NPIMap

Organization Active NPI

Centracare Health System - Long Prairie

  • Rural Health Clinic/Center
  • Long Prairie, MN
National Provider Identifier
1497986582
Registry record updated Oct 10, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
342848 Issued in 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
Last updated
Oct 10, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 10, 2019

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

Authorized official

Name
Mr. Michael A. Blair
Title
Sr. Vice President and Cfo
Phone
(320) 255-5665

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 342848 MN Primary

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497986582. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Jan 1, 1999 in MN
Enrollment address
50 Centracare Dr
Long Prairie, MN 56347-2100
Related CCNs
243451

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D0405974Centracare - Long Prairie Clinic50 Centracare Drive, Long Prairie, MN 56347Certificate of waiverDec 31, 2026

National Provider Directory

National Provider Directory

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
Tina SSN May Individual Corporate DirectorBoard Member Jul 1, 2025
Michelle Johnson Individual Corporate Director Jul 1, 2021
Thomas Knoblach Individual Corporate Director Jul 1, 2011
Michael a Blair Individual Corporate OfficerCfo Sep 30, 2019
W-2 Managing Employee Sep 30, 2019
Jeffrey Gau Individual Corporate DirectorBoard Member Jul 1, 2017
Renee S Frauendienst Individual Corporate Director Jul 1, 2017
Jacob Lyons Individual Corporate Director Jul 1, 2024
Richard Wehseler Individual Corporate DirectorBoard Member Apr 21, 2018
Bobbie Bertram Individual Corporate Director Jul 1, 2015
Kenneth D Holmen Individual Corporate DirectorCeo, Board Member Jan 1, 2015
Sherri Liebl Individual Corporate OfficerExecutive Director Sep 30, 2019
David Anfinson Individual Corporate DirectorBoard Member Apr 21, 2018
Daniel Abdul Individual Corporate Director Jul 1, 2022
James Hebl Individual Corporate DirectorBoard Member Jul 1, 2017
Carrie Henning-Smith Individual Corporate Director Jul 1, 2023
Centracare Health System Organization, Saint Cloud, MN Non-profit Operational/Managerial Control Jan 1, 1999
Bryan Rolph Individual Corporate DirectorBoard Member Jul 1, 2019

Owners & managing parties with NPI records 7

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

Facilities with the same owner 28

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

View all 28

Practitioners & affiliated clinicians

Practitioners 67

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 67

NPI Registry JSON

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

{
    "created_epoch": "1249516800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1570665600000",
    "number": "1497986582",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 6TH AVE N",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563032735",
            "telephone_number": "320-732-2141",
            "fax_number": "320-732-3802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "50 CENTRACARE DR",
            "city": "LONG PRAIRIE",
            "state": "MN",
            "postal_code": "563472100",
            "telephone_number": "320-732-2141",
            "fax_number": "320-732-3802"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "20 9th St SE",
            "address_purpose": "LOCATION",
            "city": "Long Prairie",
            "state": "MN",
            "postal_code": "563471404",
            "country_code": "US",
            "telephone_number": "320-732-2141",
            "fax_number": "320-732-3802",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "50 Centra Care Dr",
            "address_purpose": "LOCATION",
            "city": "Long Prairie",
            "state": "MN",
            "postal_code": "56347",
            "country_code": "US",
            "telephone_number": "320-732-2141",
            "fax_number": "320-732-3802",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "CENTRACARE HEALTH SYSTEM - LONG PRAIRIE",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-06",
        "last_updated": "2019-10-10",
        "status": "A",
        "authorized_official_last_name": "BLAIR",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "SR. VICE PRESIDENT AND CFO",
        "authorized_official_telephone_number": "320-255-5665",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MN",
            "license": "342848",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Long Prairie, MN

Sources for this page

Verify at the official NPI Registry.