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Affinia Healthcare

Organization Active NPI Federally Qualified Health Center (FQHC) · Saint Louis, MO

NPI 1093723959 · NPPES record last updated Sep 27, 2021

Key facts

NPI
1093723959
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
License
5008995962 (MO)
Legal business name
AFFINIA HEALTHCARE
Practice address
4414 N Florissant Ave
Saint Louis, MO 63107-1812
Phone
(314) 898-1700
Fax
(314) 898-1688
NPI assigned
Aug 4, 2006
Organization subpart
No

Authorized official

Name
Mrs. Janet Voss
Title
Cfo
Phone
(314) 814-8571

Other NPIs on the same Medicare enrollment 5

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

Other NPIs with the same Medicare PAC ID 7

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

Corporate family (same tax ID) 20

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 32

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

View all 32

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in MO

Federally qualified health center certification: CCN 261895

Legal name
AFFINIA HEALTHCARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 14, 2005
Last certification
Nov 14, 2005
Ownership / control type
For profit – partnership
Organization structure
Corporation · Non-profit
Incorporated
Jul 13, 1964 in MO
Enrollment address
4414 N Florissant Ave
Saint Louis, MO 63107-1812

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Araceli Escalante-Gudino
Individual 		Corporate Officer Jan 1, 2022
Riisa Rawlins
Individual 		Corporate Officer Jan 1, 2022
Kevin Hachegechog
Individual 		Corporate Officer Jan 1, 2018
Robert Jacobson
Individual 		Corporate Officer
Executive Committee Member of TH		 Jan 25, 2016
Debra Johns
Individual 		Corporate Officer Jan 1, 2022
Kimball McMullin
Individual 		Corporate Director Jan 25, 2016
Georgia Harris
Individual 		Corporate Officer Jan 1, 2022
David Walters
Individual 		Corporate Officer Jan 1, 2021
Jean M Frazee
Individual 		Corporate Officer
Treasurer		 Jan 25, 2016
Laurel Tinsley
Individual 		Corporate Officer Jan 1, 2021
Tondaleria Curry
Individual 		Corporate Director Jan 25, 2016
Janet L Voss
Individual 		Corporate Officer
VP/Cfo		 Apr 1, 2016 100%
Operational/Managerial Control
VP/Cfo		 Apr 1, 2016 100%
Mitchell L Baris
Individual 		Corporate Officer
Chairman of Board of Directors		 Jan 25, 2016
Carrollton Bank
Organization · Clayton, MO
Financial institution 		5% Or Greater Mortgage Interest Mar 9, 2017 30.6%
Gwendolyn Hall
Individual 		Corporate Director Jan 25, 2016
Alan O Freeman
Individual 		Corporate Director
Ceo/President		 Nov 13, 2006 100%
W-2 Managing Employee
Ceo/President		 Nov 13, 2006 100%
Paula R Davis
Individual 		Corporate Director Jan 25, 2016

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040902000048 MO Part B Supplier - Clinic/Group Practice 1052386919 Receives reassigned benefits from 90 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Louis, MO
O20051018001046 MO Part a Provider - Federally Qualified Health Center (FQHC) 1052386919 Practice locations: Saint Louis, MO

National Provider Directory

Tax ID family
Affinia Healthcare (21 organizations share this tax ID)

Locations

3396 Pershall Rd
Saint Louis, MO 63135
Phone (314) 377-4329

4414 N Florissant Ave
Saint Louis, MO 63107
Phone (314) 814-8515

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 5008995962 MO Yes

Addresses

Primary practice location

4414 N Florissant Ave
Saint Louis, MO 63107-1812

Mailing address

PO Box 551
Saint Louis, MO 63188-0551
Phone (314) 898-1700

Other identifiers

IdentifierTypeStateIssuer
26D0857809OtherCLIA
500899562MedicaidMO

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 27, 2021.

{
    "created_epoch": "1154649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632700800000",
    "number": "1093723959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 551",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631880551",
            "telephone_number": "314-898-1700",
            "fax_number": "314-814-8542"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4414 N FLORISSANT AVE",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631071812",
            "telephone_number": "314-898-1700",
            "fax_number": "314-898-1688"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AFFINIA HEALTHCARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-04",
        "last_updated": "2021-09-27",
        "certification_date": "2021-09-27",
        "status": "A",
        "authorized_official_last_name": "VOSS",
        "authorized_official_first_name": "JANET",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "314-814-8571",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": "5008995962",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "26D0857809",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500899562",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

All providers in Saint Louis, MO · Federally Qualified Health Center (FQHC) in Missouri

Sources for this page

Verify at the official NPI Registry.