NPIMap

Organization Active NPI

Centerville Clinics Inc

  • Specialist
  • Coal Center, PA
National Provider Identifier
1043498280
Registry record updated Oct 18, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
CENTERVILLE CLINICS INC
Practice address
California Middle School
40 Trojan Way
Coal Center, PA 15423-1059
Phone
(724) 785-5800
Fax
(724) 785-8860
NPI assigned
Feb 8, 2008
Last updated
Oct 18, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 18, 2018

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

Authorized official

Name
Mr. Barry R Niccolai
Title
Executive Director
Phone
(724) 632-6801

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X Primary

Addresses

Primary practice location

California Middle School
40 Trojan Way
Coal Center, PA 15423-1059

Mailing address

Centerville Clinics Inc
1070 Old National Pike Road
Fredericktown, PA 15333-2114
Phone (724) 632-6801

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210610002534 PA Part A Provider - Federally Qualified Health Center (FQHC) 7214837202 Practice locations: Coal Center, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043498280. Details of each certification follow.

Federally qualified health center certification: CCN 731847

Legal name
CENTERVILLE CLINICS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 7, 2021
Last certification
May 7, 2021
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Mar 2, 1953 in PA
Enrollment address
40 Trojan Way
Coal Center, PA 15423-1059

Other NPIs with the same Medicare PAC ID 23

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

View all 23

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Daniel L Holt Individual W-2 Managing EmployeeMedical Director Jan 1, 2011
Donna Salvino Individual Corporate DirectorSecretary/Treasurer Aug 25, 2014
Edward J Marotta Individual Corporate DirectorBoard Member Nov 17, 2014
Barry R Niccolai Individual Corporate OfficerExecutive Director Apr 1, 2017
W-2 Managing EmployeeManaging Employee Apr 1, 2017
Patricia a Gavazzi Individual Corporate DirectorBoard Member Jun 27, 2017
Darra Tyler-Owens Individual Corporate DirectorBoard Member Sep 29, 2018
Andrew Corfont Individual Corporate DirectorBoard Member Mar 25, 2013
Joseph M Yablonski Individual Corporate DirectorPresident of Board Oct 23, 2004
Patricia Martos Individual W-2 Managing EmployeeDirector of Finance & Personnel Mar 1, 1979
James T Yablonski Individual Corporate DirectorVice-President Jan 23, 1995
Marianne E Gideon Individual Corporate DirectorBoard Member Jun 27, 2016

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1202428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1539820800000",
    "number": "1043498280",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "CENTERVILLE CLINICS INC",
            "address_2": "1070 OLD NATIONAL PIKE ROAD",
            "city": "FREDERICKTOWN",
            "state": "PA",
            "postal_code": "153332114",
            "telephone_number": "724-632-6801",
            "fax_number": "724-632-6312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "CALIFORNIA MIDDLE SCHOOL",
            "address_2": "40 TROJAN WAY",
            "city": "COAL CENTER",
            "state": "PA",
            "postal_code": "154231059",
            "telephone_number": "724-785-5800",
            "fax_number": "724-785-8860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERVILLE CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-08",
        "last_updated": "2018-10-18",
        "status": "A",
        "authorized_official_last_name": "NICCOLAI",
        "authorized_official_first_name": "BARRY",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "724-632-6801",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Coal Center, PA

Sources for this page

Verify at the official NPI Registry.