NPIMap

Organization Active NPI

Peninsula Institute for Community Health Inc

  • Federally Qualified Health Center (FQHC)
  • Virginia Beach, VA
National Provider Identifier
1043790124
Registry record updated Aug 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Practice address
104 N Witchduck Rd
Virginia Beach, VA 23462-6506
Phone
(757) 591-0643
Fax
(757) 282-7810
NPI assigned
Aug 17, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 17, 2018

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

Authorized official

Name
Angela Futrell
Title
Chief Executive Officer
Phone
(757) 591-0643

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X VA Primary

Addresses

Primary practice location

104 N Witchduck Rd
Virginia Beach, VA 23462-6506

Mailing address

1033 28TH St
Newport News, VA 23607-4233
Phone (757) 591-0643

Other names 1

  • Virginia Beach Housing Resource Center Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040611000280 VA Part B Supplier - Clinic/Group Practice 9234040148 Receives reassigned benefits from 19 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chesapeake, VA; Virginia Beach, VA; Suffolk, VA; Newport News, VA; Hampton, VA
O20211122002818 VA Part A Provider - Federally Qualified Health Center (FQHC) 9234040148 Practice locations: Virginia Beach, VA

Federally qualified health center certification: CCN 491982

Legal name
PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Doing business as
SOUTHEASTERN VIRGINIA HEALTH SYSTEM
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 19, 2021
Last certification
Oct 19, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 22, 1978 in VA
Enrollment address
104 N Witchduck Rd
Virginia Beach, VA 23462-6506

Other NPIs with the same Medicare PAC ID 13

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

View all 13

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

National Provider Directory

National Provider Directory

Locations

1033 28th St
Newport News, VA 23607
Phone (757) 591-0643

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Katherine Grant-Davis Individual Corporate Director Jun 25, 2015
Stylie Williams Individual Corporate Director Sep 1, 2016
April Burwell Individual Corporate Director Feb 17, 2022
Dorothy Murray Individual Corporate Director Sep 10, 2014
Shirley Wills Individual Corporate Officer Apr 26, 2012
Asa Jenrette Individual Corporate Director Jun 25, 2015
Barrett Franklin Individual Corporate Director Mar 1, 2019
Yolanda Brannen Individual Corporate Director Feb 17, 2022
Angela Futrell Individual Corporate OfficerCheif Executive Officer Jan 12, 2009
W-2 Managing EmployeeChief Executive Officer Jan 5, 2009 100%
Juan L Garcia Individual Corporate Director Feb 1, 2021
Caryl Johnson Individual Corporate Director Feb 17, 2022
Denise Counce Individual Corporate OfficerTreasurer Jun 23, 2016
Wanda Allen Individual Corporate Director Jul 29, 1997
Aravia Johnson Individual Corporate Director Jun 25, 2015
Ruth Holmes Individual Corporate Director Jan 1, 2018

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Stoneybrook PhysiciansNewport News, VA, CCN 491913 Federally qualified health center Operational/Managerial Control Aug 16, 2011

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1534464000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1534464000000",
    "number": "1043790124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1033 28TH ST",
            "city": "NEWPORT NEWS",
            "state": "VA",
            "postal_code": "236074233",
            "telephone_number": "757-591-0643",
            "fax_number": "757-282-7810"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 N WITCHDUCK RD",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234626506",
            "telephone_number": "757-591-0643",
            "fax_number": "757-282-7810"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-08-17",
        "last_updated": "2018-08-17",
        "status": "A",
        "authorized_official_last_name": "FUTRELL",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "757-591-0643"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "VA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Virginia Beach Housing Resource Center Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Virginia Beach, VA

Sources for this page

Verify at the official NPI Registry.