NPIMap

Organization Active NPI

Centracare Health System - Sauk Centre

Doing business as CentraCare Health - Sauk Centre Clinic

  • Rural Health Clinic/Center
  • Sauk Centre, MN
National Provider Identifier
1578813762
Registry record updated Jan 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CENTRACARE HEALTH SYSTEM - SAUK CENTRE
Doing business as
CentraCare Health - Sauk Centre Clinic
Practice address
425 Elm St N
Sauk Centre, MN 56378-1010
Phone
(320) 352-2221
Fax
(320) 352-5150
NPI assigned
Sep 14, 2012
Reactivated
Jan 30, 2023
Last updated
Jan 30, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2023

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 Primary

Addresses

Primary practice location

425 Elm St N
Sauk Centre, MN 56378-1010

Mailing address

1200 6TH Ave N
Saint Cloud, MN 56303-2735
Phone (320) 352-2221

Other names 1

  • CentraCare Health - Sauk Centre Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130116000380 MN Part B Supplier - Clinic/Group Practice 4981857216 Receives reassigned benefits from 138 practitioners
1 other NPI on this enrollment
Practice locations: Sauk Centre, MN
O20130122000550 MN Part A Provider - Rural Health Clinic 4981857216 Practice locations: Sauk Centre, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1578813762. Details of each certification follow.

Rural health clinic certification: CCN 243465

Legal name
CENTRACARE HEALTH SYSTEM - SAUK CENTRE
Doing business as
CENTRACARE - SAUK CENTRE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 1, 2012
Last certification
Jul 18, 2018
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 23, 2011 in MN
Enrollment address
425 Elm St N
Sauk Centre, MN 56378-1010
Related CCNs
241368

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

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
24D0406048Centracare - Sauk Centre Clinic425 Elm Street North, Sauk Centre, MN 56378Certificate of waiverDec 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Centracare Health- Long Prairie LLC6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the 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
Tina SSN May Individual Corporate OfficerBoard 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 DirectorBoard 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, St Cloud, MN Non-profit 5% Or Greater Direct Ownership Interest Dec 1, 2012 100%
Bryan Rolph Individual Corporate Director 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 147

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 147

NPI Registry JSON

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

{
    "created_epoch": "1347580800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675036800000",
    "number": "1578813762",
    "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": "320-352-2221",
            "fax_number": "320-352-5150"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 ELM ST N",
            "city": "SAUK CENTRE",
            "state": "MN",
            "postal_code": "563781010",
            "telephone_number": "320-352-2221",
            "fax_number": "320-352-5150"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRACARE HEALTH SYSTEM - SAUK CENTRE",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-14",
        "last_updated": "2023-01-30",
        "certification_date": "2023-01-30",
        "deactivation_date": "2023-01-25",
        "reactivation_date": "2023-01-30",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CentraCare Health - Sauk Centre Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sauk Centre, MN

Sources for this page

Verify at the official NPI Registry.