NPIMap

Organization Active NPI

Monument Health Rapid City Hospital, Inc.

Doing business as Monument Health Wall Clinic

  • Rural Health Clinic/Center
  • Wall, SD
National Provider Identifier
1457730673
Registry record updated Mar 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MONUMENT HEALTH RAPID CITY HOSPITAL, INC.
Doing business as
Monument Health Wall Clinic
Wall Regional Medical Clinic
Practice address
112 7TH Avenue
Wall, SD 57790-0001
Phone
(605) 279-2149
Fax
(605) 279-1027
NPI assigned
May 20, 2015
Last updated
Mar 16, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 16, 2020

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

Authorized official

Name
John Pierce
Title
Monument Health President
Phone
(605) 755-8162

Specialties & licenses 1

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

Addresses

Primary practice location

112 7TH Avenue
Wall, SD 57790-0001

Mailing address

PO Box 860013
Minneapolis, MN 55486-0013
Phone (605) 279-2149

Other names 2

  • Monument Health Wall Clinic Doing business as
  • WALL REGIONAL MEDICAL CLINIC Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160308000849 SD Part A Provider - Rural Health Clinic 6002729506 Practice locations: Wall, SD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1457730673. Details of each certification follow.

Rural health clinic certification: CCN 433802

Legal name
MONUMENT HEALTH RAPID CITY HOSPITAL INC
Doing business as
MONUMENT HEALTH WALL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 1, 1978
Last certification
Sep 13, 2021
Ownership / control type
1B
Most recent change of ownership
Jun 15, 2015 (3 total)
Organization structure
CorporationNon-profit
Incorporated
Jun 13, 1973 in SD
Enrollment address
112 7TH Avenue
Wall, SD 57790-0001

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Massa Berry Clinic60 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Jacob Matthew Weasel Individual Corporate DirectorBoard Member Jul 1, 2020
Ruta P Davidson Individual Corporate OfficerCoo Nov 9, 2015
Corporate DirectorPresident & Ceo Aug 18, 2018
W-2 Managing EmployeePresident & Ceo Aug 18, 2018 100%
Operational/Managerial ControlCoo Nov 9, 2015 75%
Scott R Barbour Individual Corporate Director Jul 1, 2020
Jill a Tice Individual W-2 Managing EmployeeVP Quality Safety Risk MGMT Jul 25, 2019 50%
Operational/Managerial ControlVP Quality Safety Risk MGMT Jul 25, 2019 50%
Ester E Johannesen Individual W-2 Managing EmployeeClinic Coordinator Mar 1, 2014 25%
Bradley J Archer Individual Corporate DirectorChief Medical Office Jul 1, 2018
W-2 Managing EmployeeChief Medical Office Jul 1, 2018 75%
Operational/Managerial ControlChief Medical Officer Jul 1, 2018 75%
John Y Pierce Individual Corporate DirectorPresident Rapid City Market Sep 18, 2018
W-2 Managing EmployeePresident Rapid City Market Sep 18, 2018 75%
Operational/Managerial ControlPresident Rapid City Market Sep 18, 2018 75%
Nicole L Kerkenbush Individual W-2 Managing EmployeeChief Nursing Officer and Cpo Aug 22, 2016 50%
Operational/Managerial ControlChief Nursing Officer and Cpo Aug 22, 2016 50%
Dusty J Pinske Individual Corporate DirectorBoard Member Jul 1, 2020
Austin M Willuweit Individual W-2 Managing EmployeeVP Finance May 9, 2016 50%
Operational/Managerial ControlVP Finance May 9, 2016 50%
Srinivas K. Gangineni Individual Corporate DirectorBoard Member Jul 1, 2017
Monument Health Inc Organization, Rapid City, SD Corporation, Non-profit Operational/Managerial Control Jul 1, 2005 100%
Daryl L Reinicke Individual Corporate DirectorBoard Member Jun 27, 2019
Deidre N Budahl Individual Corporate DirectorBoard Member Jul 1, 2015
Ross W McKie Individual Corporate DirectorBoard Member Jun 27, 2019
Michael J Statz Individual Corporate DirectorBoard Member Jun 27, 2019
Thomas a Rau Individual Operational/Managerial ControlPresident Rapid City Market Jul 1, 2018 75%

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 9

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

FacilityTypeRoleSince
Same Day Surgery Center LLCRapid City, SD, CCN 430093 Hospital 5% Or Greater Direct Ownership Interest (40%)
5% Or Greater Mortgage Interest (100%)		 Nov 25, 1997
Jul 1, 2001
Rehabilitation and Critical Care Hospital of the Black HillsRapid City, SD, CCN 432003 Hospital 5% Or Greater Indirect Ownership Interest (49%) Jan 24, 2022
Rehabilitation and Critical Care Hospital of the Black HillsRapid City, SD, CCN 43TA03 Hospital 5% Or Greater Indirect Ownership Interest (49%) Jan 24, 2022
Monument Health Care CenterSturgis, SD, CCN 435102 Skilled nursing facility Adp of the SNF Jul 1, 2005
Monument Health Home Plus Home HealthRapid City, SD, CCN 437003 Home health agency 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2016
Monument Health Home Plus Home HealthSpearfish, SD, CCN 437037 Home health agency 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2016
Monument Health Home Plus HospiceRapid City, SD, CCN 431501 Hospice 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2016
Monument Health Home Plus HospiceSpearfish, SD, CCN 431513 Hospice 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2016
Kadoka ClinicKadoka, SD, CCN 433424 Rural health clinic Operational/Managerial Control Apr 1, 1986

Owned or controlled facilities with NPI records 8

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

Facilities with the same owner 15

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

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1432080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584316800000",
    "number": "1457730673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 860013",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554860013",
            "telephone_number": "605-279-2149",
            "fax_number": "605-279-1027"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 7TH AVENUE",
            "city": "WALL",
            "state": "SD",
            "postal_code": "577900001",
            "telephone_number": "605-279-2149",
            "fax_number": "605-279-1027"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MONUMENT HEALTH RAPID CITY HOSPITAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-20",
        "last_updated": "2020-03-16",
        "certification_date": "2020-03-16",
        "status": "A",
        "authorized_official_last_name": "PIERCE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "MONUMENT HEALTH PRESIDENT",
        "authorized_official_telephone_number": "605-755-8162"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Monument Health Wall Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALL REGIONAL MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wall, SD

Sources for this page

Verify at the official NPI Registry.