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Genesis Health System

Organization Active NPI Rural Health Clinic/Center · De Witt, IA

NPI 1124804182 · NPPES record last updated Jul 9, 2026

Key facts

NPI
1124804182
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
GENESIS HEALTH SYSTEM
Practice address
1021 11TH St
De Witt, IA 52742-1209
Phone
(563) 659-9294
Fax
(563) 659-8104
NPI assigned
Sep 6, 2023
Organization subpart
Yes
Parent organization (as reported)
GENESIS HEALTH SYSTEM

Authorized official

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

Owners & managing parties with NPI records 4

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

Owned or controlled facilities with NPI records 2

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

Other NPIs on the same Medicare enrollment 16

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

Other NPIs with the same Medicare PAC ID 10

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

Corporate family (same tax ID) 36

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

View all 36

Facilities with the same owner 215

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

View all 215

Practitioners 220

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 220

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in IA

Rural health clinic certification: CCN 168671

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

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 Director
Board Member		 Jan 4, 2024
Jordan Voigt
Individual 		Corporate Officer
President		 Jan 4, 2024
Corporate Director
Board Member		 Jan 4, 2024
Charles D Waterman
Individual 		Corporate Officer
Chair		 Apr 30, 2006
Corporate Director
Board Member		 Apr 30, 2006
Robert P Ritz
Individual 		Corporate Director
Board Member		 Mar 1, 2023
Melissa C Pepper
Individual 		Corporate Officer
Secretary		 Nov 1, 2019
Corporate Director
Board Member		 Nov 1, 2019
Peter Benson
Individual 		Corporate Officer
Vice-Chair		 Sep 3, 2009
Corporate Director
Board Member		 Sep 3, 2009
Robin R Petersen
Individual 		Corporate Director
Board Member		 Jul 29, 2004
Christopher M Crome
Individual 		Corporate Officer
Chief Operating Officer		 Nov 1, 2021
Lashonda Polite
Individual 		Corporate Director
Board Member		 Nov 6, 2020
Edmund P Coyne
Individual 		Corporate Director
Board Member		 Dec 4, 2008
Karen M Fitzsimmons
Individual 		Corporate Director
Board 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 Officer
Cfo		 Jul 1, 2020
Mark C. Kilmer
Individual 		Corporate Director
Board Member		 Sep 30, 2003
Dale D Zude
Individual 		Corporate Officer
Treasurer		 Jan 1, 2025
Corporate Director
Board Member		 Sep 25, 2001
Edwin V Motto
Individual 		Corporate Director
Board 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 Director
Board Member		 Oct 9, 2015
David Larson
Individual 		Corporate Director
Board Member		 Mar 6, 2014
Pamela Scott
Individual 		W-2 Managing Employee
Revenue Integrity Administrator		 Jan 1, 2006

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 Dewitt
De Witt, IA · CCN 165619		 Skilled nursing facility 5% Or Greater Direct Ownership Interest (40%) Feb 21, 2019
The Summit of Bettendorf
Bettendorf, IA · CCN 165793		 Skilled nursing facility 5% Or Greater Direct Ownership Interest (40%) Feb 21, 2019

Medicare enrollment records

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

National Provider Directory

Tax ID family
Dav Med (37 organizations share this tax ID)
Part of
Dav Med

Specialties & licenses

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

Addresses

Primary practice location

1021 11TH St
De Witt, IA 52742-1209

Mailing address

PO Box 4028
Rock Island, IL 61204-4028

Other names

  • Genesis Health Group, DeWitt Doing business as

Other providers in De Witt, IA

All providers in De Witt, IA · Rural Health Clinic/Center in Iowa

Sources for this page

Verify at the official NPI Registry.