NPIMap

Ukhs Great Bend, LLC

Organization Active NPI Rural Health Clinic/Center · Great Bend, KS

NPI 1073003992 · NPPES record last updated Sep 18, 2023

Key facts

NPI
1073003992
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
UKHS GREAT BEND, LLC
Practice address
3515 Broadway Ave
Great Bend, KS 67530-3633
Phone
(620) 792-5341
NPI assigned
May 16, 2018
Organization subpart
No

Authorized official

Name
Jesse Mock
Title
Authorized Official
Phone
(620) 791-6272

Owners & managing parties with NPI records 17

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

Other NPIs with the same Medicare PAC ID 5

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

Corporate family (same tax ID) 10

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

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

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Facilities with the same owner 25

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

Practitioners 69

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 69

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
17D0452730Ukhs St Rose Medical Pavilion
3515 Broadway Ave, Floors 1 & 3, Great Bend, KS 67530		Certificate of waiverSep 7, 2026

Medicare participation

Medicare fee-for-service enrollment
Enrolled in KS

Rural health clinic certification: CCN 178576

Legal name
UKHS GREAT BEND LLC
Doing business as
ST. ROSE MEDICAL PAVILION
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 1, 2013
Last certification
Jul 22, 2015
Ownership / control type
1B
Most recent change of ownership
Aug 1, 2018 (1 total)
Organization structure
LLC
Enrollment address
3515 Broadway Ave
Great Bend, KS 67530-3633
Related CCNs
170191

All disclosed owners & managing parties 31

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

NameRoleSinceShare
Elizabeth Carlton
Individual 		Corporate Director Jan 1, 2024
Christopher B Brown
Individual 		Corporate Director Jan 1, 2025
Timothy a Latimer
Individual 		Corporate Officer Sep 5, 2019
Heath Edward Latham
Individual 		Corporate Director Jan 1, 2024
Jolene Biggs
Individual 		Corporate Director Jan 1, 2024
Ann St. Peter
Individual 		Corporate Director Jan 1, 2024
Mark D Calcara
Individual 		Corporate Director Jan 1, 2024
Monte Coffman
Individual 		Corporate Director Jan 1, 2024
Jean Giddens
Individual 		Corporate Director Jan 1, 2024
Debbie Wilkerson
Individual 		Corporate Director Jan 1, 2024
Steven W Stites
Individual 		Corporate Director Jan 1, 2025
Catherine R Wiens
Individual 		Corporate Officer Sep 1, 2023
Jesus Loera
Individual 		Corporate Director Jan 1, 2024
Talal W Khan
Individual 		Corporate Director Jan 1, 2024
Jack a Newman
Individual 		Corporate Director Jan 1, 2024
Elizabeth H King
Individual 		Corporate Director Jan 1, 2024
Gregory Graves
Individual 		Corporate Director Jan 1, 2024
John Worden
Individual 		Corporate Officer Sep 1, 2023
Operational/Managerial Control Sep 1, 2023
Maureen Mahoney
Individual 		Corporate Director Jan 1, 2024
Daniel Peters
Individual 		Corporate Officer Sep 1, 2023
Douglas a Girod
Individual 		Corporate Director Jan 1, 2024
Robba Moran
Individual 		Corporate Director Jan 1, 2024
Kevin Lockett
Individual 		Corporate Director Jan 1, 2024
David B Dillon
Individual 		Corporate Director Jan 1, 2024
Donita M. Wolf
Individual 		Corporate Director Jan 1, 2024
Robert K Page
Individual 		Corporate Officer Aug 1, 2018
Akinlolu O Ojo
Individual 		Corporate Director Jan 1, 2024
Romano Delcore
Individual 		Corporate Director Jan 1, 2024
University of Kansas Hospital Authority
Organization · Kansas City, KS
Non-profit 		5% Or Greater Direct Ownership Interest Aug 1, 2018 99.9%
Matthias a Salathe
Individual 		Corporate Director Jan 1, 2024
Mark Uhlig
Individual 		Corporate Director Jan 1, 2024

Change-of-ownership history

DateEventCounterparty
Aug 1, 2018 Change of Ownership
This provider was the buyer		 Central Kansas Family Practice
CCN 178576 · KS · NPI 1811234818

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20180918002956 KS Part a Provider - Rural Health Clinic 5597016378 Practice locations: Great Bend, KS

National Provider Directory

Tax ID family
Ukhs Great Bend LLC (11 organizations share this tax ID)

Locations

514 Cleveland St
#2
Great Bend, KS 67530

1309 Polk St Great Bnd
Saint Louis, MO 63195

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Yes

Addresses

Primary practice location

3515 Broadway Ave
Great Bend, KS 67530-3633

Mailing address

3515 Broadway Ave
Great Bend, KS 67530-3633
Phone (620) 792-5341

Other providers in Great Bend, KS

All providers in Great Bend, KS · Rural Health Clinic/Center in Kansas

Sources for this page

Verify at the official NPI Registry.