NPIMap

Organization Active NPI

St Luke's Hospital

Doing business as Crosby Clinic

  • Rural Health Clinic/Center
  • Crosby, ND
National Provider Identifier
1184737231
Registry record updated Sep 15, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
353413 Issued in ND
Legal business name
ST LUKE'S HOSPITAL
Doing business as
Crosby Clinic
Practice address
702 1St St. SW
Crosby, ND 58730-0658
Phone
(701) 965-6349
Fax
(701) 965-6407
NPI assigned
Aug 15, 2006
Last updated
Sep 15, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 15, 2011

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

Authorized official

Name
Keith Baker
Title
Assistant Administrator
Phone
(701) 965-6349

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 353413 ND Primary

Addresses

Primary practice location

702 1St St. SW
Crosby, ND 58730-0658

Mailing address

PO Box C
Crosby, ND 58730-0658
Phone (701) 965-6349

Other identifiers 2

IdentifierTypeStateIssuer
5082MedicaidND
009571OtherNDNORTH DAKOTA BLUE CROSS

Other names 1

  • Crosby Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040423001224 ND Part B Supplier - Clinic/Group Practice 4486565645 Receives reassigned benefits from 9 practitioners
1 other NPI on this enrollment
Practice locations: Crosby, ND
O20100219000314 ND Part A Provider - Rural Health Clinic 4486565645 Practice locations: Crosby, ND

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1184737231. Details of each certification follow.

Rural health clinic certification: CCN 353413

Legal name
ST LUKES HOSPITAL
Doing business as
CROSBY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 1, 1995
Last certification
Feb 20, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 12, 1984 in ND
Enrollment address
702 1St St SW
Crosby, ND 58730-3329

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Wayne Lervik Individual Corporate DirectorBoard of Director Aug 11, 2015
Sandra Simonson Individual Corporate Director Dec 8, 2009
Art Schilke Individual Corporate DirectorBoard of Director Aug 11, 2015
Joshua Bummer Individual Corporate Director Aug 11, 2015
St Lukes Hospital Organization, Crosby, ND 5% Or Greater Direct Ownership Interest Dec 8, 2009
Mark Holm Individual Corporate DirectorBoard of Director Aug 11, 2015
Lucas Oberg Schumacher Individual Corporate DirectorBoard of Director Aug 11, 2015
Keith a Baker Individual Corporate Director Dec 8, 2009
W-2 Managing Employee Dec 8, 2009
Alfred Kenneth Sams Individual Corporate OfficerAssistant Administrator Aug 11, 2015
Dean Throntveit Individual Corporate DirectorBoard of Director Aug 11, 2015
Wanda Ely Individual Corporate Director Dec 8, 2009
Jody Nelson Individual Corporate DirectorBoard of Director Aug 11, 2015

Owners & managing parties with NPI records 2

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
St Lukes HospitalCrosby, ND, CCN 35Z325 Hospital Operational/Managerial Control (100%) May 1, 2018

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 1

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

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": "1155600000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1316044800000",
    "number": "1184737231",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX C",
            "city": "CROSBY",
            "state": "ND",
            "postal_code": "587300658",
            "telephone_number": "701-965-6349",
            "fax_number": "701-965-6407"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "702 1ST ST. SW",
            "city": "CROSBY",
            "state": "ND",
            "postal_code": "587300658",
            "telephone_number": "701-965-6349",
            "fax_number": "701-965-6407"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST LUKE'S HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-15",
        "last_updated": "2011-09-15",
        "status": "A",
        "authorized_official_last_name": "BAKER",
        "authorized_official_first_name": "KEITH",
        "authorized_official_title_or_position": "ASSISTANT ADMINISTRATOR",
        "authorized_official_telephone_number": "701-965-6349"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "ND",
            "license": "353413",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5082",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NORTH DAKOTA BLUE CROSS",
            "identifier": "009571",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crosby Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crosby, ND

Sources for this page

Verify at the official NPI Registry.