NPIMap

Organization Active NPI

Indianhead Medical Center Shell Lake, Inc.

Doing business as Indianhead Medical Center

  • Rural Health Clinic/Center
  • Shell Lake, WI
National Provider Identifier
1659899078
Registry record updated Mar 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Doing business as
Indianhead Medical Center
Practice address
113 4TH Ave
Shell Lake, WI 54871-4457
Phone
(715) 468-7833
Fax
(715) 468-7303
NPI assigned
Sep 6, 2017
Last updated
Mar 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2020

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

Authorized official

Name
Shannon James Jack
Title
Executive Vice President
Phone
(715) 468-7833

Specialties & licenses 1

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

Addresses

Primary practice location

113 4TH Ave
Shell Lake, WI 54871-4457

Mailing address

PO Box 300
Shell Lake, WI 54871-0300
Phone (715) 468-7833

Other identifiers 1

IdentifierTypeStateIssuer
11020700MedicaidWI

Other names 1

  • Indianhead Medical Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171010001807 WI Part A Provider - Rural Health Clinic 6406748839 Practice locations: Shell Lake, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1659899078. Details of each certification follow.

Rural health clinic certification: CCN 528589

Legal name
INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 10, 2018
Last certification
Jul 10, 2018
Ownership / control type
1B
Organization structure
CorporationNon-profit
Incorporated
Sep 30, 1990 in WI
Enrollment address
113 4TH Ave
Shell Lake, WI 54871-4457
Related CCNs
521342

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).

Care Compare: Home health agency

Medicare Care Compare
Listed as
Indianhead Medical Ctr HHACCN 527262
Ownership
Non-Profit
Certified
Dec 24, 1996
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address. The facility is not in the current Medicare enrollment files, which can mean its Medicare enrollment has ended (or, for VA and military hospitals, that it does not enroll).

National Provider Directory

National Provider Directory
Tax ID family
Indianhead Medical Ctr4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Interoperability endpoints

  • Direct secure messaging: allanhaesemeyer@indmectr.allscriptsdirect.net
  • Direct secure messaging: eugenerigstad@indmectr.allscriptsdirect.net
  • Direct secure messaging: jeffreydunham@indmectr.allscriptsdirect.net
  • Direct secure messaging: juanpreciado-riestra@indmectr.allscriptsdirect.net

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Kevin Allen Jack Individual Corporate OfficerPresident Jan 1, 2016
Shannon James Jack Individual Contracted Managing Employee Feb 1, 2021

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Shell Lake Health Care CenterShell Lake, WI, CCN 525553 Skilled nursing facility Adp of the SNF Sep 22, 2021

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • Shell Lake SNF LLC

    dba Shell Lake Health Care Center

    • Nursing Facility/Intermediate Care Facility
    • Shell Lake, WI
    • NPI 1295939049

    Adp of the SNF

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 4

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.

NPI Registry JSON

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

{
    "created_epoch": "1504656000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583712000000",
    "number": "1659899078",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 300",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "548710300",
            "telephone_number": "715-468-7833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 4TH AVE",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "548714457",
            "telephone_number": "715-468-7833",
            "fax_number": "715-468-7303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-06",
        "last_updated": "2020-03-09",
        "certification_date": "2020-03-09",
        "status": "A",
        "authorized_official_last_name": "JACK",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT",
        "authorized_official_telephone_number": "715-468-7833"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11020700",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Indianhead Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shell Lake, WI

Sources for this page

Verify at the official NPI Registry.