NPIMap

Organization Active NPI

Indianhead Medical Center Shell Lake Inc

  • Medicare Defined Swing Bed Hospital Unit
  • Shell Lake, WI
National Provider Identifier
1871500769
Registry record updated Jan 14, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
1047 Issued in WI
Legal business name
INDIANHEAD MEDICAL CENTER SHELL LAKE INC
Practice address
113 4TH Avenue
Shell Lake, WI 54871
Phone
(715) 468-7833
NPI assigned
Aug 2, 2006
Last updated
Jan 14, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 14, 2016

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

Authorized official

Name
Harold A McBee
Title
Owner
Phone
(410) 643-3393

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 1047 WI Primary

Addresses

Primary practice location

113 4TH Avenue
Shell Lake, WI 54871

Mailing address

PO Box 300
113 4TH Avenue
Shell Lake, WI 54871
Phone (715) 468-7833

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070523000149 WI Part A Provider - Critical Access Hospital 6406748839 Practice locations: Shell Lake, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871500769. Details of each certification follow.

Hospital certification: CCN 52Z342

Legal name
INDIANHEAD MEDICAL CENTER SHELL LAKE, INC.
Organization structure
CorporationNon-profit
Incorporated
Sep 30, 1989 in WI
Enrollment address
113 4TH Ave
PO Box 300
Shell Lake, WI 54871-0300
Hospital Swing-Bed Unit

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).

National Provider Directory

National Provider Directory
Tax ID family
Indianhead Medical Ctr4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Northwest Medical Management LLC Organization, Eau Claire, WI LLC Operational/Managerial Control Feb 1, 2021
Kevin Allen Jack Individual Corporate OfficerPresident Jan 1, 2016
Shannon James Jack Individual Contracted Managing Employee Feb 1, 2021
Corporate DirectorAdministrator Jan 1, 2016

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Shell Lake Health Care CenterShell Lake, WI, CCN 525553 Skilled nursing facility Adp of the SNF Sep 22, 2021

Owned or controlled facilities with NPI records 1

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

  • Shell Lake SNF LLC

    dba Shell Lake Health Care Center

    • Nursing Facility/Intermediate Care Facility
    • Shell Lake, WI
    • NPI 1295939049

    Adp of the SNF

    CMS ownership

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 1

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

NPI Registry JSON

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

{
    "created_epoch": "1154476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1452729600000",
    "number": "1871500769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 300",
            "address_2": "113 4TH AVENUE",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "54871",
            "telephone_number": "715-468-7833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 4TH AVENUE",
            "city": "SHELL LAKE",
            "state": "WI",
            "postal_code": "54871",
            "telephone_number": "715-468-7833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDIANHEAD MEDICAL CENTER SHELL LAKE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-02",
        "last_updated": "2016-01-14",
        "status": "A",
        "authorized_official_last_name": "MCBEE",
        "authorized_official_first_name": "HAROLD",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "410-643-3393"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "WI",
            "license": "1047",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Shell Lake, WI

Sources for this page

Verify at the official NPI Registry.