NPIMap

Organization Active NPI

Spectra Health

  • Federally Qualified Health Center (FQHC)
  • Grand Forks, ND
National Provider Identifier
1114343423
Registry record updated Jul 10, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SPECTRA HEALTH
Practice address
212 S 4TH St
Suite 301
Grand Forks, ND 58201-4777
Phone
(701) 757-2100
Fax
(701) 757-0305
NPI assigned
Mar 11, 2014
Last updated
Jul 10, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2019

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

Authorized official

Name
Ben Shannon
Title
Operations Manager
Phone
(701) 757-2812

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

212 S 4TH St
Suite 301
Grand Forks, ND 58201-4777

Mailing address

212 S 4TH St Ste 200
Grand Forks, ND 58201-4781
Phone (701) 757-2100

Other identifiers 1

IdentifierTypeStateIssuer
05925MedicaidND

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050103000307 ND Part B Supplier - Clinic/Group Practice 8022075258 Receives reassigned benefits from 20 practitioners
1 other NPI on this enrollment
Practice locations: Larimore, ND; Grand Forks, ND
O20141203000566 ND Part A Provider - Federally Qualified Health Center (FQHC) 8022075258 Practice locations: Grand Forks, ND

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114343423. Details of each certification follow.

Federally qualified health center certification: CCN 351817

Legal name
SPECTRA HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 30, 2014
Last certification
Jul 30, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 30, 2003 in ND
Enrollment address
212 S 4TH St
Ste 301
Grand Forks, ND 58201-4776

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Locations

607 Towner Ave
Larimore, ND 58251
Phone (701) 318-9399

301 Highway 15 W
Northwood, ND 58267
Phone (701) 587-6000

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Nicole Korsmo Individual Corporate DirectorBoard Member Dec 19, 2011
Chris Griffin Individual Corporate DirectorBoard Member Apr 1, 2008
David Korsmo Individual Corporate DirectorBoard Member Apr 22, 2013
Tiffany Schmidt Individual Corporate OfficerCfo May 1, 2014
Operational/Managerial ControlCfo May 1, 2014
Amy Redding Individual Corporate DirectorBoard Member Apr 1, 2009
Susan Trosen Individual Corporate DirectorBoard Member Apr 23, 2012
Mara Jiran Individual Corporate OfficerCeo Oct 20, 2014
Operational/Managerial ControlCeo Oct 20, 2014
Charles Gillespie Individual Corporate DirectorBoard Member Jul 1, 2010
Salli Lou Anderson Individual Corporate DirectorBoard Member Apr 23, 2012
Bruce Gustavson Individual Corporate DirectorBoard Member Oct 1, 2009
Elizabeth Thompson Individual Corporate DirectorBoard Member Apr 1, 2008
Judy Knutson Individual Corporate DirectorBoard Member Apr 1, 2008
Spectra Health Organization, Northwood, ND Operational/Managerial Control Mar 5, 2014

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 24

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 24

NPI Registry JSON

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

{
    "created_epoch": "1394496000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1562716800000",
    "number": "1114343423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "212 S 4TH ST STE 200",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582014781",
            "telephone_number": "701-757-2100",
            "fax_number": "701-757-0305"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 S 4TH ST",
            "address_2": "SUITE 301",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582014777",
            "telephone_number": "701-757-2100",
            "fax_number": "701-757-0305"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPECTRA HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-11",
        "last_updated": "2019-07-10",
        "status": "A",
        "authorized_official_last_name": "SHANNON",
        "authorized_official_first_name": "BEN",
        "authorized_official_title_or_position": "OPERATIONS  MANAGER",
        "authorized_official_telephone_number": "701-757-2812"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05925",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Forks, ND

Sources for this page

Verify at the official NPI Registry.