NPIMap

Organization Active NPI

SMDC Medical Center

Doing business as Essentia Health Duluth-Amberwing Clinic

  • Adolescent and Children Mental Health Clinic/Center
  • Duluth, MN
National Provider Identifier
1235488438
Registry record updated Feb 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adolescent and Children Mental Health Clinic/CenterTaxonomy code 261QM0855X
Legal business name
SMDC MEDICAL CENTER
Doing business as
Essentia Health Duluth-Amberwing Clinic
Practice address
615 Pecan Ave
Duluth, MN 55811
Phone
(218) 355-2100
Fax
(218) 355-2105
NPI assigned
Sep 4, 2012
Last updated
Feb 27, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 27, 2024

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

Authorized official

Name
Kevin Boren
Title
Cfo
Phone
(218) 786-1009

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adolescent and Children Mental Health Clinic/Center 261QM0855X Primary

Addresses

Primary practice location

615 Pecan Ave
Duluth, MN 55811

Mailing address

615 Pecan Ave
Duluth, MN 55811
Phone (218) 355-2100

Other names 1

  • Essentia Health Duluth-Amberwing Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031002000014 MN Part A Provider - Hospital 5890604011 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Duluth, MN; Proctor, MN; Hermantown, MN; Cloquet, MN
O20180719001604 MN Part B Supplier - Clinic/Group Practice 5890604011 Receives reassigned benefits from 29 practitioners
Practice locations: Duluth, MN; Hermantown, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235488438. Details of each certification follow.

Hospital certification: CCN 240019A

Legal name
SMDC MEDICAL CENTER
Doing business as
ESSENTIA HEALTH DULUTH
Organization structure
CorporationNon-profit
Enrollment address
502 E 2ND St
Duluth, MN 55805-1913
Other Hospital Practice Location
Hospital subgroups
General

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

Member of 1

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

Locations

4335 Hawk Circle Dr
Hermantown, MN 55811
Phone (218) 355-2100

Ownership & related parties

All disclosed owners & managing parties 15

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
Amy Bergstrom Individual Corporate DirectorBoard Member Jan 1, 2024
George Loban Individual Corporate DirectorBoard Member Jan 1, 2024
Adam Bachand Individual Corporate DirectorBoard Member Jan 1, 2025
Thomas Jamar Individual Corporate DirectorBoard Member 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%
Justin Terch Individual Corporate DirectorBoard Member Oct 22, 2025
St Marys Duluth Clinic Health System Organization, Duluth, MN Non-profit Operational/Managerial Control Nov 19, 2007
Kevin S Boren Individual Corporate OfficerVP of Finance Oct 1, 2014
W-2 Managing EmployeeVP of Finance Jul 1, 2023
Troy Duininck Individual Corporate DirectorBoard Member Jan 1, 2023
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Bruce Smith Individual Corporate DirectorBoard Member Jan 1, 2026
Nancy Aronson Norr Individual Corporate DirectorBoard Member Jan 1, 2025

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Essentia Health VirginiaVirginia, MN, CCN 240084 Hospital 5% Or Greater Direct Ownership Interest (100%) Aug 28, 2012
Essentia Health Virginia Care CenterVirginia, MN, CCN 245458 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Direct Ownership Interest (100%)		 Aug 28, 2012
Jul 1, 2012
Essentia Health International Falls ClinicInternational Falls, MN, CCN 243481 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 28, 2012
Essentia Health Ely ClinicEly, MN, CCN 243483 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 28, 2012

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 33

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 33

NPI Registry JSON

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

{
    "created_epoch": "1346716800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708992000000",
    "number": "1235488438",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 PECAN AVE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "55811",
            "telephone_number": "218-355-2100",
            "fax_number": "218-355-2105"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "615 PECAN AVE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "55811",
            "telephone_number": "218-355-2100",
            "fax_number": "218-355-2105"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SMDC MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2012-09-04",
        "last_updated": "2024-02-27",
        "certification_date": "2024-02-27",
        "status": "A",
        "authorized_official_last_name": "BOREN",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "218-786-1009"
    },
    "taxonomies": [
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health Duluth-Amberwing Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health Duluth-Amberwing Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Duluth, MN

Sources for this page

Verify at the official NPI Registry.