NPIMap

Organization Active NPI

Beloved Community Family Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1144528167
Registry record updated Aug 24, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BELOVED COMMUNITY FAMILY WELLNESS CENTER
Practice address
6821 S Halsted St
Chicago, IL 60621-1833
Phone
(773) 651-3629
Fax
(773) 651-1599
NPI assigned
Mar 1, 2011
Last updated
Aug 24, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 24, 2017

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

Authorized official

Name
Ms. Margie Neda Johnson, MS
Title
Executive Director
Phone
(773) 651-3828

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X 036113305 IL
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

6821 S Halsted St
Chicago, IL 60621-1833

Mailing address

6821 S Halsted St
Chicago, IL 60621-1833
Phone (773) 651-3629

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20061016000042 IL Part B Supplier - Clinic/Group Practice 0042216038 Receives reassigned benefits from 41 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chicago, IL; Blue Island, IL
O20101116000006 IL Part A Provider - Federally Qualified Health Center (FQHC) 0042216038 1 other NPI on this enrollment
Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144528167. Details of each certification follow.

Federally qualified health center certification: CCN 141134

Legal name
BELOVED COMMUNITY FAMILY WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 18, 2010
Last certification
Nov 18, 2010
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 5, 2005 in IL
Enrollment address
6821 S Halsted St
Chicago, IL 60621-1833
Related CCNs
141075

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 2

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

National Provider Directory

National Provider Directory
Tax ID family
Beloved Community Family Wellness Ctr5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Locations

2338 New St
Blue Island, IL 60406
Phone (708) 577-5060

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Lawrence a Seals Individual Corporate Director Feb 1, 2010
Iqbal Hussain Individual Corporate OfficerCfo Nov 17, 2014
Kacy Rush Individual Corporate Director Feb 1, 2010
Peter E Friedell Individual Corporate Director Feb 1, 2010
Margie N Johnson Individual Corporate OfficerCeo Feb 1, 2010
W-2 Managing Employee Feb 1, 2010
Paul Williams Individual Corporate Director Feb 1, 2010
Steven M Long Individual Corporate Director Feb 1, 2010

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 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1298937600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1503532800000",
    "number": "1144528167",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6821 S HALSTED ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606211833",
            "telephone_number": "773-651-3629",
            "fax_number": "773-322-1955"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6821 S HALSTED ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606211833",
            "telephone_number": "773-651-3629",
            "fax_number": "773-651-1599"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BELOVED COMMUNITY FAMILY WELLNESS CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-01",
        "last_updated": "2017-08-24",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "MARGIE",
        "authorized_official_middle_name": "NEDA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "773-651-3828",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "MS"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "IL",
            "license": "036113305",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.