NPIMap

Organization Active NPI

St Mary's Hospital of Superior

Doing business as Essentia Health Hayward Clinic

  • Rural Health Clinic/Center
  • Hayward, WI
National Provider Identifier
1528518883
Registry record updated Feb 28, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ST MARY'S HOSPITAL OF SUPERIOR
Doing business as
Essentia Health Hayward Clinic
Practice address
11134 N State Road 77
Hayward, WI 54843-5325
Phone
(715) 634-5505
NPI assigned
Oct 11, 2016
Last updated
Feb 28, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 28, 2024

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

Authorized official

Name
Kevin Boren
Title
VP of Finance
Phone
(218) 786-1009

Specialties & licenses 1

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

Addresses

Primary practice location

11134 N State Road 77
Hayward, WI 54843-5325

Mailing address

11134 N State Road 77
Hayward, WI 54843-5325
Phone (715) 634-5505

Other names 1

  • Essentia Health Hayward Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040309000070 WI Part B Supplier - Clinic/Group Practice 8628964228 Receives reassigned benefits from 458 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Superior, WI; Whitefish Bay, WI; Spooner, WI; South Range, WI; Mount Horeb, WI; Minocqua, WI; Hayward, WI; Ashland, WI
O20170314000159 WI Part A Provider - Rural Health Clinic 8628964228 Practice locations: Hayward, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1528518883. Details of each certification follow.

Rural health clinic certification: CCN 528585

Legal name
ST MARYS HOSPITAL OF SUPERIOR
Doing business as
ESSENTIA HEALTH HAYWARD CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 10, 2018
Last certification
Apr 10, 2018
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 1995 in WI
Enrollment address
11134 N State Road 77
Hayward, WI 54843-5325
Related CCNs
521329

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

Other NPIs with the same Medicare PAC ID 4

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.

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the 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
Krista Ann Skorupa Individual Corporate OfficerPresident May 6, 2024
Amy Bergstrom Individual Corporate DirectorBoard Member Jan 1, 2024
Anthony Sertich Individual Corporate DirectorBoard Member Jan 1, 2021
George Loban Individual Corporate DirectorBoard Member Jan 1, 2024
Adam Bachand Individual Corporate DirectorBoard Member Jan 1, 2025
Thomas Jamar Individual Corporate DirectorBoard Member Jan 1, 2023
Rebecca Urbanski Individual Corporate DirectorBoard Member Jan 1, 2025
Anthony Yung Individual Corporate DirectorBoard Member Jan 1, 2023
Essentia Health Organization, Duluth, MN Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2023 100%
Justin Terch Individual Corporate DirectorBoard Member Oct 22, 2025
St Marys Duluth Clinic Health System Organization, Duluth, MN Non-profit Operational/Managerial Control Jan 1, 1997
Kim Pearson Individual W-2 Managing EmployeeAdministrator Mar 2, 2020
Kevin S Boren Individual Corporate OfficerVP of Finance Sep 3, 2021
W-2 Managing EmployeeVP of Finance Sep 3, 2021
Troy Duininck Individual Corporate DirectorBoard Member Jan 1, 2023
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Bruce Smith Individual Corporate DirectorBoard Member Jan 1, 2026
Nancy Aronson Norr Individual Corporate DirectorBoard Member Jan 1, 2025

Owners & managing parties with NPI records 5

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

Facilities with the same owner 46

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

View all 46

Practitioners & affiliated clinicians

Practitioners 34

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 34

NPI Registry JSON

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

{
    "created_epoch": "1476144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709078400000",
    "number": "1528518883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11134 N STATE ROAD 77",
            "city": "HAYWARD",
            "state": "WI",
            "postal_code": "548435325",
            "telephone_number": "715-634-5505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11134 N STATE ROAD 77",
            "city": "HAYWARD",
            "state": "WI",
            "postal_code": "548435325",
            "telephone_number": "715-634-5505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST MARY'S HOSPITAL OF SUPERIOR",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2016-10-11",
        "last_updated": "2024-02-28",
        "certification_date": "2024-02-28",
        "status": "A",
        "authorized_official_last_name": "BOREN",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "218-786-1009"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health Hayward Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health Hayward Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hayward, WI

Sources for this page

Verify at the official NPI Registry.