NPIMap

Organization Active NPI

Wagner Community Memorial Hospital

  • Family Medicine Physician
  • Wagner, SD
National Provider Identifier
1740306992
Registry record updated Mar 7, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
10571 Issued in 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
Last updated
Mar 7, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2017

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

Authorized official

Name
Mrs. Bernadette R Koupal
Title
Bus. Office Manager
Phone
(605) 384-3611

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 10571 SD
Family Nurse Practitioner 363LF0000X 10571 SD
Family Medicine Physician 207Q00000X 10571 SD Primary

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 2

IdentifierTypeStateIssuer
1008854MedicaidSD
S5877OtherSDMEDICARE GROUP

Other names 1

  • Wagner Community Clinic Avera Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740306992. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Dec 1, 1947 in SD
Enrollment address
513 3Rd St SW
Wagner, SD 57380-9675
Main/Primary Hospital Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Wagner Community Memorial Hospital - CahCCN 431315 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Michele J Juffer Individual Corporate Director Sep 1, 2024
Joshua Christensen Individual Corporate OfficerCfo May 1, 2024
W-2 Managing EmployeeCfo- Chief Finance Officer May 1, 2024
Karen Soulek Individual Corporate DirectorSecretary/Treasurer Sep 1, 2013
Chad Peters Individual Corporate OfficerVice President Sep 1, 2013
Rachel Woods Individual Corporate DirectorDirector Sep 1, 2016
Brittany Barron Individual Corporate OfficerCeo Jan 1, 2026
W-2 Managing EmployeeAd; Jan 1, 2026
Operational/Managerial ControlCeo Jan 1, 2026 100%
Julie Wiechmann Individual W-2 Managing EmployeeRadiology Supervisor Oct 15, 1984
Bernadette Koupal Individual W-2 Managing EmployeeVP of Administrative Services May 20, 1985
Lisa Weisser Individual W-2 Managing EmployeeFinance Dept Aug 1, 1984
Scott Honomichl Individual W-2 Managing EmployeePhysical Plant Manager Nov 11, 2002
Beverly Jahn Individual W-2 Managing EmployeeHousekeeping & Dietary Supervisor Mar 27, 2007
Marcia Podzimek Individual W-2 Managing EmployeeHuman Resource Feb 5, 1981

Practitioners & affiliated clinicians

Practitioners 46

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 46

Affiliated clinicians 44

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

View all 44

NPI Registry JSON

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

{
    "created_epoch": "1174435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488844800000",
    "number": "1740306992",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 280",
            "city": "WAGNER",
            "state": "SD",
            "postal_code": "573800280",
            "telephone_number": "605-384-3418",
            "fax_number": "605-384-5240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "513 3RD ST SW",
            "city": "WAGNER",
            "state": "SD",
            "postal_code": "573809675",
            "telephone_number": "605-384-3418",
            "fax_number": "605-384-5240"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAGNER COMMUNITY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-21",
        "last_updated": "2017-03-07",
        "status": "A",
        "authorized_official_last_name": "KOUPAL",
        "authorized_official_first_name": "BERNADETTE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "BUS. OFFICE MANAGER",
        "authorized_official_telephone_number": "605-384-3611",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "SD",
            "license": "10571",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "SD",
            "license": "10571",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SD",
            "license": "10571",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1008854",
            "state": "SD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP",
            "identifier": "S5877",
            "state": "SD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wagner Community Clinic Avera",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Wagner, SD

Sources for this page

Verify at the official NPI Registry.