NPIMap

Organization Active NPI

Crusaders Central Clinic Association

  • Federally Qualified Health Center (FQHC)
  • Rockford, IL
National Provider Identifier
1265601488
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Practice address
1100 Broadway
Rockford, IL 61104-1429
Phone
(815) 490-1601
Fax
(815) 490-1625
NPI assigned
Feb 21, 2008
Organization subpart
Yes
Parent organization
CRUSADERS CENTRAL CLINIC ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Samuel Miller
Title
President & Ceo
Phone
(815) 490-1737

Specialties & licenses 1

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

Addresses

Primary practice location

1100 Broadway
Rockford, IL 61104-1429

Mailing address

1100 Broadway
Rockford, IL 61104-1429
Phone (815) 490-1600

Other identifiers 3

IdentifierTypeStateIssuer
103436OtherDORAL
027548OtherCHAMPUS
1011514778OtherBLUE CROSS BLUE SHIELD

Other names 1

  • Crusader Clinic Broadway Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031216000642 IL Part B Supplier - Clinic/Group Practice 5799682993 Receives reassigned benefits from 19 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Belvidere, IL; Loves Park, IL; Rockford, IL; South Beloit, IL
O20081006000063 IL Part A Provider - Federally Qualified Health Center (FQHC) 5799682993 Practice locations: Rockford, IL

Federally qualified health center certification: CCN 141847

Legal name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Doing business as
CRUSADER CLINIC BROADWAY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 1, 1992
Last certification
Sep 1, 1992
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1997 in IL
Enrollment address
1100 Broadway
Rockford, IL 61104-1429

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory
Tax ID family
Crusaders Central Clinic Association10 organizations share this tax ID, including this one
Part of
Crusaders Central Clinic Association

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Catherine L Brown Individual Corporate Officer Jan 1, 2019
Corporate Director Jan 1, 2019
James R Millikin Individual Corporate DirectorBoard Member Oct 1, 2016
Noel D Nickel Individual W-2 Managing Employee Dec 1, 2025
Leon E Hansen Individual Corporate DirectorBoard Member Jan 1, 2013
Barbara Williams Individual Corporate DirectorBoard Member Jan 1, 2016
Richard P Walsh Individual Corporate DirectorBoard Member Jan 1, 2016
Samuel Miller Individual Corporate OfficerPresident & Ceo Jan 1, 2020
W-2 Managing Employee Sep 15, 2008

Practitioners & affiliated clinicians

Practitioners 33

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

View all 33

NPI Registry JSON

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

{
    "created_epoch": "1203552000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1265601488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 BROADWAY",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611041429",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 BROADWAY",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611041429",
            "telephone_number": "815-490-1601",
            "fax_number": "815-490-1625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "enumeration_date": "2008-02-21",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-24",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "815-490-1737"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DORAL",
            "identifier": "103436",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHAMPUS",
            "identifier": "027548",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "1011514778",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crusader Clinic Broadway",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rockford, IL

Sources for this page

Verify at the official NPI Registry.