NPIMap

Organization Active NPI

Cooperstown Medical Center

  • Medicare Defined Swing Bed Hospital Unit
  • Cooperstown, ND
National Provider Identifier
1376635151
Registry record updated Aug 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
5001P Issued in 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 29, 2006
Organization subpart
Yes
Parent organization
COOPERSTOWN MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 29, 2023

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

Authorized official

Name
Kelley Shawn
Title
Admin Assist/Credentialing
Phone
(701) 786-1709

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 5001P ND Primary

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 2

IdentifierTypeStateIssuer
2774OtherNDBLUE CROSS BLUE SHIELD
1912MedicaidND

Other names 2

  • Cooperstown Medical Center Swing Bed Doing business as
  • Dakota Regional Medical Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090420000641 ND Part A Provider - Critical Access Hospital 5698687689 Receives reassigned benefits from 1 practitioner
Practice locations: Cooperstown, ND

Hospital certification: CCN 35Z306

Legal name
COOPERSTOWN MEDICAL CENTER
Doing business as
DAKOTA REGIONAL MEDICAL CENTER HOSPITAL SWINGBED
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1946 in ND
Enrollment address
107 12TH St S
Cooperstown, ND 58425-4501
Other Hospital Practice Location

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
Cooperstown Medical Center4 organizations share this tax ID, including this one
Part of
Cooperstown Medical Center

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Barry Getz Individual Corporate DirectorBoard President Apr 19, 2022
Gerald Stokka Individual Corporate DirectorBoard Vice President Dec 29, 2021
Benjamin Halvorson Individual Corporate DirectorDirector Apr 19, 2022
James Halvorson Individual Corporate DirectorDirector Dec 30, 2020
Larry Grandalen Individual Corporate DirectorDirector Apr 19, 2022
Cooperstown Medical Center Organization, Cooperstown, ND Corporation, Non-profit Operational/Managerial Control Jan 21, 2009
Nicole Johnson Individual Corporate OfficerChief Executive Officer Feb 1, 2014
W-2 Managing EmployeeAdministrator/Ceo Feb 1, 2014
Operational/Managerial ControlAdministrator/Ceo Aug 15, 2013
Barbara Anderson Individual Corporate OfficerChief Financial Officer Aug 19, 2014
W-2 Managing EmployeeChief Financial Officer Aug 19, 2014

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Dakota Regional Medical Ctr-LakotaLakota, ND, CCN 358511 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 15, 2021
Oct 15, 2021
Cooperstown Medical CenterNew Rockford, ND, CCN 358514 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 1, 2022
Aug 1, 2022

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 14

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

View all 14

Affiliated clinicians 5

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

NPI Registry JSON

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

{
    "created_epoch": "1159488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693267200000",
    "number": "1376635151",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "107 12TH ST S",
            "city": "COOPERSTOWN",
            "state": "ND",
            "postal_code": "584254501",
            "telephone_number": "701-786-1700",
            "fax_number": "701-786-7121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "107 12TH ST S",
            "city": "COOPERSTOWN",
            "state": "ND",
            "postal_code": "584254501",
            "telephone_number": "701-786-1700",
            "fax_number": "701-786-7121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COOPERSTOWN MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COOPERSTOWN MEDICAL CENTER",
        "enumeration_date": "2006-09-29",
        "last_updated": "2023-08-29",
        "certification_date": "2023-08-29",
        "status": "A",
        "authorized_official_last_name": "SHAWN",
        "authorized_official_first_name": "KELLEY",
        "authorized_official_title_or_position": "ADMIN ASSIST/CREDENTIALING",
        "authorized_official_telephone_number": "701-786-1709"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "ND",
            "license": "5001P",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "2774",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1912",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cooperstown Medical Center Swing Bed",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Dakota Regional Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cooperstown, ND

Sources for this page

Verify at the official NPI Registry.