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Glacial Ridge Hospital District

Organization Active NPI Family Medicine Physician · Brooten, MN

NPI 1255348223 · NPPES record last updated Jul 18, 2012

Key facts

NPI
1255348223
Entity type
Organization (NPI type 2)
Primary specialty
Family Medicine Physician 207Q00000X
Legal business name
GLACIAL RIDGE HOSPITAL DISTRICT
Practice address
111 Pleasant Avenue
Brooten, MN 56316
Phone
(320) 346-2272
Fax
(320) 346-2273
NPI assigned
Aug 2, 2006
Organization subpart
No

Authorized official

Name
Kirk Stensrud
Title
Ceo
Phone
(320) 634-2208

Owned or controlled facilities with NPI records 2

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

Other NPIs on the same Medicare enrollment 4

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

Other NPIs with the same Medicare PAC ID 6

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

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

Practitioners 128

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 128

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in MN

Rural health clinic certification: CCN 243456

Legal name
GLACIAL RIDGE HOSPITAL DISTRICT
Doing business as
BROOTEN MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 10, 2012
Last certification
May 17, 2019
Ownership / control type
2B
Organization structure
Corporation · Non-profit
Incorporated
Jan 1, 1990 in MN
Enrollment address
111 Pleasant Ave N
Brooten, MN 56316-4715
Related CCNs
241376

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Kirk a Stensrud
Individual 		Corporate Director Mar 4, 2011
Kyle Chase
Individual 		Corporate Director Apr 1, 2011
W-2 Managing Employee Apr 1, 2011

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Glacial Ridge Homecare
Glenwood, MN · CCN 247212		 Home health agency 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Mar 19, 2010
Mar 19, 2010
Glacial Ridge Hospice
Glenwood, MN · CCN 241502		 Hospice 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Mar 4, 1993
Aug 1, 2000

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20050719000315 MN Part B Supplier - Clinic/Group Practice 5294789194 Receives reassigned benefits from 125 practitioners
4 other NPIs on this enrollment
Practice locations: Starbuck, MN; Glenwood, MN; Brooten, MN
O20110324001015 MN Part a Provider - Rural Health Clinic 5294789194 Practice locations: Brooten, MN

National Provider Directory

Locations

111 Pleasant Ave N
Brooten, MN 56316
Phone (320) 346-2272

111 Pleasant Ave N
#69
Brooten, MN 56316

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207Q00000X Yes

Addresses

Primary practice location

111 Pleasant Avenue
Brooten, MN 56316

Mailing address

111 Pleasant Avenue
P.O. Box 69
Brooten, MN 56316
Phone (320) 346-2272

Other identifiers

IdentifierTypeStateIssuer
966011900MedicaidMN

Other names

  • BROOTEN MEDICAL CENTER Doing business as

Other providers in Brooten, MN

All providers in Brooten, MN · Family Medicine Physician in Minnesota

Sources for this page

Verify at the official NPI Registry.