NPIMap

Organization Active NPI

Covered Bridge Healthcare of St. Joseph County Inc

  • Federally Qualified Health Center (FQHC)
  • Centreville, MI
National Provider Identifier
1063876910
Registry record updated Mar 7, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COVERED BRIDGE HEALTHCARE OF ST. JOSEPH COUNTY INC
Practice address
658 E Main St
Centreville, MI 49032-9699
Phone
(269) 467-3228
NPI assigned
Apr 7, 2016
Last updated
Mar 7, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2017

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

Authorized official

Name
Richard Shaffer, RN
Title
Executive Director
Phone
(269) 467-3228

Specialties & licenses 1

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

Addresses

Primary practice location

658 E Main St
Centreville, MI 49032-9699

Mailing address

658 E Main St.
Centreville, MI 49032
Phone (269) 467-3228

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160617000993 MI Part A Provider - Federally Qualified Health Center (FQHC) 6507157773 Practice locations: Centreville, MI
O20170602000434 MI Part B Supplier - Clinic/Group Practice 6507157773 Receives reassigned benefits from 12 practitioners
Practice locations: Centreville, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063876910. Details of each certification follow.

Federally qualified health center certification: CCN 231096

Legal name
COVERED BRIDGE HEALTHCARE OF ST. JOSEPH COUNTY INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 17, 2016
Last certification
Jun 17, 2016
Ownership / control type
Non-profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 6, 2015 in MI
Enrollment address
658 E Main St
Centreville, MI 49032-9627

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
23D2115980Covered Bridge Healthcare of St Joseph County, Inc658 E Main Street, Centreville, MI 49032Certificate of waiverJul 17, 2028

National Provider Directory

National Provider Directory

Locations

658 E Main St
Centreville, MI 49032
Phone (269) 467-3228

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/ABDFAD

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Stacy Linihan Individual Corporate DirectorCeo May 1, 2016
W-2 Managing EmployeeCeo May 1, 2016
Andy Goldberger Individual Corporate DirectorVice President Jan 1, 2017

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1459987200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488844800000",
    "number": "1063876910",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "658 E MAIN ST.",
            "city": "CENTREVILLE",
            "state": "MI",
            "postal_code": "49032",
            "telephone_number": "269-467-3228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "658 E MAIN ST",
            "city": "CENTREVILLE",
            "state": "MI",
            "postal_code": "490329699",
            "telephone_number": "269-467-3228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVERED BRIDGE HEALTHCARE OF ST. JOSEPH COUNTY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-07",
        "last_updated": "2017-03-07",
        "status": "A",
        "authorized_official_last_name": "SHAFFER",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "269-467-3228",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Centreville, MI

Sources for this page

Verify at the official NPI Registry.