NPIMap

Organization Active NPI

Centracare Health-Paynesville LLC

Doing business as CentraCare Health Paynesville - Richmond Clinic

  • Rural Health Clinic/Center
  • Richmond, MN
National Provider Identifier
1144653734
Registry record updated Oct 10, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CENTRACARE HEALTH-PAYNESVILLE LLC
Doing business as
CentraCare Health Paynesville - Richmond Clinic
Practice address
130 1St St NE
Richmond, MN 56368-8183
Phone
(320) 597-2122
Fax
(320) 597-2102
NPI assigned
Aug 19, 2013
Last updated
Oct 10, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 10, 2019

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

Authorized official

Name
Mr. Michael A. Blair
Title
Sr. Vice President and Cfo
Phone
(320) 255-5665

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital Clinic/Center 261QC0050X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

130 1St St NE
Richmond, MN 56368-8183

Mailing address

200 W 1St St
Paynesville, MN 56362-1445
Phone (320) 243-3767

Other names 1

  • CentraCare Health Paynesville - Richmond Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140909002390 MN Part B Supplier - Clinic/Group Practice 1153555719 Receives reassigned benefits from 130 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Watkins, MN; Saint Cloud, MN; Richmond, MN; Cold Spring, MN; Paynesville, MN
O20181102000098 MN Part A Provider - Rural Health Clinic 1153555719 Practice locations: Richmond, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144653734. Details of each certification follow.

Rural health clinic certification: CCN 243488

Legal name
CENTRACARE HEALTH-PAYNESVILLE LLC
Doing business as
CENTRACARE PAYNESVILLE - RICHMOND CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 18, 2019
Last certification
Apr 18, 2019
Ownership / control type
2B
Organization structure
LLCNon-profit
Enrollment address
130 1St St NE
Richmond, MN 56368-8183
Related CCNs
241349

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

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 5

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D0406030Centracare Health Paynesville - Richmond Clinic130 First St NE, Richmond, MN 56368ComplianceApr 24, 2027

National Provider Directory

National Provider Directory
Tax ID family
Centracare Health-Paynesville LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

200 W 1st St
Paynesville, MN 56362
Phone (320) 243-3767

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Tina SSN May Individual Corporate Director Jul 1, 2025
Michelle Johnson Individual Corporate Director Jul 1, 2021
Thomas Knoblach Individual Corporate Director Jul 1, 2011
Michael a Blair Individual Corporate OfficerCfo Sep 30, 2019
W-2 Managing Employee Sep 30, 2019
Jeffrey Gau Individual Corporate DirectorBaord Member Jul 1, 2017
Renee S Frauendienst Individual Corporate Director Jul 1, 2017
Jacob Lyons Individual Corporate Director Jul 1, 2024
Richard Wehseler Individual Corporate DirectorBoard Member Apr 21, 2018
Bobbie Bertram Individual Corporate Director Jul 1, 2015
Kenneth D Holmen Individual Corporate DirectorCeo, Board Member Jan 1, 2015
Sherri Liebl Individual Corporate OfficerExecutive Director Sep 30, 2019
David Anfinson Individual Corporate DirectorBoard Member Apr 21, 2018
Daniel Abdul Individual Corporate Director Jul 1, 2022
James Hebl Individual Corporate DirectorBoard Member Jul 1, 2017
Carrie Henning-Smith Individual Corporate Director Jul 1, 2023
Centracare Health System Organization, Saint Cloud, MN Non-profit Operational/Managerial Control Jul 1, 1966
Bryan Rolph Individual Corporate Director Jul 1, 2019

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Centracare - Paynesville Swing BedPaynesville, MN, CCN 24Z349 Hospital Operational/Managerial Control Jun 20, 2014

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 28

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

View all 28

Practitioners & affiliated clinicians

Practitioners 22

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 22

NPI Registry JSON

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

{
    "created_epoch": "1376870400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1570665600000",
    "number": "1144653734",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 W 1ST ST",
            "city": "PAYNESVILLE",
            "state": "MN",
            "postal_code": "563621445",
            "telephone_number": "320-243-3767",
            "fax_number": "320-243-7955"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 1ST ST NE",
            "city": "RICHMOND",
            "state": "MN",
            "postal_code": "563688183",
            "telephone_number": "320-597-2122",
            "fax_number": "320-597-2102"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRACARE HEALTH-PAYNESVILLE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-08-19",
        "last_updated": "2019-10-10",
        "status": "A",
        "authorized_official_last_name": "BLAIR",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "SR. VICE PRESIDENT AND CFO",
        "authorized_official_telephone_number": "320-255-5665",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QC0050X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Critical Access Hospital",
            "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": "CentraCare Health Paynesville - Richmond Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CentraCare Health Paynesville - Richmond Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Richmond, MN

Sources for this page

Verify at the official NPI Registry.