NPIMap

Organization Active NPI

First Care Medical Services

Doing business as Essentia Health Bagley Clinic

  • Rural Health Clinic/Center
  • Bagley, MN
National Provider Identifier
1790861649
Registry record updated Oct 1, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
FIRST CARE MEDICAL SERVICES
Doing business as
Essentia Health Bagley Clinic
Practice address
121 Central St W
Bagley, MN 56621-4393
Phone
(218) 694-6281
Fax
(218) 694-6283
NPI assigned
Oct 31, 2006
Last updated
Oct 1, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 1, 2021

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

Authorized official

Name
Kim Bodensteiner
Title
Cfo
Phone
(218) 435-7633

Specialties & licenses 1

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

Addresses

Primary practice location

121 Central St W
Bagley, MN 56621-4393

Mailing address

121 Central St W
Bagley, MN 56621-4393
Phone (218) 694-6281

Other identifiers 1

IdentifierTypeStateIssuer
971428600MedicaidMN

Other names 1

  • Essentia Health Bagley 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
O20040927000035 MN Part B Supplier - Clinic/Group Practice 3678542842 Receives reassigned benefits from 106 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bagley, MN; Fosston, MN; Oklee, MN
O20111003000725 MN Part A Provider - Rural Health Clinic 3678542842 Practice locations: Bagley, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790861649. Details of each certification follow.

Rural health clinic certification: CCN 243461

Legal name
FIRST CARE MEDICAL SERVICES
Doing business as
ESSENTIA HEALTH BAGLEY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 1, 2011
Last certification
May 9, 2013
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 26, 1947 in MN
Enrollment address
121 Central St W
Bagley, MN 56621-4393
Related CCNs
241357

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 3

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

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
24D0406561Essentia Health Bagley Clinic121 Central Street West, Bagley, MN 56621Certificate of waiverJun 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
First Care Medical Services5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Locations

121 Central St W
Bagley, MN 56621
Phone (218) 694-6281

Ownership & related parties

All disclosed owners & managing parties 13

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
Aarick L Jackson Individual Corporate DirectorBoard Member Jan 1, 2020
James M Christensen Individual Corporate DirectorBoard Member Jan 1, 2020
Taylor Grant Mertz Individual Corporate DirectorBoard Member May 17, 2022
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Alan J Hurley Individual Corporate OfficerCoo May 18, 2023
W-2 Managing EmployeeCoo May 18, 2023
Beverly Mary Horn Individual Corporate DirectorBoard Member Jan 1, 2017
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
Joel Ross Haugen Individual Corporate DirectorBoard Member Jan 1, 2017
Laurie Ann Lewandowski Individual Corporate DirectorBoard Member Jan 1, 2017
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 23

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

View all 23

Practitioners & affiliated clinicians

Practitioners 30

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 30

NPI Registry JSON

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

{
    "created_epoch": "1162252800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1633046400000",
    "number": "1790861649",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "121 CENTRAL ST W",
            "city": "BAGLEY",
            "state": "MN",
            "postal_code": "566214393",
            "telephone_number": "218-694-6281",
            "fax_number": "218-694-6283"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "121 CENTRAL ST W",
            "city": "BAGLEY",
            "state": "MN",
            "postal_code": "566214393",
            "telephone_number": "218-694-6281",
            "fax_number": "218-694-6283"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FIRST CARE MEDICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-31",
        "last_updated": "2021-10-01",
        "certification_date": "2021-10-01",
        "status": "A",
        "authorized_official_last_name": "BODENSTEINER",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "218-435-7633"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "971428600",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health Bagley Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health Bagley Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bagley, MN

Sources for this page

Verify at the official NPI Registry.