NPIMap

Organization Active NPI

Ukhs Great Bend, LLC

  • Rural Health Clinic/Center
  • Great Bend, KS
National Provider Identifier
1073003992
Registry record updated Sep 18, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 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
Last updated
Sep 18, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 18, 2023

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

Authorized official

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

Specialties & licenses 1

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

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

Medicare participation

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

Enrollment records 1

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073003992. Details of each certification follow.

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

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

Other NPIs with the same Medicare PAC ID 5

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

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
17D0452730Ukhs St Rose Medical Pavilion3515 Broadway Ave, Floors 1 & 3, Great Bend, KS 67530Certificate of waiverSep 7, 2026

National Provider Directory

National Provider Directory
Tax ID family
Ukhs Great Bend LLC11 organizations share this tax ID, including this one

Other organizations with this 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.

Locations

514 Cleveland St
#2
Great Bend, KS 67530

1309 Polk St Great Bnd
Saint Louis, MO 63195

Ownership & related parties

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

Owners & managing parties with NPI records 17

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

View all 17

Facilities with the same owner 25

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

View all 25

Change-of-ownership history 1

DateEventCounterparty
Aug 1, 2018 Change of OwnershipThis provider was the buyer Central Kansas Family PracticeCCN 178576, KS, NPI 1811234818

Change of ownership 1

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

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1526428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694995200000",
    "number": "1073003992",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3515 BROADWAY AVE",
            "city": "GREAT BEND",
            "state": "KS",
            "postal_code": "675303633",
            "telephone_number": "620-792-5341"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3515 BROADWAY AVE",
            "city": "GREAT BEND",
            "state": "KS",
            "postal_code": "675303633",
            "telephone_number": "620-792-5341"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UKHS GREAT BEND, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-05-16",
        "last_updated": "2023-09-18",
        "certification_date": "2023-09-18",
        "status": "A",
        "authorized_official_last_name": "MOCK",
        "authorized_official_first_name": "JESSE",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "620-791-6272"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Great Bend, KS

Sources for this page

Verify at the official NPI Registry.