Tioga Medical Center
Organization Active NPI Rural Health Clinic/Center · Tioga, ND
NPI 1124092333 · NPPES record last updated Nov 22, 2016
Key facts
- NPI
- 1124092333
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 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
- Organization subpart
- No
Authorized official
- Name
- Randall K. Pederson
- Title
- President/Ceo
- Phone
- (701) 664-3368
Owners & managing parties with NPI records 6
Owned or controlled facilities with NPI records 3
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 7
Related certifications (CCN) 1
Facilities with the same owner 3
Practitioners 10
-
Kari Ely, FNP-C
-
Jeffrey Alden Moberg Jr., PA-C
-
Amber Nelson, FNP-BC
-
David Petrosian, DO
-
Teri Andersen, LPCC
-
Mark G Peterson, MD
-
Andrew C McCoy, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ND
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
- Corporation · Non-profit
- Incorporated
- Nov 13, 1953 in ND
- Enrollment address
- 810 N Welo St
Tioga, ND 58852-7157 - Related CCNs
- 351300
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Tioga Medical Center |
5% Or Greater Direct Ownership Interest | Aug 1, 1990 | 100% |
| Seth Wisthoff |
Corporate Director |
Mar 18, 2019 | |
| James W Booth |
Corporate Director |
Mar 20, 2013 | |
| Wendy Lenzen |
Corporate Director |
Mar 20, 2023 | |
| Patrick Joyce |
Corporate Director |
Mar 20, 2023 | |
| Kristopher Kuehn |
Corporate Director |
Mar 20, 2023 | |
| Jeremy Becker |
Corporate Director |
Apr 1, 2019 | |
| Lee a Olson |
Corporate Director |
Mar 20, 2017 | |
| Holly Bryant |
Corporate Officer |
Feb 21, 2023 | |
| W-2 Managing Employee |
Jan 27, 2023 | ||
| Operational/Managerial Control |
Jan 27, 2023 | ||
| Jamie Eraas |
Corporate Officer |
Jan 27, 2023 | |
| W-2 Managing Employee |
Jan 27, 2023 | ||
| Operational/Managerial Control |
Jan 27, 2023 | ||
| Nathan Germundson |
Corporate Director |
Apr 1, 2020 | |
| Brodie Odegaard |
Corporate Director |
Mar 20, 2017 |
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| Tioga Medical Center LTC |
Skilled nursing facility | Operational/Managerial Control (100%) | Jan 1, 1978 |
| Tioga Medical Center - Powers Lake RHC |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control |
Aug 1, 1990 Aug 1, 1990 |
| Tioga Medical Center-Ray RHC |
Rural health clinic | Operational/Managerial Control (100%) | Apr 15, 1992 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050706000091 | ND | Part a Provider - Rural Health Clinic | 1254390305 | Practice locations: Tioga, ND |
National Provider Directory
- Tax ID family
- Tioga Med Ctr Clinic
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5021 | Medicaid | ND | |
| 8516 | Other | ND | BCBSND |
Other names
- Tioga Medical Center-Tioga RHC
Other providers in Tioga, ND
- Stewart Chiropractic Center PC
- Lorena Kay Stout
- Tioga Drug Inc
- Tioga Fire Department
- Tioga Medical Center
- Tioga Medical Center
- Tioga Medical Center
- Tioga Medical Center
- Tioga Medical Center Hospital
- Tioga Medical Center Pharmacy
All providers in Tioga, ND · Rural Health Clinic/Center in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 22, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.