NPIMap

Organization Active NPI

South Big Horn County Hospital District

Doing business as Midway Clinic

  • Rural Health Clinic/Center
  • Basin, WY
National Provider Identifier
1811901515
Registry record updated Oct 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTH BIG HORN COUNTY HOSPITAL DISTRICT
Doing business as
Midway Clinic
Practice address
388 South US Hwy 20
Basin, WY 82410-8902
Phone
(307) 568-3311
Fax
(307) 568-2139
NPI assigned
Jul 28, 2006
Last updated
Oct 30, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTH BIG HORN COUNTY HOSPITAL DISTRICTAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 30, 2023

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

Authorized official

Name
Mr. Joel Jackson
Title
Chief Executive Officer
Phone
(307) 568-1426

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Physician 208D00000X NU
Rural Health Clinic/Center 261QR1300X 06-139 WY
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

388 South US Hwy 20
Basin, WY 82410-8902

Mailing address

388 South US Hwy 20
Basin, WY 82410-8902
Phone (307) 568-3311

Other identifiers 4

IdentifierTypeStateIssuer
BLUE CROSSOtherWY722001
110012205MedicaidWY
115069300MedicaidWY
110012203MedicaidWY

Other names 1

  • Midway Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080916000132 WY Part A Provider - Rural Health Clinic 1254314107 Practice locations: Basin, WY
O20171128000926 WY Part B Supplier - Clinic/Group Practice 1254314107 Receives reassigned benefits from 29 practitioners
1 other NPI on this enrollment
Practice locations: Basin, WY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811901515. Details of each certification follow.

Rural health clinic certification: CCN 533981

Legal name
SOUTH BIG HORN COUNTY HOSPITAL DISTRICT
Doing business as
MIDWAY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 24, 1995
Last certification
May 25, 2017
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
388 US Highway 20 S
Basin, WY 82410-8902
Related CCNs
531301

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.

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
53D2305228Three Rivers Health Midway Clinic388 US 20 South, Basin, WY 82410Certificate of waiverMay 27, 2028

National Provider Directory

National Provider Directory
Part of
Bonnie Bluejacket

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
South Big Horn County Hospital District Organization, Basin, WY Non-profit Operational/Managerial Control Jun 27, 1995 100%
Joel Jackson Individual Corporate OfficerChief Executive Officer May 23, 2023 100%
Jeff Petty Individual Corporate DirectorBoard Member Feb 2, 2022
Michael Scherman Individual Corporate DirectorBoard Member Jan 1, 2025
Tamara Sawyer Individual Corporate Director Nov 1, 2017
W-2 Managing Employee Nov 1, 2017
Trudy Craft Individual Corporate DirectorBoard Member Sep 20, 2023
Fred Werner Individual Corporate DirectorBoard Member Jan 1, 2023
Janet Evans Individual Corporate DirectorBoard Member Jan 1, 2023

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
South Big Horn County HospitalBasin, WY, CCN 531301 Hospital Operational/Managerial Control Apr 17, 2008
South Big Horn County HospitalBasin, WY, CCN 53Z301 Hospital Operational/Managerial Control (100%) Jul 18, 2008

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 29

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 29

NPI Registry JSON

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

{
    "created_epoch": "1154044800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698624000000",
    "number": "1811901515",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "388 SOUTH US HWY 20",
            "city": "BASIN",
            "state": "WY",
            "postal_code": "824108902",
            "telephone_number": "307-568-3311",
            "fax_number": "307-568-2139"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "388 SOUTH US HWY 20",
            "city": "BASIN",
            "state": "WY",
            "postal_code": "824108902",
            "telephone_number": "307-568-3311",
            "fax_number": "307-568-2139"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH BIG HORN COUNTY HOSPITAL DISTRICT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTH BIG HORN COUNTY HOSPITAL DISTRICT",
        "enumeration_date": "2006-07-28",
        "last_updated": "2023-10-30",
        "certification_date": "2023-10-30",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "JOEL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "307-568-1426",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WY",
            "license": "06-139",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "722001",
            "identifier": "BLUE CROSS",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110012205",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "115069300",
            "state": "WY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110012203",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Midway Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Midway Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Basin, WY

Sources for this page

Verify at the official NPI Registry.