NPIMap

Organization Active NPI

Sioux Valley Memorial Hospital Association

Doing business as Sutherland Medical Clinic

  • Family Medicine Physician
  • Sutherland, IA
National Provider Identifier
1962221903
Registry record updated Oct 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION
Doing business as
Sutherland Medical Clinic
Practice address
131 W 2ND St
Sutherland, IA 51058-7615
Phone
(712) 446-2567
Fax
(712) 446-2631
NPI assigned
Oct 7, 2024
Last updated
Oct 17, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 17, 2024

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

Authorized official

Name
Gary Jordan
Title
President & Ceo
Phone
(712) 225-5101

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary
Rural Health Clinic/Center 261QR1300X NU

Addresses

Primary practice location

131 W 2ND St
Sutherland, IA 51058-7615

Mailing address

300 Sioux Valley Dr
Cherokee, IA 51012-1205
Phone (712) 225-3368

Other names 1

  • Sutherland Medical Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241127000922 IA Part A Provider - Rural Health Clinic 4880501881 Practice locations: Sutherland, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962221903. Details of each certification follow.

Rural health clinic certification: CCN 163489

Legal name
SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION
Doing business as
SUTHERLAND MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 1, 2002
Last certification
Feb 4, 2021
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
131 W 2ND St
Sutherland, IA 51058-7615
Related CCNs
161300

Other NPIs with the same Medicare PAC ID 9

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

National Provider Directory

National Provider Directory
Tax ID family
Sioux Valley Medical9 organizations share this tax ID, including this one
Part of
Sioux Valley Medical

Other organizations with this tax ID 8

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Tyler Gerstandt Individual W-2 Managing EmployeeVP Finance/Cfo Apr 7, 2023
Operational/Managerial ControlVP Finance/Cfo Apr 7, 2023
Kellen Ludvigson Individual Corporate Officer Apr 8, 2024
Corporate Director Apr 12, 2021
Clay Leavitt Individual Corporate Director Apr 13, 2020
Sean Darrell Nelson Individual W-2 Managing EmployeeMedical Director Oct 5, 2024
Operational/Managerial ControlMedical Director Oct 5, 2024
St. Luke's Health System, Inc. Organization, Sioux City, IA Non-profit Operational/Managerial Control Oct 1, 2013
Amber Tuttle Individual W-2 Managing EmployeeDirector of Rural Health Clinics Jul 8, 2024
Operational/Managerial ControlDirector of Rural Health Clinics Jul 8, 2024
Leslie William Todd Individual Corporate Director Apr 13, 2015
Sheila Trapp Individual Corporate Director Apr 19, 2018
Kerry Marie Hurd Individual Corporate Officer Apr 8, 2024
Corporate Director Apr 11, 2022
Sarah Cook Individual Corporate Director Apr 11, 2016
Gary W Jordan Individual Contracted Managing EmployeePresident & Ceo Mar 18, 2019
Corporate OfficerPresident & Ceo Mar 18, 2019
Operational/Managerial ControlPresident & Ceo Mar 18, 2019
Brandon Henke Individual Corporate Officer Apr 8, 2024
Corporate Director Apr 12, 2021

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Heartland Care Center IncMarcus, IA, CCN 165397 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control
Adp of the SNF		 Jul 19, 2023
Jul 19, 2023
Jul 19, 2023

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 11

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

Change-of-ownership history 1

DateEventCounterparty
Oct 5, 2024 Change of OwnershipThis provider was the buyer Mercyone Sutherland Family MedicineCCN 163489, IA, NPI 1548209984

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

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.

NPI Registry JSON

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

{
    "created_epoch": "1728259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729123200000",
    "number": "1962221903",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 SIOUX VALLEY DR",
            "city": "CHEROKEE",
            "state": "IA",
            "postal_code": "510121205",
            "telephone_number": "712-225-3368",
            "fax_number": "712-225-6866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "131 W 2ND ST",
            "city": "SUTHERLAND",
            "state": "IA",
            "postal_code": "510587615",
            "telephone_number": "712-446-2567",
            "fax_number": "712-446-2631"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SIOUX VALLEY MEMORIAL HOSPITAL ASSOCIATION",
        "enumeration_date": "2024-10-07",
        "last_updated": "2024-10-17",
        "certification_date": "2024-10-17",
        "status": "A",
        "authorized_official_last_name": "JORDAN",
        "authorized_official_first_name": "GARY",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "712-225-5101"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sutherland Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sutherland, IA

Sources for this page

Verify at the official NPI Registry.