Wagner Community Memorial Hospital
Organization Active NPI Medicare Defined Swing Bed Hospital Unit · Wagner, SD
NPI 1629135645 · NPPES record last updated Mar 7, 2017
Key facts
- NPI
- 1629135645
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Medicare Defined Swing Bed Hospital Unit 275N00000X
- License
- 10571 (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
- Organization subpart
- Yes
- Parent organization (as reported)
- WAGNER COMMUNITY MEMORIAL HOSPITAL
Authorized official
- Name
- Mr. Bryan Slaba
- Title
- Ceo
- Phone
- (605) 384-3611
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 1
Related certifications (CCN) 2
Practitioners 45
-
Berkley A Erickson, CNP
-
Sandra Ellen Fortuna, BSW
-
Dana Huether, DNP
-
Ryan Kocer, CNP
-
Riyad Mohama, MD
-
Jarod Myer, FNP-C
-
Lindsey Nedved, NP-C
-
Cassie Lynn Nelson, CNP
-
Jodi Peterson, CNP
-
Brooke Lynn Plooster, CNP
-
Ashley Marie Ruhaak, CNP
-
Jazmyn Soukup, DNP
-
Tori Sarah Thaler, LCSW-PIP, LISW
-
Jordan Carl Weber, PA-C
-
Theresa A Petersen, APRN
-
Raymond H Allen, MD
-
Sherrie Marie Brooks, D.O.,FACC,FACOI
-
Paul L Carpenter, MD
-
Dylan Dethlefsen, CSW, QMHP
-
Sean C Halligan, MD
Affiliated clinicians 3
-
Jazmyn Soukup, DNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SD
Hospital certification: CCN 43Z315
- Legal name
- WAGNER COMMUNITY MEMORIAL HOSPITAL
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 1, 1947 in SD
- Enrollment address
- 513 3Rd St SW
Wagner, SD 57380-9675
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Joshua Christensen |
Corporate Officer |
May 1, 2024 | |
| Chad Peters |
Corporate Director |
Sep 1, 2013 | |
| Brittany Barron |
Corporate Officer |
Jan 1, 2026 | |
| W-2 Managing Employee |
Jan 1, 2026 | ||
| Bernadette Koupal |
W-2 Managing Employee |
May 20, 1985 | |
| Marcia Podzimek |
W-2 Managing Employee |
Feb 1, 1982 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070103000206 | SD | Part a Provider - Critical Access Hospital | 3577459700 |
1 other NPI on this enrollment Practice locations: Wagner, SD |
National Provider Directory
- Tax ID family
- Wagner Community Memori
- Part of
- Wagner Community Memori
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medicare Defined Swing Bed Hospital Unit | 275N00000X | 10571 | SD | Yes |
| 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
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1007417 | Medicaid | SD | |
| 8Z1315 | Other | SD | BC SLTC |
Other providers in Wagner, SD
- Jared Van Winkle
- Jessica M Vanderham
- Vanessa Iverson, LLC
- Diana Lynn Wackel
- Wagner Community Memorial Hospital
- Wagner Community Memorial Hospital
- Wagner Community Memorial Hospital Avera
- Wagner Indian Health Care Pharmacy
- Wagner Indian Health Service Health Center
- Wagner Indian Health Service Health Center
All providers in Wagner, SD · Medicare Defined Swing Bed Hospital Unit in South Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 7, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.