PCC Community Wellness Center
Organization Active NPI Federally Qualified Health Center (FQHC) · Berwyn, IL
NPI 1174549786 · NPPES record last updated Jul 21, 2022
Key facts
- NPI
- 1174549786
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- 005 (IL)
- Legal business name
- PCC COMMUNITY WELLNESS CENTER
- Practice address
- 6201 Roosevelt Rd
Berwyn, IL 60402-1108 - Phone
- (708) 386-0845
- Fax
- (708) 386-8472
- NPI assigned
- Jul 15, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- PCC COMMUNITY WELLNESS CENTER
Authorized official
- Name
- Robert J Urso
- Title
- President & Ceo
- Phone
- (708) 383-9786
Owners & managing parties with NPI records 2
-
Janet Y Forbes, M.D.
-
Paul S Luning, MD
Owned or controlled facilities with NPI records 2
Other NPIs with the same Medicare PAC ID 16
Corporate family (same tax ID) 20
Practitioners 91
-
Mahnaz Jeelani Ali, D.O.
-
Alinaa Alsaud, PA-C
-
Yesenia Arce, M.D.
-
Cecelia B Bacom, CNM
-
Morgan Colleen Beatty, MD, MPH
-
Patricia Billingsley, RN, APN
-
Rachel Brdicka, FNP
-
Mary L Brown, APN
-
Mary Buswell, MD
-
Yolanda Cardenas, M.D.
-
Bianca Cervantes, LCPC
-
Peter M Chapman, LCSW
-
Robin Apri D'Aversa, DNP, CNM, APRN
-
Julene Davis, PMHNP
-
Megan K Dawson, APN
-
Natasha Diaz, MD
-
Michelle Doscas, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 14D1052566 | P C C South Family Health Center | Provider-performed microscopy | Jan 7, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Federally qualified health center certification: CCN 141031
- Legal name
- PCC COMMUNITY WELLNESS CENTER
- Doing business as
- SOUTH FAMILY HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 28, 2006
- Last certification
- Sep 28, 2006
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 14, 1992 in IL
- Enrollment address
- 6201 Roosevelt Rd
Berwyn, IL 60402-1108
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Sonia Taylor |
Corporate Director |
Jan 28, 2024 | |
| W-2 Managing Employee | Jan 28, 2024 | ||
| Alyssa Sianghio |
Corporate Officer |
Apr 10, 2024 | 100% |
| W-2 Managing Employee | Apr 10, 2024 | 100% | |
| John McDonnell |
Corporate Director |
Jul 26, 2011 | |
| Patricia Ford |
Corporate Director |
Aug 25, 2009 | |
| Richard Ducatenzeller |
Corporate Director |
Jul 1, 2024 | |
| Christopher Barracks |
Corporate Director |
Jan 1, 2024 | |
| Ron Austin |
Corporate Director |
Apr 1, 2006 | |
| Nilsa Campos |
Corporate Officer |
Sep 1, 2021 | 100% |
| W-2 Managing Employee |
Sep 1, 2021 | 100% | |
| Velda Brunner |
Corporate Director |
Nov 29, 2015 | |
| Hiren Patel |
Corporate Officer |
Sep 11, 2024 | 100% |
| W-2 Managing Employee | Sep 11, 2024 | 100% | |
| Jerrard D Walker |
Corporate Officer |
Mar 8, 2021 | 100% |
| W-2 Managing Employee |
Mar 8, 2021 | 100% | |
| Janet Y Forbes |
Corporate Director |
Oct 25, 2022 | |
| Wrenetha Julion |
Corporate Director |
Jun 23, 2020 | |
| Sara Hogue |
Corporate Officer |
Nov 4, 2019 | 100% |
| W-2 Managing Employee |
Nov 4, 2019 | 100% | |
| Melissa Kirk |
Corporate Director |
Aug 1, 2024 | |
| Paul Luning |
Corporate Officer |
Sep 17, 2007 | 100% |
| W-2 Managing Employee |
Sep 17, 2007 | 100% | |
| Kenneth M Blair |
Corporate Director |
Apr 1, 2006 |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| PCC Dr Tong Health Center |
Federally qualified health center | Other (100%) | Sep 15, 2004 |
| PCC Walk-in Wellness Center at West Suburban Medical Center |
Federally qualified health center | Other (100%) | Sep 15, 2004 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060811000195 | IL | Part a Provider - Federally Qualified Health Center (FQHC) | 1557270139 | Practice locations: Berwyn, IL |
National Provider Directory
- Tax ID family
- PCC Community Wellness Ctr
- Part of
- PCC Community Wellness Ctr
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | 005 | IL | Yes |
Addresses
Primary practice location
6201 Roosevelt Rd
Berwyn, IL 60402-1108
Mailing address
6201 Roosevelt Rd
Berwyn, IL 60402-1108
Phone (708) 386-0845
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 141031 | Other | IL | MEDICARE PROVIDER ID |
Other names
- South Family Health Center
Other providers in Berwyn, IL
- Patriot Car Services, LLC
- Paul Potach D.P.M.,P.C.
- Kelli Paulson
- Justin James Payette
- Annette R Payot
- PCC Community Wellness Center
- Sharlyn Pech
- Joanna Pelayo
- Marleni Pelayo
- Pem Medical SC Centro Medico
All providers in Berwyn, IL · Federally Qualified Health Center (FQHC) in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 21, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.