NPIMap

Organization Active NPI

PCC Community Wellness Center

Doing business as PCC West Town Family Health Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1164628012
Registry record updated Mar 5, 2021
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 West Town Family Health Center
Practice address
2434 W Division St
Chicago, IL 60622-2942
Phone
(773) 292-8300
Fax
(708) 292-2601
NPI assigned
Jun 26, 2007
Last updated
Mar 5, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2021

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

Authorized official

Name
Mr. Robert J Urso
Title
President - Chief Executive Officer
Phone
(708) 383-9786

Specialties & licenses 1

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

Addresses

Primary practice location

2434 W Division St
Chicago, IL 60622-2942

Mailing address

2434 W Division St
Chicago, IL 60622-2942
Phone (773) 292-8300

Other names 1

  • PCC West Town 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
O20081120000723 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 1164628012. Details of each certification follow.

Federally qualified health center certification: CCN 141092

Legal name
PCC COMMUNITY WELLNESS CENTER
Doing business as
PCC WEST TOWN FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 12, 2009
Last certification
Jan 12, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 14, 1992 in IL
Enrollment address
2434 W Division St
Chicago, IL 60622-2942

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

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
14D1079152PCC West Town Family Health Center2434 W Division Street, Chicago, IL 60622Provider-performed microscopyJan 7, 2027

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

1044 N Mozart St
Ste 100
Chicago, IL 60622
Phone (773) 292-8300

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Sonia Taylor Individual Corporate DirectorSenior Director of Finance Jan 28, 2024
W-2 Managing Employee Jan 28, 2024
Alyssa Sianghio Individual Corporate OfficerPresident and Ceo Apr 10, 2024 100%
W-2 Managing Employee Apr 10, 2024 100%
John McDonnell Individual Corporate DirectorBoard Member Jul 26, 2011
Patricia Ford Individual Corporate DirectorBoard Member Aug 25, 2009
Richard Ducatenzeller Individual Corporate DirectorBoard Member Jul 1, 2024
Christopher Barracks Individual Corporate DirectorBoard Member Jan 1, 2024
Ron Austin Individual Corporate DirectorBoard Member Jun 8, 2001
Nilsa Campos Individual Corporate OfficerChief Operations Officer Sep 1, 2021 100%
W-2 Managing Employee Sep 1, 2021 100%
Velda Brunner Individual Corporate DirectorBoard Member Nov 29, 2015
Hiren Patel Individual Corporate OfficerChief Financial Officer Sep 11, 2024 100%
W-2 Managing Employee Sep 11, 2024 100%
Janet Y Forbes Individual Corporate DirectorBoard Member Jul 1, 2023
Wrenetha Julion Individual Corporate DirectorBoard Member Jul 1, 2020
Sara Hogue Individual Corporate OfficerChief Quality Improvement Officer Jan 1, 2020 100%
W-2 Managing Employee Jan 1, 2020 100%
Melissa Kirk Individual Corporate DirectorBoard Member Jul 1, 2024
Paul Luning Individual Corporate OfficerChief Medical Officer Sep 17, 2007 100%
W-2 Managing EmployeeChief Medical Officer Sep 17, 2007 100%
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": "1182816000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614902400000",
    "number": "1164628012",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2434 W DIVISION ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606222942",
            "telephone_number": "773-292-8300",
            "fax_number": "708-292-2601"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2434 W DIVISION ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606222942",
            "telephone_number": "773-292-8300",
            "fax_number": "708-292-2601"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PCC COMMUNITY WELLNESS CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-26",
        "last_updated": "2021-03-05",
        "certification_date": "2021-03-05",
        "status": "A",
        "authorized_official_last_name": "URSO",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT - CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "708-383-9786",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PCC West Town Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PCC West Town Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.