NPIMap

Organization Active NPI

Glencoe Regional Health Services

  • Medicare Defined Swing Bed Hospital Unit
  • Glencoe, MN
National Provider Identifier
1194832287
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
330987 Issued in MN
Legal business name
GLENCOE REGIONAL HEALTH SERVICES
Practice address
1805 Hennepin Ave North
Glencoe, MN 55336-1416
Phone
(320) 864-3121
Fax
(320) 864-7880
NPI assigned
Aug 24, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Mr. Jon D Braband
Title
President Ceo
Phone
(320) 864-7752

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 330987 MN Primary

Addresses

Primary practice location

1805 Hennepin Ave North
Glencoe, MN 55336-1416

Mailing address

1805 Hennepin Ave North
Glencoe, MN 55336-1416
Phone (320) 864-3121

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080225000695 MN Part A Provider - Critical Access Hospital 1759292980 Practice locations: Glencoe, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194832287. Details of each certification follow.

Hospital certification: CCN 24Z355

Legal name
GLENCOE REGIONAL HEALTH SERVICES
Organization structure
OtherNon-profit
Incorporated
Aug 25, 1999 in MN
Enrollment address
1805 Hennepin N Ave
Glencoe, MN 55336-1416
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Glencoe Regional HLTH4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Angela Erickson Individual W-2 Managing EmployeeChief Financial Officer Feb 9, 2019
Bryan T Petersen Individual Corporate DirectorBoard Member Jan 1, 2017
W-2 Managing EmployeeProvider Jan 25, 2018
Kristine L Knudten Individual Corporate Director Jan 1, 2012
W-2 Managing EmployeeProvider Jan 25, 2018
Benjamin Davis Individual Corporate OfficerPresident & Ceo May 15, 2023
W-2 Managing EmployeePresident & Ceo May 15, 2023
Kristen L Budahn Individual Other Jan 1, 2024
Jill M Hatlestad Individual W-2 Managing EmployeeVice President HR and Marketing Dec 19, 2007
Heather Peirce Individual Corporate Director Jan 1, 2021
Julie a Schmidt Individual W-2 Managing EmployeeVice President Long Term Care an Dec 19, 2007
Sean David Tritabaugh Individual Other Jan 1, 2024
Scott Kuehn Individual Corporate Director Jan 1, 2017
Mary K Stoltenburg Individual Corporate DirectorBoard Member Jan 1, 2018
Lynn Kathryn Beranek Individual W-2 Managing Employee Sep 4, 2023
Bryan J Fritsch Individual Corporate DirectorBoard Member Jan 1, 2016
W-2 Managing EmployeeProvider Jan 25, 2018

Owners & managing parties with NPI records 4

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

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.

Affiliated clinicians 9

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

NPI Registry JSON

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

{
    "created_epoch": "1156377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1194832287",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1805 HENNEPIN AVE NORTH",
            "city": "GLENCOE",
            "state": "MN",
            "postal_code": "553361416",
            "telephone_number": "320-864-3121",
            "fax_number": "320-864-7880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1805 HENNEPIN AVE NORTH",
            "city": "GLENCOE",
            "state": "MN",
            "postal_code": "553361416",
            "telephone_number": "320-864-3121",
            "fax_number": "320-864-7880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GLENCOE REGIONAL HEALTH SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BRABAND",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PRESIDENT  CEO",
        "authorized_official_telephone_number": "320-864-7752",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "MN",
            "license": "330987",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Glencoe, MN

Sources for this page

Verify at the official NPI Registry.