NPIMap

Organization Active NPI

Thayer County Memorial Hospital

Doing business as Davenport Medical Clinic

  • Rural Health Clinic/Center
  • Davenport, NE
National Provider Identifier
1972589349
Registry record updated Dec 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
THAYER COUNTY MEMORIAL HOSPITAL
Doing business as
Davenport Medical Clinic
Practice address
105 S Linden Ave
Davenport, NE 68335-3129
Phone
(402) 364-2105
Fax
(402) 768-4640
NPI assigned
Dec 19, 2005
Last updated
Dec 17, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
THAYER COUNTY MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 17, 2021

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

Authorized official

Name
Brian Rokusek
Title
Ceo
Phone
(402) 768-6041

Specialties & licenses 1

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

Addresses

Primary practice location

105 S Linden Ave
Davenport, NE 68335-3129

Mailing address

120 Park Ave
Hebron, NE 68370-2019
Phone (402) 768-6041

Other identifiers 1

IdentifierTypeStateIssuer
=========MedicaidNE

Other names 1

  • Davenport Medical Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050222000206 NE Part A Provider - Rural Health Clinic 3577559145 Practice locations: Davenport, NE

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972589349. Details of each certification follow.

Rural health clinic certification: CCN 283436

Legal name
THAYER COUNTY MEMORIAL HOSPITAL
Doing business as
DAVENPORT MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 15, 1996
Last certification
Sep 27, 2022
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
105 S Linden Ave
Davenport, NE 68335-3129
Related CCNs
281304

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

Other NPIs with the same Medicare PAC ID 6

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

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
28D0958691Davenport Medical Clinic105 Linden Ave, Davenport, NE 68335Certificate of waiverMar 23, 2027

National Provider Directory

National Provider Directory
Tax ID family
Thayer County Memorial7 organizations share this tax ID, including this one
Part of
Thayer County Memorial

Other organizations with this tax ID 6

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

Locations

105 S Linden Ave
Davenport, NE 68335
Phone (402) 364-2105

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Loren Wiedel Individual Corporate Officer Jan 29, 2017
Corporate Director Jan 1, 2013
Alegent Creighton Health Organization, Omaha, NE Corporation, Management services company, Non-profit Operational/Managerial Control Jul 29, 2016
Brian Rokusek Individual Contracted Managing EmployeeCeo Dec 13, 2021
Corporate OfficerCeo Dec 13, 2021
Operational/Managerial ControlCeo Dec 13, 2021
Laura Tuma Individual Corporate Officer Jan 30, 2019
Corporate Director Jan 29, 2017
Karen S Dahlkoetter Individual Corporate Officer Feb 14, 2017
Corporate Director Feb 14, 2017
Lindsey B Myers Individual W-2 Managing EmployeeMD; Jan 28, 2025
Operational/Managerial ControlMedical Director Jan 28, 2025
Kimberly Brennfoerder Individual W-2 Managing EmployeeAd;RHC Clinic Director Nov 5, 2024
Operational/Managerial ControlRHC Clinic Director Nov 5, 2024
Zachary D Messman Individual Corporate Director Jan 29, 2025
Michael S Defoe Individual W-2 Managing EmployeeCfo Aug 25, 2021
Operational/Managerial ControlCfo Aug 25, 2021
Michael L Long Individual Corporate Officer Jan 29, 2025
Corporate Director Jan 1, 2021

Owners & managing parties with NPI records 1

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

Facilities with the same owner 6

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

Practitioners & affiliated clinicians

Practitioners 9

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": "1134950400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1639699200000",
    "number": "1972589349",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 PARK AVE",
            "city": "HEBRON",
            "state": "NE",
            "postal_code": "683702019",
            "telephone_number": "402-768-6041",
            "fax_number": "402-768-4643"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 S LINDEN AVE",
            "city": "DAVENPORT",
            "state": "NE",
            "postal_code": "683353129",
            "telephone_number": "402-364-2105",
            "fax_number": "402-768-4640"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THAYER COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "THAYER COUNTY MEMORIAL HOSPITAL",
        "enumeration_date": "2005-12-19",
        "last_updated": "2021-12-17",
        "certification_date": "2021-12-17",
        "status": "A",
        "authorized_official_last_name": "ROKUSEK",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "402-768-6041"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "=========",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Davenport Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Davenport Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Davenport, NE

Sources for this page

Verify at the official NPI Registry.