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West Side Community Health Services, Inc

Organization Active NPI Federally Qualified Health Center (FQHC) · Saint Paul, MN

NPI 1194902072 · NPPES record last updated May 15, 2024

Key facts

NPI
1194902072
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
WEST SIDE COMMUNITY HEALTH SERVICES, INC
Practice address
1212 University Ave W
Saint Paul, MN 55104-4123
Phone
(651) 293-5900
Fax
(651) 602-7517
NPI assigned
Jan 23, 2008
Organization subpart
No

Authorized official

Name
Reuben Moore
Title
Ceo
Phone
(651) 602-7500

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 17

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

Other NPIs with the same Medicare PAC ID 15

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

Corporate family (same tax ID) 21

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

Practitioners 54

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 54

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in MN

Federally qualified health center certification: CCN 241860

Legal name
WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Doing business as
MN COMMUNITY CARE - GORDON PARKS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 16, 2009
Last certification
Oct 16, 2009
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Feb 1, 1972 in MN
Enrollment address
1212 University Ave W
Saint Paul, MN 55104-4123

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Rudolph Dufour
Individual 		Corporate Director Aug 20, 2019
Christine Singer
Individual 		W-2 Managing Employee
Coo		 May 29, 2015
Operational/Managerial Control
Coo		 May 29, 2015
Jeanette Jones
Individual 		Corporate Director Nov 19, 2015
Summer Abdalla
Individual 		Corporate Director May 7, 2018
Sarah Shrader
Individual 		Corporate Director Sep 26, 2019
Peter Surdo
Individual 		Corporate Director May 1, 2009
Roman Cress
Individual 		Corporate Director May 7, 2018
Amelia Hardy
Individual 		Corporate Director May 7, 2018
Blake Darsow
Individual 		Corporate Officer
Cfo		 Aug 26, 2016
William Thompson
Individual 		Corporate Director Jul 22, 2010
Catherine Ellingson
Individual 		W-2 Managing Employee
Business Office Manager		 Jun 1, 2006
Cordell Hardy
Individual 		Corporate Director May 7, 2018
Reuben Moore
Individual 		Corporate Officer
Ceo		 Oct 3, 2017
Zachary Hylton
Individual 		Corporate Director May 7, 2018
Krisa Ryan
Individual 		Corporate Director May 7, 2018
Alejandro Diez
Individual 		Corporate Director Oct 25, 2018
Andreatte E Hames
Individual 		Corporate Director Jan 1, 2014
Janet Zastrow
Individual 		Corporate Director May 7, 2018

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
West Side Community Health Services, Inc.
Saint Paul, MN · CCN 241804		 Federally qualified health center Operational/Managerial Control Dec 8, 1988
Creative Arts Clinic
Saint Paul, MN · CCN 241006		 Federally qualified health center Operational/Managerial Control (100%) Nov 1, 2018

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040209000647 MN Part B Supplier - Clinic/Group Practice 2062306434 Receives reassigned benefits from 116 practitioners
18 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Paul, MN; Saint Paul Park, MN; Maplewood, MN; St. Paul, MN; Minneapolis, MN
O20091016000170 MN Part a Provider - Federally Qualified Health Center (FQHC) 2062306434 Practice locations: Saint Paul, MN

National Provider Directory

Tax ID family
WSHC-Homeless Center (22 organizations share this tax ID)

Locations

1212 University Ave S
Saint Paul, MN 55155

Specialties & licenses

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

Addresses

Primary practice location

1212 University Ave W
Saint Paul, MN 55104-4123

Mailing address

153 Cesar Chavez St
Saint Paul, MN 55107-2226
Phone (651) 602-7500

Other names

  • Gordon Parks Area Learning Center(ALC) Other name

Other providers in Saint Paul, MN

All providers in Saint Paul, MN · Federally Qualified Health Center (FQHC) in Minnesota

Sources for this page

Verify at the official NPI Registry.