NPIMap

Organization Active NPI

St. Croix Regional Medical Center

  • Rural Health Clinic/Center
  • Saint Croix Falls, WI
National Provider Identifier
1669988861
Registry record updated Jan 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
1041 Issued in WI
Legal business name
ST. CROIX REGIONAL MEDICAL CENTER
Practice address
216 S Adams St
Saint Croix Falls, WI 54024-9449
Phone
(715) 483-3221
Fax
(715) 483-0507
NPI assigned
Dec 26, 2017
Last updated
Jan 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2023

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

Authorized official

Name
Mike Youso
Title
Cfo
Phone
(715) 483-0535

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 1041 WI Primary

Addresses

Primary practice location

216 S Adams St
Saint Croix Falls, WI 54024-9449

Mailing address

235 E State St
Saint Croix Falls, WI 54024-4117
Phone (715) 483-3221

Other names 1

  • St. Croix Falls Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180803000941 WI Part A Provider - Rural Health Clinic 9335032184 Practice locations: Saint Croix Falls, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669988861. Details of each certification follow.

Rural health clinic certification: CCN 528604

Legal name
ST. CROIX REGIONAL MEDICAL CENTER
Doing business as
ST. CROIX FALLS CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 8, 2019
Last certification
Feb 8, 2019
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Mar 15, 1954 in WI
Enrollment address
216 S Adams St
Saint Croix Falls, WI 54024-9449
Related CCNs
521337

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).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D2153797St Croix Falls Clinic216 South Adams Street, St Croix Falls, WI 54024Certificate of waiverAug 29, 2026

National Provider Directory

National Provider Directory
Tax ID family
St Croix Regional Med3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

216 S Adams St
St Croix Fls, WI 54024
Phone (715) 483-0426

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Michael J Youso Individual Corporate OfficerCeo Jun 28, 2022
Trudy Canine Individual Corporate DirectorGoverning Board Chair Jan 1, 2021
Mark Burandt Individual Corporate DirectorGoverning Board Treasurer Apr 23, 2024
William Ties Individual Corporate DirectorGoverning Board Vice-Chair Oct 30, 2019
Kimberly J Ericson Individual Corporate OfficerCfo Apr 17, 2023
Rebecca R Lyman Individual Corporate DirectorVP Medical Affairs Sep 1, 2018
Tanya K Mortel Individual W-2 Managing EmployeeCredentialing Supervisor Jan 6, 1992

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Adoray Home Health and HospiceBaldwin, WI, CCN 527137 Home health agency 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014
Adoray Home Health and HospiceBaldwin, WI, CCN 521521 Hospice 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014

Owned or controlled facilities with NPI records 2

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

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

NPI Registry JSON

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

{
    "created_epoch": "1514246400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674604800000",
    "number": "1669988861",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "235 E STATE ST",
            "city": "SAINT CROIX FALLS",
            "state": "WI",
            "postal_code": "540244117",
            "telephone_number": "715-483-3221",
            "fax_number": "715-483-0507"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "216 S ADAMS ST",
            "city": "SAINT CROIX FALLS",
            "state": "WI",
            "postal_code": "540249449",
            "telephone_number": "715-483-3221",
            "fax_number": "715-483-0507"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CROIX REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-12-26",
        "last_updated": "2023-01-25",
        "certification_date": "2023-01-25",
        "status": "A",
        "authorized_official_last_name": "YOUSO",
        "authorized_official_first_name": "MIKE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "715-483-0535"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WI",
            "license": "1041",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Croix Falls Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Saint Croix Falls, WI

Sources for this page

Verify at the official NPI Registry.