NPIMap

Organization Active NPI

St. Croix Regional Medical Center

  • Rural Health Clinic/Center
  • Frederic, WI
National Provider Identifier
1811256126
Registry record updated Jan 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
1041 Issued in WI
Legal business name
ST. CROIX REGIONAL MEDICAL CENTER
Practice address
205 West Oak Street
Frederic, WI 54837
Phone
(715) 327-5700
Fax
(715) 327-5784
NPI assigned
May 7, 2012
Last updated
Jan 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2023

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

Authorized official

Name
Mike Youso
Title
Cfo
Phone
(715) 483-0535

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 1041 WI Primary

Addresses

Primary practice location

205 West Oak Street
Frederic, WI 54837

Mailing address

235 E State St
Saint Croix Falls, WI 54024-4117
Phone (715) 483-3221

Other names 1

  • Frederic Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120807000264 WI Part A Provider - Rural Health Clinic 9335032184 Practice locations: Frederic, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811256126. Details of each certification follow.

Rural health clinic certification: CCN 528555

Legal name
ST. CROIX REGIONAL MEDICAL CENTER
Doing business as
FREDERIC CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 24, 2013
Last certification
Jul 30, 2019
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Apr 16, 1953 in WI
Enrollment address
205 Oak St W
Frederic, WI 54837-8953
Related CCNs
521337

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

Other NPIs with the same Medicare PAC ID 4

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

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
52D0940535Frederic Clinic205 W Oak St, Frederic, WI 54837AccreditationJun 12, 2028

National Provider Directory

National Provider Directory

Locations

26425 Lakeland Ave S
Webster, WI 54893
Phone (715) 866-4271

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Michael J Youso Individual Corporate OfficerCeo Jun 28, 2022
Trudy Canine Individual Corporate DirectorGoverning Board Chair Jan 1, 2021
Kimberly J Ericson Individual Corporate OfficerCfo Apr 17, 2023
Tanya K Mortel Individual W-2 Managing EmployeeCredentialing Supervisor Jan 6, 1992

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Adoray Home Health and HospiceBaldwin, WI, CCN 527137 Home health agency 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014
Adoray Home Health and HospiceBaldwin, WI, CCN 521521 Hospice 5% Or Greater Direct Ownership Interest (18.62%) Sep 1, 2014

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 24

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 24

NPI Registry JSON

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

{
    "created_epoch": "1336348800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674604800000",
    "number": "1811256126",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "235 E STATE ST",
            "city": "SAINT CROIX FALLS",
            "state": "WI",
            "postal_code": "540244117",
            "telephone_number": "715-483-3221",
            "fax_number": "715-483-0507"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 WEST OAK STREET",
            "city": "FREDERIC",
            "state": "WI",
            "postal_code": "54837",
            "telephone_number": "715-327-5700",
            "fax_number": "715-327-5784"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CROIX REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-07",
        "last_updated": "2023-01-25",
        "certification_date": "2023-01-25",
        "status": "A",
        "authorized_official_last_name": "YOUSO",
        "authorized_official_first_name": "MIKE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "715-483-0535"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WI",
            "license": "1041",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Frederic Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Frederic, WI

Sources for this page

Verify at the official NPI Registry.