NPIMap

Organization Active NPI

Grande Ronde Hospital, Inc.

Doing business as Grande Ronde Hospital Internal Medicine Clinic

  • Primary Care Clinic/Center
  • La Grande, OR
National Provider Identifier
1174553929
Registry record updated Jul 26, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
GRANDE RONDE HOSPITAL, INC.
Doing business as
Grande Ronde Hospital Internal Medicine Clinic
Grande Ronde Hospital Regional Medical Clinic
Practice address
506 4TH St
La Grande, OR 97850-1906
Phone
(541) 963-3138
Fax
(541) 963-5918
NPI assigned
Jul 4, 2006
Last updated
Jul 26, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2021

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

Authorized official

Name
Jeremy P Davis
Title
President/Ceo
Phone
(541) 963-8421

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

506 4TH St
La Grande, OR 97850-1906

Mailing address

PO Box 460
La Grande, OR 97850-0460
Phone (541) 963-3138

Other identifiers 2

IdentifierTypeStateIssuer
DE0048OtherORRR MEDICARE
276310MedicaidOR

Other names 2

  • GRANDE RONDE HOSPITAL INTERNAL MEDICINE CLINIC Doing business as
  • GRANDE RONDE HOSPITAL REGIONAL MEDICAL CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031124000758 OR Part B Supplier - Clinic/Group Practice 0547170789 Receives reassigned benefits from 163 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: La Grande, OR
O20061104000155 OR Part A Provider - Critical Access Hospital 0547170789 Receives reassigned benefits from 154 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: La Grande, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174553929. Details of each certification follow.

Hospital certification: CCN 381321

Legal name
GRANDE RONDE HOSPITAL INC
Doing business as
GRANDE RONDE HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Aug 1, 2004
Last certification
Apr 5, 2013
Beds
49 (25 certified)
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1986 in OR
Enrollment address
900 Sunset Dr
La Grande, OR 97850-1387
Main/Primary Hospital Location

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

Other NPIs on the same Medicare enrollment 4

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Grande Ronde HospitalCCN 381321 · All quality measures
Overall star rating
5 of 5
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Stephen M McLean Individual Corporate Director Jan 1, 2016
Samuel H Kimball Individual Corporate Director Feb 22, 2017
Michael a Hetrick Individual Corporate Director Jan 1, 2016
Suzanne D Hopper Individual Corporate Director Jan 1, 2015
Blake a Gornowicz Individual Corporate Director Jan 1, 2022
Robert P Seymour Individual W-2 Managing Employee Jan 1, 2017
Lara Kay Moore Individual Corporate Director Nov 16, 2016
John Garlitz Individual Corporate Director Jan 1, 2016
Nicholas Alvin Huelter Individual Corporate Director Jan 1, 2021
Jeremy P Davis Individual Corporate OfficerCeo Nov 26, 2018
Teri S Champlin Individual Corporate Director Jan 1, 2014
Jared Cole Rogers Individual Corporate Director Dec 24, 2019
Robert Coulter Individual Corporate Director Jan 1, 2021
Michael E Billman Individual Corporate Director Jan 1, 2019

Owners & managing parties with NPI records 3

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

Practitioners & affiliated clinicians

Practitioners 8

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.

Affiliated clinicians 219

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 219

NPI Registry JSON

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

{
    "created_epoch": "1151971200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1627257600000",
    "number": "1174553929",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 460",
            "city": "LA GRANDE",
            "state": "OR",
            "postal_code": "978500460",
            "telephone_number": "541-963-3138",
            "fax_number": "541-963-5918"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "506 4TH ST",
            "city": "LA GRANDE",
            "state": "OR",
            "postal_code": "978501906",
            "telephone_number": "541-963-3138",
            "fax_number": "541-963-5918"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRANDE RONDE HOSPITAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-04",
        "last_updated": "2021-07-26",
        "certification_date": "2021-07-26",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "JEREMY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "541-963-8421"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "DE0048",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "276310",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "GRANDE RONDE HOSPITAL INTERNAL MEDICINE CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "GRANDE RONDE HOSPITAL REGIONAL MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in La Grande, OR

Sources for this page

Verify at the official NPI Registry.