NPIMap

Organization Active NPI

PCC Community Wellness Center

Doing business as PCC Parkside Family Health Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1114498540
Registry record updated Dec 11, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PCC COMMUNITY WELLNESS CENTER
Doing business as
PCC Parkside Family Health Center
Practice address
115 N Parkside Ave FL 1
Chicago, IL 60644-3040
Phone
(708) 406-3056
Fax
(708) 406-3051
NPI assigned
Dec 11, 2018
Last updated
Dec 11, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 11, 2018

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

Authorized official

Name
Kathleen A Hand
Title
Financial Analyst
Phone
(708) 406-3056

Specialties & licenses 1

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

Addresses

Primary practice location

115 N Parkside Ave FL 1
Chicago, IL 60644-3040

Mailing address

6201 Roosevelt Rd
Berwyn, IL 60402-1108
Phone (708) 406-3056

Other names 1

  • PCC Parkside Family Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190107003042 IL Part A Provider - Federally Qualified Health Center (FQHC) 1557270139 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114498540. Details of each certification follow.

Federally qualified health center certification: CCN 781918

Legal name
PCC COMMUNITY WELLNESS CENTER
Doing business as
PCC PARKSIDE FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 21, 2018
Last certification
Dec 21, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 14, 1992 in IL
Enrollment address
115 N Parkside Ave
FL 1
Chicago, IL 60644-3040

Other NPIs with the same Medicare PAC ID 16

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

View all 16

National Provider Directory

National Provider Directory
Tax ID family
PCC Community Wellness Ctr21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

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

View all 20

Locations

115 N Parkside Ave
Fl 1
Chicago, IL 60644
Phone (708) 406-3056

Ownership & related parties

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
Melinda S Malecki Individual Corporate DirectorBoard Secretary Jun 28, 2001
Teresa Reyes Individual Corporate DirectorBoard Vice Chairperson Nov 18, 2008
John McDonnell Individual Corporate DirectorDirector Jul 26, 2011
Patricia Ford Individual Corporate DirectorDirector Aug 25, 2009
Ron Austin Individual Corporate DirectorDirector Jun 8, 2001
Lynn Hopkins Individual W-2 Managing EmployeeChief Operating Officer Nov 27, 2007 100%
Robert Urso Individual Corporate OfficerPresident and Ceo Apr 2, 2001 100%
W-2 Managing EmployeePresident and Ceo Apr 2, 2001 100%
Velda Brunner Individual Corporate DirectorDirector Nov 29, 2015
Shawnda Steer Individual Corporate DirectorDirector Sep 27, 2011
Mariana Osoria Individual Corporate DirectorDirector Jul 23, 2013
Barbara Diggins Individual Corporate DirectorDirector Nov 11, 2003
Patrick Garrick Individual W-2 Managing EmployeeChief Financial Officer Jul 1, 2013 100%
Amanda Brooks Individual W-2 Managing EmployeeChief Population Health Officer Dec 1, 2017 100%
Paul Luning Individual W-2 Managing EmployeeChief Medical Officer Sep 17, 2007 100%
Carolyn Elaine Fitzpatrick Individual Corporate DirectorBoard Chairperson Feb 19, 2008
Kathleen Hand Individual W-2 Managing EmployeeDelegated Official Aug 3, 2003
Kenneth M Blair Individual Corporate DirectorBoard Treasurer Jul 31, 1992

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
PCC Dr Tong Health CenterOak Park, IL, CCN 141034 Federally qualified health center Other (100%) Sep 15, 2004
PCC Walk-in Wellness Center at West Suburban Medical CenterOak Park, IL, CCN 781802 Federally qualified health center Other (100%) Sep 15, 2004

Owned or controlled facilities with NPI records 2

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

NPI Registry JSON

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

{
    "created_epoch": "1544486400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1544486400000",
    "number": "1114498540",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6201 ROOSEVELT RD",
            "city": "BERWYN",
            "state": "IL",
            "postal_code": "604021108",
            "telephone_number": "708-406-3056",
            "fax_number": "708-406-3051"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 N PARKSIDE AVE FL 1",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606443040",
            "telephone_number": "708-406-3056",
            "fax_number": "708-406-3051"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PCC COMMUNITY WELLNESS CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-12-11",
        "last_updated": "2018-12-11",
        "status": "A",
        "authorized_official_last_name": "HAND",
        "authorized_official_first_name": "KATHLEEN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "FINANCIAL ANALYST",
        "authorized_official_telephone_number": "708-406-3056"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PCC Parkside Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.