219 Health Network, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Munster, IN
NPI 1013690718 · NPPES record last updated Aug 16, 2024
Key facts
- NPI
- 1013690718
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- 219 HEALTH NETWORK, INC.
- Practice address
- 9112 Columbia Ave
Munster, IN 46321-2925 - Phone
- (219) 836-5040
- Fax
- (219) 836-6835
- NPI assigned
- Aug 9, 2023
- Organization subpart
- No
Authorized official
- Name
- William Cortes
- Title
- Executive Director
- Phone
- (219) 703-2585
Corporate family (same tax ID) 38
Practitioners 3
-
Tracy M Collins, MD
-
Kimberly Scott, APRN-BC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D0972887 | 219 Health Network, Inc | Certificate of waiver | Dec 31, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Federally qualified health center certification: CCN C51013
- Legal name
- 219 HEALTH NETWORK INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 16, 2024
- Last certification
- Jan 16, 2024
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Proprietary
- Incorporated
- Jul 27, 2017 in IN
- Enrollment address
- 9112 Columbia Ave
Munster, IN 46321-2925
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Luis Molina |
Corporate Director |
Jul 25, 2018 | |
| Gloria Vela |
Corporate Director |
Apr 9, 2018 | |
| Marjol Rush-Collet |
Corporate Director |
Apr 9, 2018 | |
| Leo Correa |
Corporate Director |
Jul 25, 2018 | |
| Sandra Noe |
Corporate Director |
Jul 25, 2018 | |
| Patricia a Johnson |
Corporate Director |
Jul 25, 2021 | |
| W-2 Managing Employee |
Jul 25, 2021 | ||
| Other |
Jul 25, 2021 | ||
| Sava Pavkovich |
Corporate Director |
Oct 26, 2022 | |
| Milton Reed |
Corporate Director |
Apr 9, 2018 | |
| Sara Jiminez |
Corporate Director |
Dec 18, 2018 | |
| Martha Gonzalez |
Corporate Director |
Oct 26, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240116003815 | IN | Part a Provider - Federally Qualified Health Center (FQHC) | 0547521452 | Practice locations: Munster, IN |
National Provider Directory
- Tax ID family
- 219 Health Network Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Obstetrics & Gynecology Physician |
207V00000X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
9112 Columbia Ave
Munster, IN 46321-2925
Mailing address
100 W Chicago Ave Ste F
East Chicago, IN 46312-3261
Phone (219) 392-7016
Other providers in Munster, IN
- 1St Choice Cardiovascular Associates LLC
- 219 Health Network, Inc.
- 219 Health Network, Inc.
- 219 Health Network, Inc.
- 219 Health Network, Inc.
- 219 Health Network, Inc.
- 219 Health Network, Inc.
All providers in Munster, IN · Federally Qualified Health Center (FQHC) in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 16, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.