NPIMap

Organization Active NPI

Tioga Medical Center

  • Rural Health Clinic/Center
  • Tioga, ND
National Provider Identifier
1124092333
Registry record updated Nov 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TIOGA MEDICAL CENTER
Practice address
810 N Welo St
Tioga, ND 58852-7157
Phone
(701) 664-3368
Fax
(701) 664-3300
NPI assigned
Feb 14, 2006
Last updated
Nov 22, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2016

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

Authorized official

Name
Randall K. Pederson
Title
President/Ceo
Phone
(701) 664-3368

Specialties & licenses 1

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

Addresses

Primary practice location

810 N Welo St
Tioga, ND 58852-7157

Mailing address

PO Box 159
Tioga, ND 58852-0159
Phone (701) 664-3305

Other identifiers 2

IdentifierTypeStateIssuer
8516OtherNDBCBSND
5021MedicaidND

Other names 1

  • Tioga Medical Center-Tioga RHC Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050706000091 ND Part A Provider - Rural Health Clinic 1254390305 Practice locations: Tioga, ND

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124092333. Details of each certification follow.

Rural health clinic certification: CCN 353986

Legal name
TIOGA MEDICAL CENTER
Doing business as
TIOGA MEDICAL CENTER-TIOGA RHC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 11, 1992
Last certification
Jan 7, 2025
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Nov 13, 1953 in ND
Enrollment address
810 N Welo St
Tioga, ND 58852-7157
Related CCNs
351300

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

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Tioga Comm Hospital8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Tioga Medical Center Organization, Tioga, ND Non-profit 5% Or Greater Direct Ownership Interest Aug 1, 1990 100%
Seth Wisthoff Individual Corporate DirectorDirector Mar 18, 2019
James W Booth Individual Corporate DirectorChairman Mar 20, 2013
Wendy Lenzen Individual Corporate DirectorDirector Mar 20, 2023
Patrick Joyce Individual Corporate DirectorDirector Mar 20, 2023
Kristopher Kuehn Individual Corporate DirectorDirector Mar 20, 2023
Jeremy Becker Individual Corporate DirectorDirector Apr 1, 2019
Lee a Olson Individual Corporate DirectorDirector Mar 20, 2017
Holly Bryant Individual Corporate OfficerChief Financial Officer Feb 21, 2023
W-2 Managing EmployeeChief Financial Officer Jan 27, 2023
Operational/Managerial ControlChief Financial Officer Jan 27, 2023
Jamie Eraas Individual Corporate OfficerChief Executive Officer Jan 27, 2023
W-2 Managing EmployeeChief Executive Officer Jan 27, 2023
Operational/Managerial ControlChief Executive Officer Jan 27, 2023
Nathan Germundson Individual Corporate DirectorDirector Apr 1, 2020
Brodie Odegaard Individual Corporate DirectorVice-Chairman Mar 20, 2017

Owners & managing parties with NPI records 6

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

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tioga Medical Center LTCTioga, ND, CCN 355034 Skilled nursing facility Operational/Managerial Control (100%) Jan 1, 1978
Tioga Medical Center - Powers Lake RHCPowers Lake, ND, CCN 353987 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Aug 1, 1990
Aug 1, 1990
Tioga Medical Center-Ray RHCRay, ND, CCN 353988 Rural health clinic Operational/Managerial Control (100%) Apr 15, 1992

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1139875200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1479772800000",
    "number": "1124092333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 159",
            "city": "TIOGA",
            "state": "ND",
            "postal_code": "588520159",
            "telephone_number": "701-664-3305",
            "fax_number": "701-664-2240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "810 N WELO ST",
            "city": "TIOGA",
            "state": "ND",
            "postal_code": "588527157",
            "telephone_number": "701-664-3368",
            "fax_number": "701-664-3300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIOGA MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-14",
        "last_updated": "2016-11-22",
        "status": "A",
        "authorized_official_last_name": "PEDERSON",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_middle_name": "K.",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "701-664-3368"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSND",
            "identifier": "8516",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5021",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tioga Medical Center-Tioga RHC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Tioga, ND

Sources for this page

Verify at the official NPI Registry.