NPIMap

Organization Active NPI

St Clare Memorial Hospital, Inc

Doing business as St Clare Memorial Hospital Oconto Health Center

  • Family Medicine Physician
  • Oconto, WI
National Provider Identifier
1467583278
Registry record updated Sep 2, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
25152-20 Issued in WI
Legal business name
ST CLARE MEMORIAL HOSPITAL, INC
Doing business as
St Clare Memorial Hospital Oconto Health Center
Practice address
103 1St St
Oconto, WI 54153-1117
Phone
(920) 835-1144
Fax
(920) 835-1145
NPI assigned
Mar 7, 2007
Last updated
Sep 2, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
ST CLARE MEMORIAL HOSPITAL, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 2, 2014

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

Authorized official

Name
Daniel Degroot
Title
Ceo
Phone
(920) 846-3444

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 1515-23 WI
Physician Assistant 363A00000X 212-23 WI
Family Medicine Physician 207Q00000X 25152-20 WI Primary

Addresses

Primary practice location

103 1St St
Oconto, WI 54153-1117

Mailing address

103 1St St
Oconto, WI 54153-1117
Phone (920) 835-1144

Other identifiers 5

IdentifierTypeStateIssuer
11014110MedicaidWI
1851477913OtherCMH NPI
1215024716OtherNPI BIRK
1477750644OtherNPI FOX
1760462352OtherNPI KNUTSON

Other names 1

  • St Clare Memorial Hospital Oconto Health Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050510001159 WI Part A Provider - Critical Access Hospital 0446211395 Receives reassigned benefits from 7 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Oconto Falls, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467583278. Details of each certification follow.

Hospital certification: CCN 521310

Legal name
ST CLARE MEMORIAL HOSPITAL, INC
Doing business as
HSHS ST. CLARE MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Feb 1, 2001
Last certification
Sep 20, 2023
Beds
15
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Enrollment address
855 S Main St
Oconto Falls, WI 54154-1241
Other Hospital Practice Location

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

Other NPIs on the same Medicare enrollment 3

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

Care Compare: Hospital

Medicare Care Compare
Listed as
HSHS St Clare Memorial HospitalCCN 521310 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Part of
St Clare Memorial Hospital

Member of 2

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

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
Hospital Sisters Health System Inc Organization, Springfield, IL Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Sep 1, 2014 100%
Michael M Nelessen Individual Corporate Director Nov 1, 2018
Ginny Oharrow Individual Corporate DirectorBoard Member Nov 1, 2023
Jan Stranz Individual Corporate Director Feb 1, 1999
Cara B Peterson Individual Corporate DirectorBoard Member Nov 1, 2023
Patricia L Allen Individual Corporate OfficerCfo Jan 1, 2020
Corporate DirectorCfo Jan 1, 2020
Lori Dufek Individual Corporate DirectorBoard Member Nov 1, 2021
Hospital Sisters Services Inc Organization, Springfield, IL Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2014 100%
Ron Christensen Individual Corporate DirectorBoard Member Nov 1, 2023
John Wagner Individual Corporate OfficerCoo Oct 15, 2022
Corporate DirectorCoo Oct 15, 2022
Damond Williams Boatwright Individual Corporate OfficerPresident/Ceo Jul 19, 2021
W-2 Managing EmployeePresident/Ceo Jul 19, 2021 100%
Robert Erickson Individual Corporate OfficerPresident/Ceo Apr 29, 2024
Corporate DirectorPresident/Ceo Apr 29, 2024
Travis Pitzen Individual Corporate DirectorDirector of Finance Sep 30, 2024
W-2 Managing EmployeeDirector of Finance Sep 30, 2024
Stacee Goedtel Birr Individual Corporate DirectorBoard Member Nov 1, 2023

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 19

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 19

Affiliated clinicians 118

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

View all 118

NPI Registry JSON

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

{
    "created_epoch": "1173225600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1409616000000",
    "number": "1467583278",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 1ST ST",
            "city": "OCONTO",
            "state": "WI",
            "postal_code": "541531117",
            "telephone_number": "920-835-1144",
            "fax_number": "920-835-1145"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 1ST ST",
            "city": "OCONTO",
            "state": "WI",
            "postal_code": "541531117",
            "telephone_number": "920-835-1144",
            "fax_number": "920-835-1145"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST CLARE MEMORIAL HOSPITAL, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST CLARE MEMORIAL HOSPITAL, INC",
        "enumeration_date": "2007-03-07",
        "last_updated": "2014-09-02",
        "status": "A",
        "authorized_official_last_name": "DEGROOT",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "920-846-3444"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WI",
            "license": "1515-23",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WI",
            "license": "212-23",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "25152-20",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11014110",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CMH NPI",
            "identifier": "1851477913",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI BIRK",
            "identifier": "1215024716",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI FOX",
            "identifier": "1477750644",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI KNUTSON",
            "identifier": "1760462352",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Clare Memorial Hospital Oconto Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Oconto, WI

Sources for this page

Verify at the official NPI Registry.