NPIMap

Organization Active NPI

St. Joseph's Medical Center

Doing business as Essentia Health St. Joseph's-Pine River Clinic

  • Primary Care Clinic/Center
  • Pine River, MN
National Provider Identifier
1649223603
Registry record updated Feb 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
330736 Issued in MN
Legal business name
ST. JOSEPH'S MEDICAL CENTER
Doing business as
Essentia Health St. Joseph's-Pine River Clinic
Practice address
280 Barclay Ave W
Pine River, MN 56474-5197
Phone
(218) 587-4416
Fax
(218) 587-2677
NPI assigned
May 18, 2006
Last updated
Feb 27, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 27, 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
Primary Care Clinic/Center 261QP2300X 330736 MN Primary

Addresses

Primary practice location

280 Barclay Ave W
Pine River, MN 56474-5197

Mailing address

280 Barclay Ave W
Pine River, MN 56474-5197
Phone (218) 587-4416

Other practice location 1

415 Barclay Ave
Pine River, MN 56474-5139
Phone (218) 587-4416

Other identifiers 1

IdentifierTypeStateIssuer
699019300MedicaidMN

Other names 1

  • Essentia Health St. Joseph's-Pine River 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
O20030702000029 MN Part A Provider - Hospital 8224948443 10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pierz, MN; Pillager, MN; Brainerd, MN; Pequot Lakes, MN; Crosslake, MN; Staples, MN; Pine River, MN; Deerwood, MN…
O20031119000468 MN Part B Supplier - Clinic/Group Practice 8224948443 Receives reassigned benefits from 361 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pequot Lakes, MN; Pierz, MN; Pillager, MN; Pine River, MN; Plymouth, MN; Saint Paul, MN; Crosslake, MN; Shoreview, MN…

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649223603. Details of each certification follow.

Hospital certification: CCN 240075

Legal name
ST JOSEPHS MEDICAL CENTER
Doing business as
ESSENTIA HEALTH - ST JOSEPHS MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Oct 1, 2015
Beds
162
Ownership / control type
Private (not for profit)
Most recent change of ownership
Oct 1, 1985 (2 total)
Organization structure
CorporationNon-profit
Enrollment address
523 N 3Rd St
Brainerd, MN 56401-3054
Main/Primary Hospital Location
Hospital subgroups
Acute care

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

Care Compare: Hospital

Medicare Care Compare
Listed as
Essentia Health St Joseph's Medical CenterCCN 240075 · All quality measures
Overall star rating
3 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Locations

13060 Isle Dr
Brainerd, MN 56425
Phone (218) 454-5920

Ownership & related parties

All disclosed owners & managing parties 20

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
Mark Bortnem Individual Corporate OfficerTreasurer Sep 25, 2025
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%
Beverly Raway Individual Corporate DirectorBoard Member Jan 1, 2017
St Marys Duluth Clinic Health System Organization, Duluth, MN Non-profit Operational/Managerial Control Jul 1, 2023
Bradley J Beard Individual Corporate OfficerChief Operating Officer Jul 1, 2023
W-2 Managing EmployeeChief Operating Officer Jul 1, 2023
Jeanne Weber Individual Corporate DirectorBoard Member Feb 15, 2019
Sandra Zutz-Wiczek Individual W-2 Managing EmployeeAd; May 6, 2024
Kevin S Boren Individual Corporate OfficerVP of Finance Jan 3, 2022
W-2 Managing EmployeeVP of Finance Jul 1, 2023
Troy Duininck Individual Corporate DirectorBoard Member Jan 1, 2023
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Jan Linse Baldwin Individual Corporate Director Jan 1, 2017
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.

Practitioners & affiliated clinicians

Practitioners 20

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 20

Affiliated clinicians 342

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

View all 342

NPI Registry JSON

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

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708992000000",
    "number": "1649223603",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "280 BARCLAY AVE W",
            "city": "PINE RIVER",
            "state": "MN",
            "postal_code": "564745197",
            "telephone_number": "218-587-4416",
            "fax_number": "218-587-2677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "280 BARCLAY AVE W",
            "city": "PINE RIVER",
            "state": "MN",
            "postal_code": "564745197",
            "telephone_number": "218-587-4416",
            "fax_number": "218-587-2677"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "415 Barclay Ave",
            "address_purpose": "LOCATION",
            "city": "Pine River",
            "state": "MN",
            "postal_code": "564745139",
            "country_code": "US",
            "telephone_number": "218-587-4416",
            "fax_number": "218-587-2677",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "ST. JOSEPH'S MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2006-05-18",
        "last_updated": "2024-02-27",
        "certification_date": "2024-02-27",
        "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": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "MN",
            "license": "330736",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "699019300",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health St. Joseph's-Pine River Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health St. Joseph's-Pine River Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pine River, MN

Sources for this page

Verify at the official NPI Registry.