NPIMap

Organization Active NPI

Cooperstown Medical Center

Doing business as CMC Rural Health Clinic

  • Rural Health Clinic/Center
  • Cooperstown, ND
National Provider Identifier
1962548214
Registry record updated Sep 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COOPERSTOWN MEDICAL CENTER
Doing business as
CMC Rural Health Clinic
DRMC Rural Health Clinic
Dakota Regional Medical Center
Practice address
107 12TH St S
Cooperstown, ND 58425-4501
Phone
(701) 786-1709
Fax
(701) 786-7121
NPI assigned
Jan 30, 2007
Last updated
Sep 8, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
COOPERSTOWN MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 8, 2023

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

Authorized official

Name
Kelley Shawn
Title
Admin Assist/Credentialing
Phone
(701) 786-1709

Specialties & licenses 1

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

Addresses

Primary practice location

107 12TH St S
Cooperstown, ND 58425-4501

Mailing address

107 12TH St S
Cooperstown, ND 58425-4501
Phone (701) 786-1709

Other identifiers 2

IdentifierTypeStateIssuer
4770OtherNDBLUE CROSS BLUE SHIELD
5000MedicaidND

Other names 3

  • CMC Rural Health Clinic Doing business as
  • DRMC Rural Health Clinic Doing business as
  • Dakota Regional Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20030929000016 ND Part A Provider - Rural Health Clinic 5698687689 Practice locations: Cooperstown, ND
O20040203000722 ND Part B Supplier - Clinic/Group Practice 5698687689 Receives reassigned benefits from 46 practitioners
Practice locations: Cooperstown, ND; Lakota, ND; New Rockford, ND

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962548214. Details of each certification follow.

Rural health clinic certification: CCN 353979

Legal name
COOPERSTOWN MEDICAL CENTER
Doing business as
DAKOTA REGIONAL MEDICAL CENTER CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 6, 1991
Last certification
Jun 28, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1946 in ND
Enrollment address
107 12TH St S
Cooperstown, ND 58425-4501
Related CCNs
351306

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
Part of
Cooperstown Medical Center

Locations

1200 Roberts Ave NE
Cooperstown, ND 58425
Phone (701) 797-2128

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Barry Getz Individual Corporate DirectorBoard President Apr 19, 2022
Gerald Stokka Individual Corporate DirectorBoard Vice President Dec 29, 2021
Benjamin Halvorson Individual Corporate DirectorDirector Apr 19, 2022
Larry Grandalen Individual Corporate DirectorDirector Apr 19, 2022
Nicole Johnson Individual Corporate OfficerCeo Feb 1, 2014
W-2 Managing EmployeeCeo Jan 14, 2014
Operational/Managerial ControlCeo Aug 15, 2013

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Dakota Regional Medical Center Hospital SwingbedCooperstown, ND, CCN 35Z306 Hospital Operational/Managerial Control Jan 21, 2009
Dakota Regional Medical Ctr-LakotaLakota, ND, CCN 358511 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 15, 2021
Oct 15, 2021
Cooperstown Medical CenterNew Rockford, ND, CCN 358514 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 1, 2022
Aug 1, 2022

Owned or controlled facilities with NPI records 3

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

  • Cooperstown Medical Center

    dba Cooperstown Medical Center Swing Bed

    • Medicare Defined Swing Bed Hospital Unit
    • Cooperstown, ND
    • NPI 1376635151

    Operational/Managerial Control

    CMS ownership
  • Cooperstown Medical Center

    dba Dakota Regional Medical Center

    • Rural Health Clinic/Center
    • Lakota, ND
    • NPI 1821760679

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • Cooperstown Medical Center

    dba DRMC New Rockford RHC

    • Rural Health Clinic/Center
    • New Rockford, ND
    • NPI 1992459721

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 47

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 47

NPI Registry JSON

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

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694131200000",
    "number": "1962548214",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "107 12TH ST S",
            "city": "COOPERSTOWN",
            "state": "ND",
            "postal_code": "584254501",
            "telephone_number": "701-786-1709",
            "fax_number": "701-786-7121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "107 12TH ST S",
            "city": "COOPERSTOWN",
            "state": "ND",
            "postal_code": "584254501",
            "telephone_number": "701-786-1709",
            "fax_number": "701-786-7121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COOPERSTOWN MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COOPERSTOWN MEDICAL CENTER",
        "enumeration_date": "2007-01-30",
        "last_updated": "2023-09-08",
        "certification_date": "2023-09-08",
        "status": "A",
        "authorized_official_last_name": "SHAWN",
        "authorized_official_first_name": "KELLEY",
        "authorized_official_title_or_position": "ADMIN ASSIST/CREDENTIALING",
        "authorized_official_telephone_number": "701-786-1709"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "4770",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5000",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CMC Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "DRMC Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Dakota Regional Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cooperstown, ND

Sources for this page

Verify at the official NPI Registry.