NPIMap

Organization Active NPI

Under 21

Doing business as Covenant House

  • Clinic/Center
  • New York, NY
National Provider Identifier
1053588988
Registry record updated Jun 9, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
UNDER 21
Doing business as
Covenant House
Practice address
460 W 41St
New York, NY 10036
Phone
(212) 613-0300
Fax
(212) 268-2832
NPI assigned
May 9, 2008
Last updated
Jun 9, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2017

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

Authorized official

Name
David J Davis, D.O.
Title
Medical Director
Phone
(212) 613-0300

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary
Federally Qualified Health Center (FQHC) 261QF0400X

Addresses

Primary practice location

460 W 41St
New York, NY 10036

Mailing address

460 W 41St
New York, NY 10036
Phone (212) 613-0300

Other identifiers 1

IdentifierTypeStateIssuer
00733826MedicaidNY

Other names 1

  • Covenant House Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170525000685 NY Part A Provider - Federally Qualified Health Center (FQHC) 6103193024 Practice locations: New York, NY
O20231214000173 NY Part B Supplier - Clinic/Group Practice 6103193024 Receives reassigned benefits from 3 practitioners
Practice locations: New York, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053588988. Details of each certification follow.

Federally qualified health center certification: CCN 571072

Legal name
UNDER 21
Doing business as
COVENANT HOUSE NEW YORK
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 26, 2017
Last certification
May 26, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1981 in NY
Enrollment address
460 W 41St St
New York, NY 10036-6801

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
33D0909992Covenant House Health Services Department460 W 41St Street, New York, NY 10036Provider-performed microscopyMar 26, 2027

National Provider Directory

National Provider Directory

Locations

460 W 41st St
New York, NY 10036
Phone (212) 613-0300

460 W 41st St
Bldg A
New York, NY 10036

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Misha Nonen Individual W-2 Managing Employee Apr 8, 2013
Philip Andryc Individual Corporate Officer Jan 1, 2013
Peter Greatrex Individual Corporate Director Sep 17, 2014
Catherine Newcomb Individual Corporate Director Nov 16, 2005
Eric Hutcherson Individual Corporate Director Sep 8, 2016
Matthew Schmeelk Individual Corporate Director Mar 21, 2010
Mary Mayland Individual Corporate Director May 9, 2012
Jennifer Enslin Individual Corporate Director Dec 9, 2015
Kenneth Willman Individual Corporate Director Nov 16, 2005
Covenant House Organization, New York, NY Corporation 5% Or Greater Direct Ownership Interest Jun 1, 1981
Rick Vanbenschoten Vanbenschoten Individual Corporate Director Mar 21, 2010
Louis Rauchenberger Individual Corporate Director Dec 4, 2013
Joseph Royce Individual Corporate Director Jun 20, 2007
Kerri Anne Bradin Individual Corporate Director Nov 16, 2008
Douglas Blagdon Individual Corporate Director Feb 26, 2014
Jo Reyes Individual Corporate Officer Mar 1, 2010
Mandell Crawley Individual Corporate Director Dec 9, 2015
Nancy Downing Individual Corporate Officer Dec 19, 2016

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1210291200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1496966400000",
    "number": "1053588988",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "460 W 41ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "10036",
            "telephone_number": "212-613-0300",
            "fax_number": "212-268-2832"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "460 W 41ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "10036",
            "telephone_number": "212-613-0300",
            "fax_number": "212-268-2832"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNDER 21",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-05-09",
        "last_updated": "2017-06-09",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "212-613-0300",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00733826",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Covenant House",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in New York, NY

Sources for this page

Verify at the official NPI Registry.