Centracare Health System - Long Prairie
Organization Active NPI Rural Health Clinic/Center · Long Prairie, MN
NPI 1497986582 · NPPES record last updated Oct 10, 2019
Key facts
- NPI
- 1497986582
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 342848 (MN)
- Legal business name
- CENTRACARE HEALTH SYSTEM - LONG PRAIRIE
- Practice address
- 50 Centracare Dr
Long Prairie, MN 56347-2100 - Phone
- (320) 732-2141
- Fax
- (320) 732-3802
- NPI assigned
- Aug 6, 2009
- Organization subpart
- No
Authorized official
- Name
- Mr. Michael A. Blair
- Title
- Sr. Vice President and Cfo
- Phone
- (320) 255-5665
Owners & managing parties with NPI records 7
-
Bobbie Jo Bertram, RN, CNP
-
James Russell Hebl, M.D.
-
Jacob Lyons, MD
-
Bryan P Rolph, MD
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 2
Facilities with the same owner 28
Practitioners 108
-
Stacy Marie Longnecker, M.D.
-
Paul L Marek, MD, FHM
-
Khalid M Sonbol, MD
-
Jennifer M Taves, MD
-
Ramesh Kumar Tentu, MBBS
-
Janelle Mary Terhaar, CNP
-
Jastindeep Brar, MD
-
Jerome Frazier, D.O.
-
Kamran Ilyas, MD
-
Olayiwola R. Adetunji, MBBS
-
Malik Ahmad, M.D.
-
Kristina Tester-Klashnya Chien, MD, JD
-
Anjali Dahiya, M D
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0405974 | Centracare - Long Prairie Clinic | Certificate of waiver | Dec 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MN
Rural health clinic certification: CCN 243451
- Legal name
- CENTRACARE HEALTH SYSTEM - LONG PRAIRIE
- Doing business as
- CENTRACARE - LONG PRAIRIE CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 1, 2010
- Last certification
- Sep 19, 2012
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 1, 1999 in MN
- Enrollment address
- 50 Centracare Dr
Long Prairie, MN 56347-2100 - Related CCNs
- 243451
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Tina SSN May |
Corporate Director |
Jul 1, 2025 | |
| Michelle Johnson |
Corporate Director | Jul 1, 2021 | |
| Thomas Knoblach |
Corporate Director | Jul 1, 2011 | |
| Michael a Blair |
Corporate Officer |
Sep 30, 2019 | |
| W-2 Managing Employee | Sep 30, 2019 | ||
| Jeffrey Gau |
Corporate Director |
Jul 1, 2017 | |
| Renee S Frauendienst |
Corporate Director | Jul 1, 2017 | |
| Jacob Lyons |
Corporate Director | Jul 1, 2024 | |
| Richard Wehseler |
Corporate Director |
Apr 21, 2018 | |
| Bobbie Bertram |
Corporate Director | Jul 1, 2015 | |
| Kenneth D Holmen |
Corporate Director |
Jan 1, 2015 | |
| Sherri Liebl |
Corporate Officer |
Sep 30, 2019 | |
| David Anfinson |
Corporate Director |
Apr 21, 2018 | |
| Daniel Abdul |
Corporate Director | Jul 1, 2022 | |
| James Hebl |
Corporate Director |
Jul 1, 2017 | |
| Carrie Henning-Smith |
Corporate Director | Jul 1, 2023 | |
| Centracare Health System |
Operational/Managerial Control | Jan 1, 1999 | |
| Bryan Rolph |
Corporate Director |
Jul 1, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050823000460 | MN | Part B Supplier - Clinic/Group Practice | 3870524598 |
Receives reassigned benefits from 171 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Long Prairie, MN |
| O20100804000406 | MN | Part a Provider - Rural Health Clinic | 3870524598 | Practice locations: Long Prairie, MN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 342848 | MN | Yes |
Addresses
Primary practice location
50 Centracare Dr
Long Prairie, MN 56347-2100
Mailing address
1200 6TH Ave N
Saint Cloud, MN 56303-2735
Phone (320) 732-2141
Other practice location 1
20 9th St SE
Long Prairie, MN 56347-1404
Phone (320) 732-2141
Other practice location 2
50 Centra Care Dr
Long Prairie, MN 56347
Phone (320) 732-2141
Other providers in Long Prairie, MN
- Gwen Lea Berry
- Audrey Elissa Brandt Loer
- Samuel Tucker Burns
- Centracare Clinic - Long Prairie
- Centracare Health System - Long Prairie
- Centracare Health System - Long Prairie
- Annie E Christensen
- Jennifer Christensen
- Mark A. Christiansen
- Dion Claseman
All providers in Long Prairie, MN · Rural Health Clinic/Center in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 10, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.