NPIMap

Organization Active NPI

Portland Community Health Center

Doing business as Casco Bay High

  • Federally Qualified Health Center (FQHC)
  • Portland, ME
National Provider Identifier
1184178246
Registry record updated Jun 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PORTLAND COMMUNITY HEALTH CENTER
Doing business as
Casco Bay High
Practice address
196 Allen Ave
Portland, ME 04103-3711
Phone
(207) 842-4693
NPI assigned
Aug 6, 2016
Last updated
Jun 9, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
PORTLAND COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 9, 2023

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

Authorized official

Name
Ms. Ann Tucker
Title
Cfo
Phone
(207) 874-2141

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207V00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

196 Allen Ave
Portland, ME 04103-3711

Mailing address

180 Park Ave
Portland, ME 04102-2957
Phone (207) 874-2141

Other names 1

  • Casco Bay High Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130206000120 ME Part B Supplier - Clinic/Group Practice 5395998017 Receives reassigned benefits from 73 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Westbrook, ME; South Portland, ME; Portland, ME
O20200520000984 ME Part A Provider - Federally Qualified Health Center (FQHC) 5395998017 Practice locations: Portland, ME

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1184178246. Details of each certification follow.

Federally qualified health center certification: CCN 201943

Legal name
PORTLAND COMMUNITY HEALTH CENTER
Doing business as
CASCO BAY HIGH SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 20, 2020
Last certification
May 20, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 30, 2013 in ME
Enrollment address
196 Allen Ave
Portland, ME 41033711

Other NPIs with the same Medicare PAC ID 17

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

View all 17

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory
Tax ID family
Portland Community Health Center43 organizations share this tax ID, including this one
Part of
Portland Community Health Center

Other organizations with this tax ID 42

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

View all 42

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
Axel Nimbona Individual Corporate DirectorBoard Member Apr 16, 2024
Ann Tucker Individual Corporate DirectorCeo Mar 1, 2017
W-2 Managing EmployeeCeo Oct 1, 2013
Paul Santomenna Individual Corporate DirectorPresident Dec 26, 2017
Belviga Mpolo Individual Corporate DirectorBoard Member Jan 27, 2026
Christine Caulfield Individual Corporate DirectorVice President Jan 24, 2023
Connor O'Neill Individual Corporate DirectorBoard Member Apr 16, 2024
Christopher Dana Individual Corporate DirectorSecretary Jul 27, 2021
Isaac Macdougal Individual Corporate DirectorBoard Member Apr 16, 2024
Marie a Guay Individual Corporate DirectorBoard Member Apr 16, 2024
Richard M White Individual Corporate DirectorTreasurer Jan 24, 2017
Doreen Karigirwa Individual Corporate DirectorBoard Member Jan 27, 2026
John Dearmond Individual Corporate DirectorBoard Member Jan 27, 2026

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1470441600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686268800000",
    "number": "1184178246",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "180 PARK AVE",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041022957",
            "telephone_number": "207-874-2141"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "196 ALLEN AVE",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041033711",
            "telephone_number": "207-842-4693"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORTLAND COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PORTLAND COMMUNITY HEALTH CENTER",
        "enumeration_date": "2016-08-06",
        "last_updated": "2023-06-09",
        "certification_date": "2023-06-09",
        "status": "A",
        "authorized_official_last_name": "TUCKER",
        "authorized_official_first_name": "ANN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "207-874-2141",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Casco Bay High",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Casco Bay High",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portland, ME

Sources for this page

Verify at the official NPI Registry.