NPIMap

Organization Active NPI

Mobridge Regional Hospital

Doing business as Selby Medical Clinic

  • Rural Health Clinic/Center
  • Selby, SD
National Provider Identifier
1093335333
Registry record updated Jan 28, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MOBRIDGE REGIONAL HOSPITAL
Doing business as
Selby Medical Clinic
Practice address
4401 Main St
Selby, SD 57472-2010
Phone
(605) 649-9999
NPI assigned
Apr 16, 2020
Last updated
Jan 28, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
MOBRIDGE REGIONAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 28, 2021

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

Authorized official

Name
John Joseph Ayoub
Title
Ceo
Phone
(605) 845-8105

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

4401 Main St
Selby, SD 57472-2010

Mailing address

PO Box 580
Mobridge, SD 57601-0580
Phone (605) 649-9999

Other names 1

  • Selby Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040130000772 SD Part B Supplier - Clinic/Group Practice 6507776135 Receives reassigned benefits from 26 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Mobridge, SD
O20200616002751 SD Part A Provider - Rural Health Clinic 6507776135 Practice locations: Selby, SD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093335333. Details of each certification follow.

Rural health clinic certification: CCN 438502

Legal name
MOBRIDGE REGIONAL HOSPITAL
Doing business as
SELBY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 1, 2020
Last certification
Sep 1, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 20, 1953 in SD
Enrollment address
4401 Main St
Selby, SD 57472-2010
Related CCNs
431325

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).

Other NPIs on the same Medicare enrollment 2

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

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
43D2183203Selby Medical Clinic4401 Main St, Selby, SD 57472Certificate of waiverApr 30, 2028

National Provider Directory

National Provider Directory
Part of
Mobridge Regional Hospi

Interoperability endpoints

  • FHIR API: https://fhir-myrecord.cerner.com/r4/95143858-4077-4cf1-b5d2-c2a999f62bb3/

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Renae Karst Individual Corporate Officer Jan 1, 2011
Corporate Director Jan 1, 2011
W-2 Managing Employee Jan 1, 2011
Travis B Henderson Individual Corporate Director Jan 1, 2007
Kristi Kraft Individual W-2 Managing Employee Mar 1, 2015
Christopher Bohlander Individual Corporate Director Jan 1, 2018
Joshua Wudel Individual Corporate Director Jan 27, 2021
Laurie Bauer Individual Corporate Director Jan 27, 2021
Richard Gross Individual Corporate Director Jan 22, 2020
Adam Hayes Individual Corporate Director Jan 22, 2020
Heidi a Roshau Individual Corporate Director Jan 1, 2010
Patricia Schmeichel Individual Corporate Director Jan 1, 2018
William Bachmeier Individual Corporate Director Jan 1, 2006
Lori Heil Individual Corporate Director Sep 1, 2014
Duane J Kraft Individual Corporate Director Jan 1, 2006
Robert C Marciano Individual Corporate Director Jan 1, 2006
John Ayoub Individual Corporate Officer Jan 9, 2017
Corporate Director Jan 9, 2017
W-2 Managing Employee Jan 9, 2017

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 31

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 31

NPI Registry JSON

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

{
    "created_epoch": "1586995200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611792000000",
    "number": "1093335333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 580",
            "city": "MOBRIDGE",
            "state": "SD",
            "postal_code": "576010580",
            "telephone_number": "605-649-9999"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4401 MAIN ST",
            "city": "SELBY",
            "state": "SD",
            "postal_code": "574722010",
            "telephone_number": "605-649-9999"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOBRIDGE REGIONAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOBRIDGE REGIONAL HOSPITAL",
        "enumeration_date": "2020-04-16",
        "last_updated": "2021-01-28",
        "certification_date": "2021-01-28",
        "status": "A",
        "authorized_official_last_name": "AYOUB",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "JOSEPH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "605-845-8105"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Selby Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Selby Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Selby, SD

Sources for this page

Verify at the official NPI Registry.