NPIMap

Organization Active NPI

Providence St Joseph Medical Center

Doing business as Prov St Joseph Med Ctr Polson

  • Rural Health Clinic/Center
  • Polson, MT
National Provider Identifier
1609104165
Registry record updated May 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PROVIDENCE ST JOSEPH MEDICAL CENTER
Doing business as
Prov St Joseph Med Ctr Polson
Practice address
6 13TH Ave E
Polson, MT 59860-5315
Phone
(406) 883-5680
Fax
(406) 883-8926
NPI assigned
Nov 20, 2009
Last updated
May 7, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH & SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 7, 2025

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

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary Enrollments
Phone
(425) 358-9786

Specialties & licenses 1

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

Addresses

Primary practice location

6 13TH Ave E
Polson, MT 59860-5315

Mailing address

PO Box 31001-4110
Pasadena, CA 91110-4110

Other names 1

  • Prov St Joseph Med Ctr Polson Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100219000280 MT Part A Provider - Rural Health Clinic 0446230247 Practice locations: Polson, MT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609104165. Details of each certification follow.

Rural health clinic certification: CCN 273415

Legal name
PROVIDENCE ST JOSEPH MEDICAL CENTER
Doing business as
PROVIDENCE ST JOSEPH MEDICAL CENTER - POLSON
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 1, 2010
Last certification
Jan 18, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Mar 1, 1991 in MT
Enrollment address
6 13TH E Ave
Polson, MT 59860-5315
Related CCNs
271343

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).

National Provider Directory

National Provider Directory
Tax ID family
St Joseph Hospital Corporation7 organizations share this tax ID, including this one
Part of
Providence Service Corporation

Other organizations with this tax ID 6

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 24

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

NameRoleSinceShare
Diane L Hejna Individual Corporate DirectorBoard Member Jul 1, 2016
Richard S Blair Individual Corporate DirectorBoard Member Jul 1, 2016
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Providence Health & Services - Washington Organization, Renton, WA Corporation, Non-profit Operational/Managerial Control Jan 1, 2006
Mary E Lyons Individual Corporate DirectorBoard Member Jul 1, 2016
Kirk Francis Bodlovic Individual W-2 Managing Employee Oct 18, 2009
Phyllis M Hughes Individual Corporate DirectorBoard Member Jul 1, 2016
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
James Martin Individual Corporate OfficerAssistant Treasurer Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorBoard Member Jan 1, 2019
Donald Wayne Anderson Individual Corporate OfficerAsst Sec Enrollmt/Dir Reimb Reg Jan 1, 2017
Gregory David Hoffman Individual Corporate OfficerPresident/Ceo & Treasurer Oct 1, 2020
Providence Health & Services Mt Organization, Renton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Dec 18, 2009
Operational/Managerial Control Dec 18, 2009
Isiaah D Crawford Individual Corporate DirectorBoard Member Feb 1, 2012
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard Member Jan 1, 2020
Providence Health & Services Organization, Renton, WA Corporation, Non-profit Other Dec 18, 2009
Mary Beth Kingston Individual Corporate DirectorBoard of Directors Sep 1, 2022
Eric D Sprunk Individual Corporate DirectorBoard of Directors Jan 1, 2022
Anna R Newsom Individual Corporate OfficerCorporate Secretary May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident/Ce Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Other Jul 1, 2016

Owners & managing parties with NPI records 6

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

Facilities with the same owner 141

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

View all 141

NPI Registry JSON

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

{
    "created_epoch": "1258675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746576000000",
    "number": "1609104165",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-4110",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6 13TH AVE E",
            "city": "POLSON",
            "state": "MT",
            "postal_code": "598605315",
            "telephone_number": "406-883-5680",
            "fax_number": "406-883-8926"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE ST JOSEPH MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH & SERVICES",
        "enumeration_date": "2009-11-20",
        "last_updated": "2025-05-07",
        "certification_date": "2025-05-07",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Prov St Joseph Med Ctr Polson",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Prov St Joseph Med Ctr Polson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Polson, MT

Sources for this page

Verify at the official NPI Registry.