NPIMap

Organization Active NPI

St. Mary's Medical Center

Doing business as Essentia Health St. Mary's Hospice & Palliative Care

  • Community Based Hospice Care Agency
  • Duluth, MN
National Provider Identifier
1225089634
Registry record updated Feb 28, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
02562 Issued in MN
Legal business name
ST. MARY'S MEDICAL CENTER
Doing business as
Essentia Health St. Mary's Hospice & Palliative Care
Practice address
407 E 4TH St
Duluth, MN 55805-2282
Phone
(218) 786-4020
Fax
(218) 786-4223
NPI assigned
May 12, 2006
Last updated
Feb 28, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 28, 2024

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

Authorized official

Name
Kevin Boren
Title
VP of Finance
Phone
(218) 786-1009

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 02562 MN Primary

Addresses

Primary practice location

407 E 4TH St
Duluth, MN 55805-2282

Mailing address

407 E 4TH St
Duluth, MN 55805-2282
Phone (218) 786-4020

Other identifiers 4

IdentifierTypeStateIssuer
7L61STOtherMNBLUE CROSS BLUE SHIELD
1225089634MedicaidWI
5025446OtherMNMEDICA
1225089634MedicaidMN

Other names 1

  • Essentia Health St. Mary's Hospice & Palliative Care Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060814000569 MN Part A Provider - Hospice 6901706357 Practice locations: Duluth, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1225089634. Details of each certification follow.

Hospice certification: CCN 241521

Legal name
ST MARYS MEDICAL CENTER
Doing business as
ESSENTIA HEALTH ST MARYS HOSPICE AND PALLIATIVE CARE SERVICES
Certification status
Active
Provider type (POS)
Hospice
Participating since
Mar 21, 1991
Last certification
Nov 8, 2018
Ownership / control type
Non-Profit - Private
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1997 in MN
Enrollment address
407 E 4TH St
Duluth, MN 55805-2282

Other NPIs with the same Medicare PAC ID 1

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

Care Compare: Hospice

Medicare Care Compare
Listed as
Essentia Health St Mary's Hospice & Palliative Care ServicesCCN 241521 · All quality measures
Ownership
Non-Profit
Certified
Mar 21, 1991
Medicare certification status
ActiveFrom the Provider of Services file

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
24D1056896St Marys Hospice & Palliative Care407 East 4TH St 5TH Floor, Duluth, MN 55805Certificate of waiverJul 27, 2028

National Provider Directory

National Provider Directory
Tax ID family
St Mary's Medical Center3 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 of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

330 E 2nd St
Duluth, MN 55805
Phone (218) 786-4020

407 E 4th St
Duluth, MN 55805
Phone (218) 786-4020

Ownership & related parties

All disclosed owners & managing parties 21

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

NameRoleSinceShare
Krista Ann Skorupa Individual Corporate OfficerPresident May 6, 2024
Mark Bortnem Individual Corporate OfficerTreasurer Sep 29, 2025
Amy Bergstrom Individual Corporate DirectorBoard Member Jan 1, 2024
Anthony Sertich Individual Corporate Director Jan 1, 2021
George Loban Individual Corporate DirectorBoard Member Jan 1, 2024
Adam Bachand Individual Corporate DirectorBoard Member Jan 1, 2025
Thomas Jamar Individual Corporate Director Jan 1, 2023
Rebecca Urbanski Individual Corporate DirectorBoard Member Jan 1, 2025
Anthony Yung Individual Corporate DirectorBoard Member Jan 1, 2023
Essentia Health Organization, Duluth, MN Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2023 100%
Beverly Raway Individual Corporate DirectorBoard Member Oct 1, 2018
St Marys Duluth Clinic Health System Organization, Duluth, MN Non-profit Operational/Managerial Control Jun 26, 2006
Bradley J Beard Individual Corporate OfficerCoo Aug 5, 2019
W-2 Managing EmployeeCoo Aug 5, 2019
Jeanne Weber Individual Corporate DirectorBoard Member Feb 15, 2019
Jill Rehl Individual W-2 Managing EmployeeAdministrator Jan 29, 2024
Kevin S Boren Individual Corporate OfficerVP of Finance Apr 1, 2018
W-2 Managing EmployeeVP of Finance Jul 1, 2023
Troy Duininck Individual Corporate Director Jan 1, 2023
Vineetha Jose Individual W-2 Managing EmployeeMD; Jul 1, 2024
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Jan Linse Baldwin Individual Corporate DirectorBoard Member Oct 1, 2018
Nancy Aronson Norr Individual Corporate DirectorBoard Member Jan 1, 2025

Owners & managing parties with NPI records 6

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

Facilities with the same owner 46

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

View all 46

Practitioners & affiliated clinicians

Practitioners 28

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 28

Affiliated clinicians 2

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": "1147392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709078400000",
    "number": "1225089634",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "407 E 4TH ST",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558052282",
            "telephone_number": "218-786-4020",
            "fax_number": "218-786-4223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "407 E 4TH ST",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558052282",
            "telephone_number": "218-786-4020",
            "fax_number": "218-786-4223"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY'S MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2006-05-12",
        "last_updated": "2024-02-28",
        "certification_date": "2024-02-28",
        "status": "A",
        "authorized_official_last_name": "BOREN",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "218-786-1009"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "MN",
            "license": "02562",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "7L61ST",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1225089634",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "5025446",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1225089634",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health St. Mary's Hospice & Palliative Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health St. Mary's Hospice & Palliative Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.