NPIMap

Organization Active NPI

Mitchell County Memorial Hospital

Doing business as St Ansgar Clinic

  • Rural Health Clinic/Center
  • Saint Ansgar, IA
National Provider Identifier
1518059138
Registry record updated Dec 7, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MITCHELL COUNTY MEMORIAL HOSPITAL
Doing business as
St Ansgar Clinic
Practice address
140 W 4TH St
Suite 1
Saint Ansgar, IA 50472-1352
Phone
(641) 736-4401
Fax
(641) 713-4977
NPI assigned
Sep 29, 2006
Last updated
Dec 7, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 7, 2020

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

Authorized official

Name
Michele Russell
Title
Ceo
Phone
(641) 732-6003

Specialties & licenses 1

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

Addresses

Primary practice location

140 W 4TH St
Suite 1
Saint Ansgar, IA 50472-1352

Mailing address

616 N 8TH St
Osage, IA 50461-1456
Phone (641) 732-6000

Other identifiers 1

IdentifierTypeStateIssuer
0634451MedicaidIA

Other names 1

  • ST ANSGAR CLINIC Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address MI.MHN.HIM@direct.2.mycarefile.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040127000973 IA Part B Supplier - Clinic/Group Practice 5890603070 Receives reassigned benefits from 22 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Ansgar, IA; Riceville, IA; Osage, IA
O20050211000412 IA Part A Provider - Rural Health Clinic 5890603070 Practice locations: Saint Ansgar, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1518059138. Details of each certification follow.

Rural health clinic certification: CCN 163445

Legal name
MITCHELL COUNTY MEMORIAL HOSPITAL
Doing business as
ST ANSGAR CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 15, 1995
Last certification
Sep 14, 2021
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Incorporated
Oct 28, 1951 in IA
Enrollment address
140 W 4TH St
Ste 1
Saint Ansgar, IA 50472-1352
Related CCNs
161323

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 4

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
16D0384141St Ansgar Clinic140 West 4TH Street, Saint Ansgar, IA 50472ComplianceDec 18, 2027

National Provider Directory

National Provider Directory

Locations

713 Woodland Ave
Ste A
Riceville, IA 50466
Phone (641) 985-2122

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Jon W Koster Individual Corporate Director Aug 28, 2012
Betty Lee McCarthy Individual Corporate Director Nov 1, 2012
Cheryl Jean Smalley Individual Corporate Director Jun 26, 2014
Luke Porisch Individual Corporate Director Nov 1, 2014
Mercy Health Network Inc Organization, Clive, IA Corporation, Non-profit Operational/Managerial Control Mar 1, 2016 100%
Gregory J Burkel Individual Corporate OfficerCfo Jan 23, 2013 100%
Operational/Managerial Control Jan 23, 2013
Jean a Brumm Individual Corporate Director Mar 11, 2005
Mitchell County Memorial Hospital Organization, Osage, IA Operational/Managerial Control Sep 1, 1994
Steve Jay Norby Individual Corporate Director Nov 1, 2014
Corrina Follmuth Individual Corporate Director Jan 1, 2018
Michele Russell Individual Contracted Managing Employee Jul 28, 2014 100%
Corporate OfficerCeo Jul 28, 2014 100%
Operational/Managerial Control Jul 28, 2014

Owners & managing parties with NPI records 5

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
Riceville ClinicRiceville, IA, CCN 163497 Rural health clinic Operational/Managerial Control Sep 1, 1994
Mitchell County Regional Health Center-Osage ClinicOsage, IA, CCN 163454 Rural health clinic Operational/Managerial Control Sep 1, 1994

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 98

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

View all 98

Practitioners & affiliated clinicians

Practitioners 4

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.

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": "1607299200000",
    "number": "1518059138",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "616 N 8TH ST",
            "city": "OSAGE",
            "state": "IA",
            "postal_code": "504611456",
            "telephone_number": "641-732-6000",
            "fax_number": "641-732-6028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 W 4TH ST",
            "address_2": "SUITE 1",
            "city": "SAINT ANSGAR",
            "state": "IA",
            "postal_code": "504721352",
            "telephone_number": "641-736-4401",
            "fax_number": "641-713-4977"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MITCHELL COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-29",
        "last_updated": "2020-12-07",
        "certification_date": "2020-12-07",
        "status": "A",
        "authorized_official_last_name": "RUSSELL",
        "authorized_official_first_name": "MICHELE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "641-732-6003"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0634451",
            "state": "IA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "MI.MHN.HIM@direct.2.mycarefile.org",
            "affiliation": "N",
            "endpointDescription": "Mitchell County Regional Health Center",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCDA",
            "address_1": "140 W 4th St",
            "address_2": "SUITE 1",
            "city": "Saint Ansgar",
            "state": "IA",
            "country_code": "US",
            "postal_code": "504721352",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "ST ANSGAR CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "ST ANSGAR CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Ansgar, IA

Sources for this page

Verify at the official NPI Registry.