NPIMap

Organization Active NPI

Whitney M Young Jr. Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Watervliet, NY
National Provider Identifier
1073960100
Registry record updated Jun 5, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WHITNEY M YOUNG JR. HEALTH CENTER, INC
Practice address
1804 2ND Ave
Watervliet, NY 12189-2818
Phone
(518) 833-6900
Fax
(518) 833-6919
NPI assigned
May 18, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 2017

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

Authorized official

Name
Mary Connolly
Title
Cfo
Phone
(518) 465-4771

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1804 2ND Ave
Watervliet, NY 12189-2818

Mailing address

920 Lark Dr
Albany, NY 12207-1300
Phone (518) 465-4771

Other names 1

  • Whitney Young Health Other name

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040821000073 NY Part B Supplier - Clinic/Group Practice 6507830031 Receives reassigned benefits from 31 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Albany, NY; Troy, NY; Watervliet, NY
O20170622000847 NY Part A Provider - Federally Qualified Health Center (FQHC) 6507830031 Practice locations: Watervliet, NY

Federally qualified health center certification: CCN 571074

Legal name
WHITNEY M YOUNG JR HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 27, 2017
Last certification
Jun 27, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 5, 1974 in NY
Enrollment address
1804 2ND Ave
Watervliet, NY 12189-2818

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 5

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

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
33D2112206Whitney M Young Jr Health Center - Watervliet1804 Second Ave, Watervliet, NY 12189Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory

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
Gus Birkhead Individual Corporate DirectorBoard Member Apr 12, 2022
Casey Parker Individual Corporate DirectorBoard Member Apr 6, 2021
Charles Welge Individual Corporate DirectorBoard Member Apr 9, 2024
David Harold Shippee Individual Corporate DirectorPresident & Ceo Apr 28, 2011
W-2 Managing EmployeePresident & Ceo Apr 28, 2011
Marlowe Cochran Individual Corporate DirectorBoard Member Apr 5, 2016
Rosalyn Duvall Individual Corporate DirectorBoard Member Apr 11, 2023
Gary Guy Individual Corporate DirectorBoard Member Apr 11, 2023
Annette Johnson Individual Corporate DirectorBoard Member Apr 11, 2023
Sheila Nelson Individual Corporate DirectorBoard Member Apr 4, 2017
Susanne M Isabella Individual Corporate DirectorRevenue Cycle Director Jul 23, 2021
W-2 Managing EmployeeRevenue Cycle Director Jul 23, 2021
Ceylon Moore Individual Corporate DirectorBoard Member Jun 6, 2016
Tracey Johnson Individual Corporate DirectorBoard Member Apr 11, 2023
John E Fraher Individual Corporate DirectorCfo Nov 19, 2018
W-2 Managing EmployeeCfo Nov 19, 2018
Kelli Arnold Individual Corporate DirectorBoard Member May 14, 2024
Lauri Rosmarin-Plattner Individual Corporate DirectorBoard Member Apr 11, 2023

NPI Registry JSON

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

{
    "created_epoch": "1463529600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1496620800000",
    "number": "1073960100",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "920 LARK DR",
            "city": "ALBANY",
            "state": "NY",
            "postal_code": "122071300",
            "telephone_number": "518-465-4771",
            "fax_number": "518-242-4784"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1804 2ND AVE",
            "city": "WATERVLIET",
            "state": "NY",
            "postal_code": "121892818",
            "telephone_number": "518-833-6900",
            "fax_number": "518-833-6919"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WHITNEY M YOUNG JR. HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-18",
        "last_updated": "2017-06-05",
        "status": "A",
        "authorized_official_last_name": "CONNOLLY",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "518-465-4771"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Whitney Young Health",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Watervliet, NY

Sources for this page

Verify at the official NPI Registry.