NPIMap

Organization Active NPI

Essentia Health Virginia, LLC

Doing business as Essentia Health International Falls Clinic

  • Rural Health Clinic/Center
  • International Falls, MN
National Provider Identifier
1881144970
Registry record updated Apr 7, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ESSENTIA HEALTH VIRGINIA, LLC
Doing business as
Essentia Health International Falls Clinic
Practice address
2501 Keenan Dr
International Falls, MN 56649-2181
Phone
(218) 283-9431
NPI assigned
Oct 12, 2016
Last updated
Apr 7, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 7, 2022

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

Authorized official

Name
Samuel Stone
Title
Coo
Phone
(218) 749-9496

Specialties & licenses 1

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

Addresses

Primary practice location

2501 Keenan Dr
International Falls, MN 56649-2181

Mailing address

2501 Keenan Dr
International Falls, MN 56649-2181
Phone (218) 283-9431

Other names 1

  • Essentia Health International Falls 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
O20130306000467 MN Part B Supplier - Clinic/Group Practice 7810149002 Receives reassigned benefits from 193 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Babbitt, MN; Ely, MN; International Falls, MN; Virginia, MN
O20161205002144 MN Part A Provider - Rural Health Clinic 7810149002 Practice locations: International Falls, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881144970. Details of each certification follow.

Rural health clinic certification: CCN 243481

Legal name
ESSENTIA HEALTH VIRGINIA LLC
Doing business as
ESSENTIA HEALTH INTERNATIONAL FALLS CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 26, 2017
Last certification
Sep 26, 2017
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Aug 28, 2012 in MN
Enrollment address
2501 Keenan Dr
International Falls, MN 56649-2181
Related CCNs
240084

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

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory

Member of 2

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

Ownership & related parties

All disclosed owners & managing parties 20

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

NameRoleSinceShare
Krista Ann Skorupa Individual Corporate OfficerPresident May 6, 2024
Mark Bortnem Individual Corporate OfficerTreasurer Sep 29, 2025
Amy Bergstrom Individual Corporate Director Jan 1, 2024
Anthony Sertich Individual Corporate DirectorBoard Member Jan 1, 2021
George Loban Individual Corporate Director Jan 1, 2024
Adam Bachand Individual Corporate DirectorBoard Member Jan 1, 2025
Thomas Jamar Individual Corporate DirectorBoard Member Jan 1, 2023
Rebecca Urbanski Individual Corporate DirectorBoard Member Jan 1, 2025
Anthony Yung Individual Corporate DirectorBoard Member Jan 1, 2023
Essentia Health Organization, Duluth, MN Non-profit 5% Or Greater Indirect Ownership Interest Aug 28, 2012 100%
Justin Terch Individual Corporate DirectorBoard Member Oct 22, 2025
St Marys Duluth Clinic Health System Organization, Duluth, MN Non-profit Operational/Managerial Control Aug 28, 2012
Bradley J Beard Individual Corporate OfficerChief Operating Officer Jul 1, 2023
W-2 Managing EmployeeChief Operating Officer Jul 1, 2023
Kevin S Boren Individual Corporate OfficerVP of Finance Jul 1, 2023
W-2 Managing EmployeeVP of Finance Jul 1, 2023
Troy Duininck Individual Corporate DirectorBoard Member Jan 1, 2023
SMDC Medical Center Organization, Duluth, MN Non-profit 5% Or Greater Direct Ownership Interest Aug 28, 2012 100%
Michael Watters Individual Corporate OfficerSecretary Jul 1, 2023
Bruce Smith Individual Corporate DirectorBoard Member Jan 1, 2026
Samuel Stone Individual W-2 Managing EmployeeAdministrator May 1, 2018
Nancy Aronson Norr Individual Corporate DirectorBoard Member Jan 1, 2025

Owners & managing parties with NPI records 8

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

Facilities with the same owner 46

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

View all 46

Practitioners & affiliated clinicians

Practitioners 33

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 33

NPI Registry JSON

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

{
    "created_epoch": "1476230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649289600000",
    "number": "1881144970",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2501 KEENAN DR",
            "city": "INTERNATIONAL FALLS",
            "state": "MN",
            "postal_code": "566492181",
            "telephone_number": "218-283-9431"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2501 KEENAN DR",
            "city": "INTERNATIONAL FALLS",
            "state": "MN",
            "postal_code": "566492181",
            "telephone_number": "218-283-9431"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ESSENTIA HEALTH VIRGINIA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-12",
        "last_updated": "2022-04-07",
        "certification_date": "2022-04-07",
        "status": "A",
        "authorized_official_last_name": "STONE",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "218-749-9496"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health International Falls Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health International Falls Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in International Falls, MN

Sources for this page

Verify at the official NPI Registry.