Wagner Community Memorial Hospital
Organization Active NPI Family Medicine Physician · Wagner, SD
NPI 1740306992 · NPPES record last updated Mar 7, 2017
Key facts
- NPI
- 1740306992
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 10571 (SD)
- Legal business name
- WAGNER COMMUNITY MEMORIAL HOSPITAL
- Practice address
- 513 3Rd St SW
Wagner, SD 57380-9675 - Phone
- (605) 384-3418
- Fax
- (605) 384-5240
- NPI assigned
- Mar 21, 2007
- Organization subpart
- No
Authorized official
- Name
- Mrs. Bernadette R Koupal
- Title
- Bus. Office Manager
- Phone
- (605) 384-3611
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 2
Related certifications (CCN) 2
Practitioners 46
-
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
-
Theresa A Petersen, APRN
-
Jordan Carl Weber, PA-C
-
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 44
-
Amber Louise Authier, PA-C
-
Leann Bassing, M.D.
-
Paul David Berndt, M.D.
-
Berkley A Erickson, CNP
-
Sandra Ellen Fortuna, BSW
-
Kenzie Suzette Gant, DNP, FNP
-
Patrick R Heiser, PA-C
-
Dana Huether, DNP
-
Meredith L Hunhoff, CNP
-
Ryan Kocer, CNP
-
Dawn Lauer, PA-C
-
Lawrence M Leon, M.D.
-
Vicki Lubbers, CNP
-
Jarod Myer, FNP-C
-
Ali Nazim, MD
-
Lindsey Nedved, NP-C
-
Cassie Lynn Nelson, CNP
-
Byron S Nielsen, M.D.
Medicare Care Compare: Hospital
- Listed as
- Wagner Community Memorial Hospital - Cah
- Type
- Critical Access Hospitals
- Ownership
- Voluntary non-profit - Private
- Medicare certification status
- Active
- Emergency services
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in SD
Hospital certification: CCN 431315
- Legal name
- WAGNER COMMUNITY MEMORIAL HOSPITAL
- Certification status
- Active
- Provider type (POS)
- Hospital – Critical access hospital
- Participating since
- Jul 1, 2000
- Last certification
- Mar 29, 2023
- Beds
- 20
- Ownership / control type
- Private (not for profit)
- 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 12
| Name | Role | Since | Share |
|---|---|---|---|
| Michele J Juffer |
Corporate Director | Sep 1, 2024 | |
| Joshua Christensen |
Corporate Officer |
May 1, 2024 | |
| W-2 Managing Employee |
May 1, 2024 | ||
| Karen Soulek |
Corporate Director |
Sep 1, 2013 | |
| Chad Peters |
Corporate Officer |
Sep 1, 2013 | |
| Rachel Woods |
Corporate Director |
Sep 1, 2016 | |
| Brittany Barron |
Corporate Officer |
Jan 1, 2026 | |
| W-2 Managing Employee |
Jan 1, 2026 | ||
| Operational/Managerial Control |
Jan 1, 2026 | 100% | |
| Julie Wiechmann |
W-2 Managing Employee |
Oct 15, 1984 | |
| Bernadette Koupal |
W-2 Managing Employee |
May 20, 1985 | |
| Lisa Weisser |
W-2 Managing Employee |
Aug 1, 1984 | |
| Scott Honomichl |
W-2 Managing Employee |
Nov 11, 2002 | |
| Beverly Jahn |
W-2 Managing Employee |
Mar 27, 2007 | |
| Marcia Podzimek |
W-2 Managing Employee |
Feb 5, 1981 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040225000391 | SD | Part B Supplier - Clinic/Group Practice | 3577459700 |
Receives reassigned benefits from 45 practitioners 1 other NPI on this enrollment Practice locations: Wagner, SD |
| O20061104000487 | SD | Part a Provider - Critical Access Hospital | 3577459700 |
Receives reassigned benefits from 17 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Wagner, SD |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 10571 | SD | Yes |
| Physician Assistant |
363A00000X | 10571 | SD | |
| Family Nurse Practitioner |
363LF0000X | 10571 | SD |
Addresses
Primary practice location
513 3Rd St SW
Wagner, SD 57380-9675
Mailing address
PO Box 280
Wagner, SD 57380-0280
Phone (605) 384-3418
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| S5877 | Other | SD | MEDICARE GROUP |
| 1008854 | Medicaid | SD |
Other names
- Wagner Community Clinic Avera
Other providers in Wagner, SD
- 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
- Wagner School District
All providers in Wagner, SD · Family Medicine Physician 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.