NPIMap

Organization Active NPI

Wagner Community Memorial Hospital

  • Medicare Defined Swing Bed Hospital Unit
  • Wagner, SD
National Provider Identifier
1629135645
Registry record updated Mar 7, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
10571 Issued in SD
Legal business name
WAGNER COMMUNITY MEMORIAL HOSPITAL
Practice address
513 3Rd St SW
Wagner, SD 57380-0280
Phone
(605) 384-3611
Fax
(605) 384-3232
NPI assigned
Jan 2, 2007
Last updated
Mar 7, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
WAGNER COMMUNITY MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 7, 2017

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

Authorized official

Name
Mr. Bryan Slaba
Title
Ceo
Phone
(605) 384-3611

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 10571 SD Primary
Long Term Care Hospital 282E00000X 10571 SD

Addresses

Primary practice location

513 3Rd St SW
Wagner, SD 57380-0280

Mailing address

513 3Rd St SW
PO Box 280
Wagner, SD 57380-0280
Phone (605) 384-3611

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070103000206 SD Part A Provider - Critical Access Hospital 3577459700 1 other NPI on this enrollment
Practice locations: Wagner, SD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629135645. Details of each certification follow.

Hospital certification: CCN 43Z315

Legal name
WAGNER COMMUNITY MEMORIAL HOSPITAL
Organization structure
CorporationNon-profit
Incorporated
Dec 1, 1947 in SD
Enrollment address
513 3Rd St SW
Wagner, SD 57380-9675
Hospital Swing-Bed Unit

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.

National Provider Directory

National Provider Directory
Tax ID family
Wagner Community Clinic2 organizations share this tax ID, including this one
Part of
Wagner Community Clinic

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Joshua Christensen Individual Corporate OfficerCfo May 1, 2024
Chad Peters Individual Corporate DirectorVice President Sep 1, 2013
Brittany Barron Individual Corporate OfficerCeo Jan 1, 2026
W-2 Managing EmployeeAd; Jan 1, 2026
Bernadette Koupal Individual W-2 Managing EmployeeVP of Administrative Services May 20, 1985
Marcia Podzimek Individual W-2 Managing EmployeeHR Director Feb 1, 1982

Practitioners & affiliated clinicians

Practitioners 45

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 45

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1167696000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488844800000",
    "number": "1629135645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "513 3RD ST SW",
            "address_2": "PO BOX 280",
            "city": "WAGNER",
            "state": "SD",
            "postal_code": "573800280",
            "telephone_number": "605-384-3611",
            "fax_number": "605-384-3232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "513 3RD ST SW",
            "city": "WAGNER",
            "state": "SD",
            "postal_code": "573800280",
            "telephone_number": "605-384-3611",
            "fax_number": "605-384-3232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAGNER COMMUNITY MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WAGNER COMMUNITY MEMORIAL HOSPITAL",
        "enumeration_date": "2007-01-02",
        "last_updated": "2017-03-07",
        "status": "A",
        "authorized_official_last_name": "SLABA",
        "authorized_official_first_name": "BRYAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "605-384-3611",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "SD",
            "license": "10571",
            "primary": true
        },
        {
            "code": "282E00000X",
            "taxonomy_group": "",
            "desc": "Long Term Care Hospital",
            "state": "SD",
            "license": "10571",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Wagner, SD

Sources for this page

Verify at the official NPI Registry.