NPIMap

Organization Active NPI

Bethel Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Bethel, AK
National Provider Identifier
1124078019
Registry record updated Nov 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BETHEL FAMILY CLINIC
Practice address
631 Main Street
Bethel, AK 99559-1908
Phone
(907) 543-3773
Fax
(907) 543-3545
NPI assigned
May 11, 2006
Last updated
Nov 27, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2018

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

Authorized official

Name
Suzanne Niemi
Title
Finance
Phone
(907) 543-9852

Specialties & licenses 1

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

Addresses

Primary practice location

631 Main Street
Bethel, AK 99559-1908

Mailing address

PO Box 1908
631 Main Street
Bethel, AK 99559-1908
Phone (907) 543-3773

Other identifiers 2

IdentifierTypeStateIssuer
02-1835OtherAKMEDICARE PART A PTAN
1029936MedicaidAK

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040311000904 AK Part B Supplier - Clinic/Group Practice 7719876416 Receives reassigned benefits from 7 practitioners
1 other NPI on this enrollment
Practice locations: Bethel, AK
O20070817000095 AK Part A Provider - Federally Qualified Health Center (FQHC) 7719876416 Practice locations: Bethel, AK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124078019. Details of each certification follow.

Federally qualified health center certification: CCN 021835

Legal name
BETHEL FAMILY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 1, 2008
Last certification
Feb 1, 2008
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Nov 1, 1982 in AK
Enrollment address
631 4TH Ave
Bethel, AK 99559-1908

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Bethel Family Clinic Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Michael Riley Individual Corporate DirectorBoard Member May 1, 2012
Dean Swope Individual Corporate DirectorBoard Member Jun 1, 2012
Delbert Egoak Individual Corporate DirectorBoard Member Mar 1, 2014
Ana Patricia Jones Individual Corporate OfficerBoard President Apr 1, 2011
Jeanne Evans Individual Corporate DirectorBoard Member Aug 1, 2014
Grace Haas Individual Corporate Director Aug 1, 1999
Christine McCaffery Individual Corporate OfficerBoard Secretary Oct 1, 2012
Kathleen Naneng Individual Corporate OfficerBoard Treasurer Jan 1, 2011
Donald Black Individual Corporate OfficerBoard Vice President Mar 1, 2014
Shadi Rabi Individual Corporate Director Jun 1, 2024
W-2 Managing EmployeeDirector Jun 1, 2024
Claudia Palacios Individual Corporate DirectorBoard Member Jul 1, 2014
Michael Chung Individual Corporate DirectorBoard Member Dec 1, 2014

Practitioners & affiliated clinicians

Practitioners 21

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 21

NPI Registry JSON

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

{
    "created_epoch": "1147305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1543276800000",
    "number": "1124078019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1908",
            "address_2": "631 MAIN STREET",
            "city": "BETHEL",
            "state": "AK",
            "postal_code": "995591908",
            "telephone_number": "907-543-3773",
            "fax_number": "907-543-3545"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "631 MAIN STREET",
            "city": "BETHEL",
            "state": "AK",
            "postal_code": "995591908",
            "telephone_number": "907-543-3773",
            "fax_number": "907-543-3545"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BETHEL FAMILY CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-11",
        "last_updated": "2018-11-27",
        "status": "A",
        "authorized_official_last_name": "NIEMI",
        "authorized_official_first_name": "SUZANNE",
        "authorized_official_title_or_position": "FINANCE",
        "authorized_official_telephone_number": "907-543-9852"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A PTAN",
            "identifier": "02-1835",
            "state": "AK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1029936",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bethel, AK

Sources for this page

Verify at the official NPI Registry.