NPIMap

Organization Active NPI

Genesis Health System

Doing business as Genesis Health Group, DeWitt

  • Rural Health Clinic/Center
  • De Witt, IA
National Provider Identifier
1124804182
Registry record updated Jul 9, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GENESIS HEALTH SYSTEM
Doing business as
Genesis Health Group, DeWitt
Practice address
1021 11TH St
De Witt, IA 52742-1209
Phone
(563) 659-9294
Fax
(563) 659-8104
NPI assigned
Sep 6, 2023
Last updated
Jul 9, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
GENESIS HEALTH SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 9, 2026

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

Authorized official

Name
Edward Rogalski
Title
Administrator
Phone
(563) 659-4220

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1021 11TH St
De Witt, IA 52742-1209

Mailing address

PO Box 4028
Rock Island, IL 61204-4028

Other names 1

  • Genesis Health Group, DeWitt Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031113000044 IA Part B Supplier - Clinic/Group Practice 7214841436 Receives reassigned benefits from 306 practitioners
16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bettendorf, IA; Davenport, IA; Eldridge, IA; Durant, IA; De Witt, IA
O20231107003044 IA Part A Provider - Rural Health Clinic 7214841436 Practice locations: De Witt, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124804182. Details of each certification follow.

Rural health clinic certification: CCN 168671

Legal name
GENESIS HEALTH SYSTEM
Doing business as
MERCYONE GENESIS DEWITT FAMILY MEDICINE
Organization structure
CorporationNon-profit
Enrollment address
1021 11TH St
De Witt, IA 52742-1209

Other NPIs with the same Medicare PAC ID 10

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

Other NPIs on the same Medicare enrollment 16

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

View all 16

National Provider Directory

National Provider Directory
Tax ID family
Dav Med37 organizations share this tax ID, including this one
Part of
Dav Med

Other organizations with this tax ID 36

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

View all 36

Locations

1021 11th St
De Witt, IA 52742
Phone (563) 659-9294

Ownership & related parties

All disclosed owners & managing parties 20

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

NameRoleSinceShare
Lyn Ketelsen Individual Corporate DirectorBoard Member Jan 4, 2024
Jordan Voigt Individual Corporate OfficerPresident Jan 4, 2024
Corporate DirectorBoard Member Jan 4, 2024
Charles D Waterman Individual Corporate OfficerChair Apr 30, 2006
Corporate DirectorBoard Member Apr 30, 2006
Robert P Ritz Individual Corporate DirectorBoard Member Mar 1, 2023
Melissa C Pepper Individual Corporate OfficerSecretary Nov 1, 2019
Corporate DirectorBoard Member Nov 1, 2019
Peter Benson Individual Corporate OfficerVice-Chair Sep 3, 2009
Corporate DirectorBoard Member Sep 3, 2009
Robin R Petersen Individual Corporate DirectorBoard Member Jul 29, 2004
Christopher M Crome Individual Corporate OfficerChief Operating Officer Nov 1, 2021
Lashonda Polite Individual Corporate DirectorBoard Member Nov 6, 2020
Edmund P Coyne Individual Corporate DirectorBoard Member Dec 4, 2008
Karen M Fitzsimmons Individual Corporate DirectorBoard Member Nov 6, 2020
Mercy Health Network Inc Organization, Clive, IA Corporation, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Mar 1, 2023 100%
Joseph Malas Individual Corporate OfficerCfo Jul 1, 2020
Mark C. Kilmer Individual Corporate DirectorBoard Member Sep 30, 2003
Dale D Zude Individual Corporate OfficerTreasurer Jan 1, 2025
Corporate DirectorBoard Member Sep 25, 2001
Edwin V Motto Individual Corporate DirectorBoard Member Jul 23, 1996
Trinity Health Corporation Organization, Livonia, MI Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Mar 1, 2023 100%
Patricia S Groves Individual Corporate DirectorBoard Member Oct 9, 2015
David Larson Individual Corporate DirectorBoard Member Mar 6, 2014
Pamela Scott Individual W-2 Managing EmployeeRevenue Integrity Administrator Jan 1, 2006

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Fieldstone of DewittDe Witt, IA, CCN 165619 Skilled nursing facility 5% Or Greater Direct Ownership Interest (40%) Feb 21, 2019
The Summit of BettendorfBettendorf, IA, CCN 165793 Skilled nursing facility 5% Or Greater Direct Ownership Interest (40%) Feb 21, 2019

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 215

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

View all 215

Practitioners & affiliated clinicians

Practitioners 9

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": "1693958400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1783555200000",
    "number": "1124804182",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 4028",
            "city": "ROCK ISLAND",
            "state": "IL",
            "postal_code": "612044028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1021 11TH ST",
            "city": "DE WITT",
            "state": "IA",
            "postal_code": "527421209",
            "telephone_number": "563-659-9294",
            "fax_number": "563-659-8104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESIS HEALTH SYSTEM",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GENESIS HEALTH SYSTEM",
        "enumeration_date": "2023-09-06",
        "last_updated": "2026-07-09",
        "certification_date": "2026-07-09",
        "status": "A",
        "authorized_official_last_name": "ROGALSKI",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "563-659-4220"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "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": "Genesis Health Group, DeWitt",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Genesis Health Group, DeWitt",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in De Witt, IA

Sources for this page

Verify at the official NPI Registry.