NPIMap

Organization Active NPI

Northwest Health Services Inc

Doing business as South Side Health Center

  • Federally Qualified Health Center (FQHC)
  • Saint Joseph, MO
National Provider Identifier
1194846550
Registry record updated Nov 10, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHWEST HEALTH SERVICES INC
Doing business as
South Side Health Center
Practice address
5001 Lake Ave
Saint Joseph, MO 64504-1170
Phone
(816) 238-7788
Fax
(816) 238-9285
NPI assigned
Apr 3, 2007
Last updated
Nov 10, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 10, 2021

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

Authorized official

Name
Matt Younger
Title
Ceo
Phone
(816) 232-6818

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

5001 Lake Ave
Saint Joseph, MO 64504-1170

Mailing address

5001 Lake Ave
Saint Joseph, MO 64504-1170
Phone (816) 238-7788

Other names 1

  • South Side Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040421001394 MO Part A Provider - Federally Qualified Health Center (FQHC) 7113835174 Practice locations: Saint Joseph, MO
O20040720001347 MO Part B Supplier - Clinic/Group Practice 7113835174 Receives reassigned benefits from 24 practitioners
16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gower, MO; Savannah, MO; Saint Joseph, MO; King City, MO; Hamilton, MO; Braymer, MO; Chillicothe, MO; Cainsville, MO…

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1194846550. Details of each certification follow.

Federally qualified health center certification: CCN 261875

Legal name
NORTHWEST HEALTH SERVICES INC
Doing business as
SOUTH SIDE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 7, 2004
Last certification
May 7, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 1, 1983 in MO
Enrollment address
5001 Lake Ave
Saint Joseph, MO 64504-1170

Federally qualified health center certification: CCN 261032

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
SOUTH SIDE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 17, 2009
Last certification
Mar 17, 2009
Ownership / control type
For profit – partnership
Facility address
5001 Lake Avenue
Saint Joseph, MO 64504

Other NPIs with the same Medicare PAC ID 14

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

View all 14

Other NPIs on the same Medicare enrollment 16

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

View all 16

National Provider Directory

National Provider Directory

Locations

109 N Main St
Braymer, MO 64624
Phone (660) 234-3090

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Kimberly Ireland Individual Corporate DirectorBoard of Directors Vice President Mar 2, 2010 100%
Whitney Lanning Individual Corporate DirectorBoard of Directors President Jan 1, 2020 100%
Steve Loucks Individual Corporate DirectorBoard Member Jan 1, 2014 100%
Tina R Taylor Individual Corporate DirectorInterim Cfo Mar 1, 2016 100%
W-2 Managing EmployeeInterim Cfo Mar 1, 2016 100%
Robin Moppin Individual W-2 Managing EmployeeBilling & Coding Manager Feb 1, 2020 100%
Operational/Managerial ControlBilling & Coding Manager Feb 1, 2020 100%

Practitioners & affiliated clinicians

Practitioners 6

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": "1175558400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1636502400000",
    "number": "1194846550",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5001 LAKE AVE",
            "city": "SAINT JOSEPH",
            "state": "MO",
            "postal_code": "645041170",
            "telephone_number": "816-238-7788",
            "fax_number": "816-238-9285"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5001 LAKE AVE",
            "city": "SAINT JOSEPH",
            "state": "MO",
            "postal_code": "645041170",
            "telephone_number": "816-238-7788",
            "fax_number": "816-238-9285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST HEALTH SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-03",
        "last_updated": "2021-11-10",
        "certification_date": "2021-11-10",
        "status": "A",
        "authorized_official_last_name": "YOUNGER",
        "authorized_official_first_name": "MATT",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "816-232-6818"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "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": "South Side Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Side Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Joseph, MO

Sources for this page

Verify at the official NPI Registry.