Cooperstown Medical Center
Organization Active NPI Critical Access Hospital · Cooperstown, ND
NPI 1235239229 · NPPES record last updated Aug 29, 2023
Key facts
- NPI
- 1235239229
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Critical Access Hospital 282NC0060X
- License
- 5010P (ND)
- Legal business name
- COOPERSTOWN MEDICAL CENTER
- Practice address
- 107 12TH St S
Cooperstown, ND 58425-4501 - Phone
- (701) 786-1700
- Fax
- (701) 786-7121
- NPI assigned
- Sep 22, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- COOPERSTOWN MEDICAL CENTER
Authorized official
- Name
- Kelley Shawn
- Title
- Admin Assistant/Credentialing
- Phone
- (701) 786-1709
Owned or controlled facilities with NPI records 3
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 3
Related certifications (CCN) 4
Practitioners 21
-
Jonathon H Berg, MD
-
Larissa Ann Haug, PA
-
Brenna L Hudson, PA-C
-
Kathleen Marjorie Rogan, FNP-C
-
Kristen Marie Young, FNP
-
Karla Edwards, ARNP, FNP-C
-
Sarah Margaret Gordon, M.D.
-
Rachel Koch, NURSE PRACTITIONER
-
Steven Barlow, FNP
-
Richard Joseph Macker, FNP-C
-
Kali Susan Manz, CNP
-
Kristine Louise Martin, APRN-CNP
-
Jacqueline D Nelson, PA-C
-
Liza A Ystaas, FNP-C
-
Shadoe M Daniels, MPAS, PA-C
-
Robert Paul Glantz, NP-C
-
Cyril Kuriakose, MD
-
Jimmy Abraham Thomas, MBBS, MPH
-
Lance Michael Varga, APRN
Affiliated clinicians 12
-
Steven Barlow, FNP
-
Larissa Ann Haug, PA
-
Kali Susan Manz, CNP
-
Kristine Louise Martin, APRN-CNP
-
Justin Mauch, MD
-
Jacqueline D Nelson, PA-C
-
Liza A Ystaas, FNP-C
-
Shadoe M Daniels, MPAS, PA-C
-
Robert Paul Glantz, NP-C
-
Jimmy Abraham Thomas, MBBS, MPH
Medicare Care Compare: Hospital
- Listed as
- Cooperstown Medical Center
- Type
- Critical Access Hospitals
- Ownership
- Voluntary non-profit - Private
- Medicare certification status
- Active
- Emergency services
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ND
Hospital certification: CCN 351306
- Legal name
- COOPERSTOWN MEDICAL CENTER
- Doing business as
- DAKOTA REGIONAL MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Hospital – Critical access hospital
- Participating since
- Jul 1, 2000
- Last certification
- Jun 29, 2022
- Beds
- 18
- Ownership / control type
- Private (not for profit)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 17, 1946 in ND
- Enrollment address
- 107 12TH St S
Cooperstown, ND 58425-4501
All disclosed owners & managing parties 7
| Name | Role | Since | Share |
|---|---|---|---|
| Barry Getz |
Corporate Director |
Jan 1, 2015 | |
| Gerald Stokka |
Corporate Director |
Dec 29, 2021 | |
| Benjamin Halvorson |
Corporate Director | Apr 19, 2022 | |
| James Halvorson |
Corporate Director | Dec 30, 2020 | |
| Larry Grandalen |
Corporate Director | Apr 19, 2022 | |
| Nicole Johnson |
Corporate Officer |
Feb 1, 2014 | |
| W-2 Managing Employee |
Feb 1, 2014 | ||
| Operational/Managerial Control |
Aug 15, 2013 | ||
| Barbara Anderson |
Corporate Officer |
Aug 19, 2014 | |
| W-2 Managing Employee |
Aug 19, 2014 |
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| Dakota Regional Medical Center Hospital Swingbed |
Hospital | Operational/Managerial Control | Jan 21, 2009 |
| Dakota Regional Medical Ctr-Lakota |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Oct 15, 2021 Oct 15, 2021 |
| Cooperstown Medical Center |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Aug 1, 2022 Aug 1, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060502000847 | ND | Part a Provider - Critical Access Hospital | 5698687689 |
Receives reassigned benefits from 9 practitioners Practice locations: Cooperstown, ND |
National Provider Directory
- Tax ID family
- Cooperstown Medical Center
- Part of
- Cooperstown Medical Center
Locations
107 12th St S
Cooperstown, ND 58425
Phone (701) 786-1700
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Critical Access Hospital | 282NC0060X | 5010P | ND | Yes |
Addresses
Primary practice location
107 12TH St S
Cooperstown, ND 58425-4501
Mailing address
107 12TH St S
Cooperstown, ND 58425-4501
Phone (701) 786-1700
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 87726 | Other | MEDICA | |
| 1009 | Medicaid | ND | |
| 489 | Other | ND | BLUE CROSS BLUE SHIELD |
| 01009717 | Other | PREFERED ONE |
Other names
- Cooperstown Medical Center Critical Access Hospital
- Dakota Regional Medical Center
Other providers in Cooperstown, ND
- Amy Joy Andel
- Cortney Beattie
- Norman Leo Berthiaume
- City of Cooperstown
- Cooperstown Medical Center
- Cooperstown Medical Center
- Cooperstown Medical Center
- Cooperstown Medical Center
- Rachel Marie Dahl
- Essential Chiropractic PLLC
All providers in Cooperstown, ND · Critical Access Hospital in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 29, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.