NPIMap

Organization Active NPI

St. Cloud Hospital

Doing business as CentraCare Hospice

  • Community Based Hospice Care Agency
  • Waite Park, MN
National Provider Identifier
1740340496
Registry record updated Oct 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
331506 Issued in MN
Legal business name
ST. CLOUD HOSPITAL
Doing business as
CentraCare Hospice
Practice address
110 2ND St S Ste 104
Waite Park, MN 56387-1367
Phone
(320) 251-2700
NPI assigned
Dec 11, 2006
Last updated
Oct 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2020

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

Authorized official

Name
Mr. Michael A. Blair
Title
Sr. Vice President & Cfo
Phone
(320) 255-5665

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 331506 MN Primary

Addresses

Primary practice location

110 2ND St S Ste 104
Waite Park, MN 56387-1367

Mailing address

1406 6TH Ave N
Saint Cloud, MN 56303-1900
Phone (320) 251-2700

Other identifiers 1

IdentifierTypeStateIssuer
081018500MedicaidMN

Other names 1

  • CentraCare Hospice Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100510000691 MN Part A Provider - Hospice 4880594779 Practice locations: Waite Park, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740340496. Details of each certification follow.

Hospice certification: CCN 241500

Legal name
ST CLOUD HOSPITAL
Doing business as
CENTRACARE HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Jun 4, 1984
Last certification
Jan 31, 2019
Ownership / control type
Non-Profit - Other
Organization structure
CorporationNon-profit
Incorporated
Sep 12, 1962 in MN
Enrollment address
110 2ND St S
Ste 104
Waite Park, MN 56387-1367

Other NPIs with the same Medicare PAC ID 6

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

Care Compare: Hospice

Medicare Care Compare
Listed as
Centracare HospiceCCN 241500 · All quality measures
Ownership
Non-Profit
Certified
Jun 4, 1984
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
St Cloud Hosp15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

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

View all 14

Locations

2035 15th St N
Ste 110
Saint Cloud, MN 56303
Phone (320) 259-9395

110 2nd St S
Ste 104
Waite Park, MN 56387
Phone (320) 259-9375

Ownership & related parties

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Tina SSN May Individual Corporate Director Jul 1, 2025
Michelle Johnson Individual Corporate Director Jul 1, 2021
Thomas Knoblach Individual Corporate Director Jul 1, 2011
Michael a Blair Individual Corporate OfficerSr VP & Cfo Sep 30, 2019
W-2 Managing EmployeeSr VP & Cfo Sep 30, 2019
Jeffrey Gau Individual Corporate Director Jul 1, 2017
Renee S Frauendienst Individual Corporate DirectorBoard Member Jul 1, 2017
Jacob Lyons Individual Corporate Director Jul 1, 2024
Richard Wehseler Individual Corporate Director Apr 21, 2018
Bobbie Bertram Individual Corporate Director Jul 1, 2015
Kenneth D Holmen Individual Corporate Director Jan 1, 2015
Sherri Liebl Individual Corporate DirectorExecutive Director Sep 30, 2019
David Anfinson Individual Corporate Director Apr 21, 2018
Kristen Husen Individual Corporate Director Jun 30, 2014
W-2 Managing EmployeeAd; Jan 1, 2025
Daniel Abdul Individual Corporate Director Jul 1, 2022
James Hebl Individual Corporate Director Jul 1, 2017
Carrie Henning-Smith Individual Corporate Director Jul 1, 2023
Centracare Health System Organization, Saint Cloud, MN Corporation, Non-profit Operational/Managerial Control Jan 1, 1966
Paula a Lindhorst Individual W-2 Managing EmployeeMedical Director Mar 26, 2024
Bryan Rolph Individual Corporate Director Jul 1, 2019

Owners & managing parties with NPI records 8

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Centracare - St Cloud Hospital Inpatient RehabilitationSaint Cloud, MN, CCN 24T036 Hospital Operational/Managerial Control Apr 20, 2015

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 28

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 28

Practitioners & affiliated clinicians

Affiliated clinicians 53

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

View all 53

NPI Registry JSON

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

{
    "created_epoch": "1165795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602201600000",
    "number": "1740340496",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1406 6TH AVE N",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563031900",
            "telephone_number": "320-251-2700",
            "fax_number": "320-656-7009"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 2ND ST S STE 104",
            "city": "WAITE PARK",
            "state": "MN",
            "postal_code": "563871367",
            "telephone_number": "320-251-2700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CLOUD HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-11",
        "last_updated": "2020-10-09",
        "certification_date": "2020-10-09",
        "status": "A",
        "authorized_official_last_name": "BLAIR",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "SR. VICE PRESIDENT & CFO",
        "authorized_official_telephone_number": "320-255-5665",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "MN",
            "license": "331506",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "081018500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CentraCare Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waite Park, MN

Sources for this page

Verify at the official NPI Registry.