy Aloysius Welsh Individual Corporate DirectorBoard Member Dec 1, 2017
Vicki Rasmusen Individual Corporate DirectorBoard Member Jun 13, 2019
Debbra Schoneman Individual Corporate DirectorBoard Member Jan 1, 2015
James Kolar Individual Corporate DirectorBoard Director Sep 13, 2024
Lisa Shannon Individual Corporate DirectorPresident and Ceo Jan 1, 2022
Shawn M Ulreich Individual Corporate DirectorBoard Member Sep 13, 2023
Chanda L Baker Individual Corporate DirectorBoard Member Feb 20, 2024
Melinda Estes Individual Corporate DirectorBoard Member Jun 13, 2025
Whitney Ann Johnson Individual Corporate Officer Jan 8, 2024
Louis Julius King Individual Corporate DirectorBoard Member Jun 12, 2017
Ruth Evelyn Williams-Brinkley Individual Corporate DirectorBoard Member Sep 13, 2023
Patricia W Schirmers Individual Corporate DirectorDirector Reimbursement Jan 1, 2015
W-2 Managing EmployeeDirector Reimbursement Jan 1, 2015
Barbara a Butts Williams Individual Corporate DirectorBoard Member Jun 10, 2015
Thomas S Schreier Individual Corporate DirectorBoard Member Jan 1, 2015
Dominica Marie Tallarico Individual Corporate OfficerCoo Mar 11, 2024
Roger Scott Newcome Individual Corporate DirectorManager May 6, 2016
W-2 Managing EmployeeManager May 6, 2016
Joshua Steven Shepherd Individual Corporate OfficerVP Oct 1, 2025

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 21

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 21

Affiliated clinicians 281

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

View all 281

NPI Registry JSON

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

{
    "created_epoch": "1398297600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1740355200000",
    "number": "1063832475",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 43",
            "address_2": "MAIL ROUTE 10585",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554400043",
            "telephone_number": "612-262-1166"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 STATE AVE",
            "city": "FARIBAULT",
            "state": "MN",
            "postal_code": "550216339",
            "telephone_number": "507-334-6451"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALLINA HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-24",
        "last_updated": "2025-02-24",
        "certification_date": "2025-02-24",
        "status": "A",
        "authorized_official_last_name": "TALLARICO",
        "authorized_official_first_name": "DOMINICA",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "612-222-2222"
    },
    "taxonomies": [
        {
            "code": "103TP2701X",
            "taxonomy_group": "",
            "desc": "Psychologist, Group Psychotherapy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207L00000X",
            "taxonomy_group": "",
            "desc": "Anesthesiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.cioxhealth.com:8291/Gateway/DocumentSubmission/1_1/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.6635.1.1",
            "affiliationName": "Ciox Health",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "925 N Point Pkwy",
            "city": "Alpharetta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300055210",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Allina Health Faribault Medical Center Professional Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Faribault, MN

Sources for this page

Verify at the official NPI Registry.