NPIMap

Organization Active NPI

Sid Peterson Memorial Hospital

Doing business as Peterson Community Care Clinic RHC

  • Rural Health Clinic/Center
  • Kerrville, TX
National Provider Identifier
1376129296
Registry record updated Mar 11, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SID PETERSON MEMORIAL HOSPITAL
Doing business as
Peterson Community Care Clinic RHC
Practice address
1740 Junction Hwy
Kerrville, TX 78028-9401
Phone
(830) 258-7900
NPI assigned
Mar 22, 2021
Last updated
Mar 11, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2023

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

Authorized official

Name
Mr. Christopher L Ballesteros
Title
Rev Cycle Director, Privacy Officer
Phone
(830) 258-7343

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1740 Junction Hwy
Kerrville, TX 78028-9401

Mailing address

551 Hill Country Dr
Kerrville, TX 78028-6085
Phone (830) 258-7343

Other names 1

  • PETERSON COMMUNITY CARE CLINIC RHC Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210405001255 TX Part A Provider - Rural Health Clinic 6002724887 Practice locations: Kerrville, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376129296. Details of each certification follow.

Rural health clinic certification: CCN 678558

Legal name
SID PETERSON MEMORIAL HOSPITAL
Doing business as
PETERSON COMMUNITY CARE CLINIC RHC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 19, 2021
Last certification
Aug 6, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
1740 Junction Hwy
Kerrville, TX 78028-9401
Related CCNs
450007

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

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Progressive Health Cent6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

203 US Highway 87
Ste 206
Comfort, TX 78013
Phone (830) 995-3644

1121 Broadway
Kerrville, TX 78028
Phone (830) 258-6300

1407 Water St
Kerrville, TX 78028

1420 Water St
Kerrville, TX 78028
Phone (830) 257-3111

320 W Main St
Ste A
Kerrville, TX 78028

701 Water St
Kerrville, TX 78028
Phone (830) 258-7799

823 Junction Hwy
Kerrville, TX 78028
Phone (830) 258-6300

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Gaye Avery Individual Corporate DirectorBoard Member Jul 1, 2024
Michael D Ross Individual Corporate DirectorBoard Member Jul 1, 2024
Norman Williams Individual Corporate DirectorBoard Member Jul 1, 2022
Toni Manchester Individual Corporate DirectorBoard Member Jul 1, 2022
Rose Bradshaw Individual Corporate DirectorBoard Member Jul 1, 2022
James a Young Individual W-2 Managing EmployeeMD; Jul 1, 2024
Lisa M Medovich Individual Corporate OfficerCfo Apr 8, 2019
W-2 Managing EmployeeCfo Apr 8, 2019
Brian P Bowers Individual Corporate DirectorBoard Member Apr 8, 2019
Sid Peterson Memorial Hospital Organization, Kerrville, TX Corporation 5% Or Greater Direct Ownership Interest Jan 1, 1990
Operational/Managerial Control Jan 1, 1990
Joseph Thomas Piszczor Individual Corporate OfficerCoo Jul 14, 2020
W-2 Managing Employee Jul 14, 2020
Jeremy Walther Individual Corporate DirectorBoard Member Jul 1, 2024
Kendall Davison Individual Corporate DirectorBoard Member Jul 1, 2023
Johnathan W McDonald Individual Corporate OfficerPresident/Ceo May 27, 2025
W-2 Managing EmployeePresident/Ceo May 27, 2025
Christopher Ballesteros Individual W-2 Managing EmployeeCompliance Officer Aug 29, 2019
Thomas Houdeshell Individual Corporate DirectorBoard Member Jul 1, 2020
Kristen McAlexander Individual Corporate DirectorBoard Member Jul 1, 2023

Owners & managing parties with NPI records 6

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
Peterson Community Care Clinic RHCKerrville, TX, CCN 450007 Hospital 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 1990
Jan 1, 1990
Peterson Regional Medical CenterKerrville, TX, CCN 45T007 Hospital Operational/Managerial Control Jan 1, 1990
Peterson Home CareKerrville, TX, CCN 677052 Home health agency Operational/Managerial Control Feb 13, 2007
Peterson HospiceKerrville, TX, CCN 671585 Hospice 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 26, 2007
Apr 26, 2007

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 4

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

Practitioners & affiliated clinicians

Practitioners 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1616371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678492800000",
    "number": "1376129296",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "551 HILL COUNTRY DR",
            "city": "KERRVILLE",
            "state": "TX",
            "postal_code": "780286085",
            "telephone_number": "830-258-7343",
            "fax_number": "830-258-7678"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1740 JUNCTION HWY",
            "city": "KERRVILLE",
            "state": "TX",
            "postal_code": "780289401",
            "telephone_number": "830-258-7900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SID PETERSON MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-22",
        "last_updated": "2023-03-11",
        "certification_date": "2023-03-11",
        "status": "A",
        "authorized_official_last_name": "BALLESTEROS",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "REV CYCLE DIRECTOR, PRIVACY OFFICER",
        "authorized_official_telephone_number": "830-258-7343",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PETERSON COMMUNITY CARE CLINIC RHC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PETERSON COMMUNITY CARE CLINIC RHC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kerrville, TX

Sources for this page

Verify at the official NPI Registry.