NPIMap

Organization Active NPI

St. Mary's Regional Health Center

Doing business as Essentia Health St. Mary's - Mahnomen Clinic

  • Rural Health Clinic/Center
  • Mahnomen, MN
National Provider Identifier
1750725586
Registry record updated Mar 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ST. MARY'S REGIONAL HEALTH CENTER
Doing business as
Essentia Health St. Mary's - Mahnomen Clinic
Practice address
117 N Main St
Mahnomen, MN 56557-4003
Phone
(218) 936-5616
NPI assigned
Apr 23, 2013
Last updated
Mar 1, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 1, 2024

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

Authorized official

Name
Alan Hurley
Title
Coo
Phone
(701) 364-7667

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

117 N Main St
Mahnomen, MN 56557-4003

Mailing address

1027 Washington Ave
Detroit Lakes, MN 56501-3409
Phone (218) 847-5611

Other identifiers 1

IdentifierTypeStateIssuer
892442000MedicaidMN

Other names 1

  • Essentia Health St. Mary's - Mahnomen Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031117000090 MN Part B Supplier - Clinic/Group Practice 2062326820 Receives reassigned benefits from 290 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Frazee, MN; Lake Park, MN; Mahnomen, MN; Menahga, MN; Park Rapids, MN; Pelican Rapids, MN; Walker, MN; Detroit Lakes, MN
O20111209000744 MN Part A Provider - Rural Health Clinic 2062326820 1 other NPI on this enrollment
Practice locations: Mahnomen, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1750725586. Details of each certification follow.

Rural health clinic certification: CCN 243468

Legal name
ST MARYS REGIONAL HEALTH CENTER
Doing business as
ESSENTIA HEALTH ST MARY'S MAHNOMEN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 10, 2013
Last certification
Jul 18, 2013
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
117 N Main St
Mahnomen, MN 56557-4003
Related CCNs
240101

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

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 13

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

View all 13

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
24D2063648Essentia Health St Mary's - Mahnomen Clinic117 North Main Street, Mahnomen, MN 56557Certificate of waiverAug 6, 2027

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Stefanie Gefroh Ellison Individual Corporate OfficerPresident Aug 12, 2024
Tim D Heilman Individual Corporate DirectorBoard Member Jan 1, 2020
Marc Adams Individual Corporate DirectorBoard Member Jan 1, 2026
Mark Krejci Individual Corporate DirectorBoard Member Jan 1, 2026
Kimberly Pladson Individual Corporate DirectorBoard Member Jan 1, 2025
Essentia Health Organization, Duluth, MN Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2023 100%
James M Christensen Individual Corporate DirectorBoard Member Jan 1, 2020
Kevin S Boren Individual Corporate OfficerTreasurer Sep 29, 2025
Taylor Grant Mertz Individual Corporate DirectorBoard Member May 17, 2022
Anderson Saint Georges Individual Corporate DirectorBoard Member Jan 1, 2025
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Alan J Hurley Individual Corporate OfficerCoo May 18, 2023
W-2 Managing EmployeeCoo May 18, 2023
Benjamin Cody Smith Individual Corporate DirectorBoard Member May 17, 2022
Douglas J Arvin Individual Corporate OfficerVP of Finance / Cfo May 18, 2023
W-2 Managing EmployeeVP of Finance/Cfo May 18, 2023
Laurie Ann Lewandowski Individual Corporate Director Jul 1, 2011
Innovis Health LLC Organization, Fargo, ND LLC, Non-profit Operational/Managerial Control Jan 1, 2017

Owners & managing parties with NPI records 11

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

Facilities with the same owner 50

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

View all 50

Practitioners & affiliated clinicians

Practitioners 19

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 19

NPI Registry JSON

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

{
    "created_epoch": "1366675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709251200000",
    "number": "1750725586",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1027 WASHINGTON AVE",
            "city": "DETROIT LAKES",
            "state": "MN",
            "postal_code": "565013409",
            "telephone_number": "218-847-5611",
            "fax_number": "218-847-0881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "117 N MAIN ST",
            "city": "MAHNOMEN",
            "state": "MN",
            "postal_code": "565574003",
            "telephone_number": "218-936-5616"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY'S REGIONAL HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2013-04-23",
        "last_updated": "2024-03-01",
        "certification_date": "2024-03-01",
        "status": "A",
        "authorized_official_last_name": "HURLEY",
        "authorized_official_first_name": "ALAN",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "701-364-7667"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "892442000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health St. Mary's - Mahnomen Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health St. Mary's - Mahnomen Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mahnomen, MN

Sources for this page

Verify at the official NPI Registry.