NPIMap

Organization Active NPI

Agnesian Healthcare, Inc

Doing business as SSM Health St Agnes Hospital Fond Du Lac

  • General Acute Care Hospital
  • Fond Du Lac, WI
National Provider Identifier
1346228541
Registry record updated Jun 5, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
Legal business name
AGNESIAN HEALTHCARE, INC
Doing business as
SSM Health St Agnes Hospital Fond Du Lac
Practice address
430 E Division St
Fond Du Lac, WI 54935-4560
Phone
(920) 929-2300
Fax
(920) 926-8885
NPI assigned
Jan 6, 2006
Last updated
Jun 5, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 2024

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

Authorized official

Name
Amy Grinnell
Title
VP-Finance, Cfo
Phone
(608) 260-3586

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Day Care Clinic/Center 261QA0600X NU
Medicare Defined Swing Bed Hospital Unit 275N00000X NU
General Acute Care Hospital 282N00000X NU Primary

Addresses

Primary practice location

430 E Division St
Fond Du Lac, WI 54935-4560

Mailing address

430 E Division St
Fond Du Lac, WI 54935-4560
Phone (920) 929-2300

Other identifiers 3

IdentifierTypeStateIssuer
101159OtherWIVESTICA
11013000MedicaidWI
547140OtherWIDEAN CARE

Other names 1

  • SSM HEALTH ST AGNES HOSPITAL FOND DU LAC Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031104000263 WI Part B Supplier - Clinic/Group Practice 1658289624 Receives reassigned benefits from 630 practitioners
6 other NPIs on this enrollment
O20071108000506 WI Part A Provider - Hospital 1658289624 Practice locations: Fond Du Lac, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1346228541. Details of each certification follow.

Hospital certification: CCN 520088

Legal name
AGNESIAN HEALTHCARE INC
Doing business as
SSM HEALTH ST AGNES HOSPITAL FOND DU LAC
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Oct 22, 2016
Beds
151
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Mar 7, 1997 in WI
Enrollment address
430 E Division St
Fond Du Lac, WI 54935-4560
Main/Primary Hospital Location
Hospital subgroups
Acute care

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

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Other NPIs on the same Medicare enrollment 5

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

Care Compare: Hospital

Medicare Care Compare
Listed as
SSM Health St Agnes Hospital-Fond Du LacCCN 520088 · All quality measures
Overall star rating
4 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Member of 1

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

Locations

100 N Peters Ave
Fond du Lac, WI 54935

371 E 1st St
Fond du Lac, WI 54935
Phone (920) 907-3928

396 Linden St
Fond du Lac, WI 54935

401 S Military Rd
Fond du Lac, WI 54935
Phone (920) 906-6660

525 E Pioneer Rd
Fond du Lac, WI 54935

1098 Prospect Ave
North Fond du Lac, WI 54937

305 McKinley St
North Fond du Lac, WI 54937

325 McKinley St
North Fond du Lac, WI 54937

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Hertha Longo Individual Corporate DirectorBoard Member Oct 31, 2007
Katherine R Vergos Individual Corporate OfficerPresident Jan 1, 2019
W-2 Managing EmployeePresident Jan 1, 2019
Donna Innes Individual Corporate DirectorBoard Member Jan 1, 2023
Theodore D Miller Individual Corporate DirectorBoard Member Jan 1, 2018
Thor H Gilbertson Individual Corporate Director Jan 1, 2017
Amy Collett Individual Corporate OfficerBoard Member Jan 1, 2023
Jeffrey a Strong Individual Corporate Director Jan 1, 2017
Krista Ebbens Individual Corporate DirectorBoard Member Jan 1, 2023
Susan M Stucki Individual Corporate DirectorBoard Member Jan 1, 2018
Marysue C Michels Individual Corporate Director Jan 1, 2017
Joseph Minerath Individual Corporate DirectorDirector Jan 1, 2023
W-2 Managing EmployeeRegional Director Jan 1, 2023
SSM Health Care Corporation Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2018 100%
Toni L Stanley Individual Corporate Director Jan 1, 2017
Laura Kaiser Individual W-2 Managing EmployeeCeo Jan 1, 2018

Owners & managing parties with NPI records 1

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
SSM Health Waupun Memorial HospitalWaupun, WI, CCN 52Z327 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2000
SSM Health Ripon Community HospitalRipon, WI, CCN 521321 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2011
SSM Health Ripon Community HospitalRipon, WI, CCN 52Z321 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2011
St Francis HomeFond Du Lac, WI, CCN 525595 Skilled nursing facility Operational/Managerial Control Jun 1, 1978

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 30

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

View all 30

Practitioners & affiliated clinicians

Practitioners 649

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 649

Affiliated clinicians 380

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

View all 380

NPI Registry JSON

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

{
    "created_epoch": "1136505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717545600000",
    "number": "1346228541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "430 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-929-2300",
            "fax_number": "920-926-8885"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "430 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-929-2300",
            "fax_number": "920-926-8885"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGNESIAN HEALTHCARE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-06",
        "last_updated": "2024-06-05",
        "certification_date": "2024-06-05",
        "status": "A",
        "authorized_official_last_name": "GRINNELL",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "VP-FINANCE, CFO",
        "authorized_official_telephone_number": "608-260-3586"
    },
    "taxonomies": [
        {
            "code": "261QA0600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Day Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VESTICA",
            "identifier": "101159",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11013000",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEAN CARE",
            "identifier": "547140",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "SSM HEALTH ST AGNES HOSPITAL FOND DU LAC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fond Du Lac, WI

Sources for this page

Verify at the official NPI Registry.