NPIMap

Organization Active NPI

Trustees of Purdue University

Doing business as Family Health Clinic of Burlington

  • Federally Qualified Health Center (FQHC)
  • Burlington, IN
National Provider Identifier
1295104669
Registry record updated Apr 18, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRUSTEES OF PURDUE UNIVERSITY
Doing business as
Family Health Clinic of Burlington
Practice address
425 E 5TH Street
Suite B
Burlington, IN 46915
Phone
(765) 564-3016
Fax
(765) 564-2608
NPI assigned
Sep 16, 2015
Last updated
Apr 18, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 18, 2022

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

Authorized official

Name
Mr. Daniel J Layman
Title
Executive Director
Phone
(765) 564-3016

Specialties & licenses 1

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

Addresses

Primary practice location

425 E 5TH Street
Suite B
Burlington, IN 46915

Mailing address

901 Prince William Rd
Suite a
Delphi, IN 46923-1758
Phone (765) 564-3016

Other names 1

  • Family Health Clinic of Burlington Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160226001154 IN Part A Provider - Federally Qualified Health Center (FQHC) 2567373012 Practice locations: Burlington, IN
O20200821001390 IN Part B Supplier - Clinic/Group Practice 2567373012 Receives reassigned benefits from 41 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Burlington, IN; Delphi, IN; Monon, IN; West Lafayette, IN; Wolcott, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1295104669. Details of each certification follow.

Federally qualified health center certification: CCN 151966

Legal name
TRUSTEES OF PURDUE UNIVERSITY
Doing business as
FAMILY HEALTH CLINIC OF BURLINGTON
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 26, 2016
Last certification
Feb 26, 2016
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
425 E 5TH St
Ste B
Burlington, IN 46915-9103

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 4

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2101685Family Health Clinic of Burlington, the425 E 5TH St, Ste B, Burlington, IN 46915Certificate of waiverSep 7, 2027

National Provider Directory

National Provider Directory
Tax ID family
Purdue University Student19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

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

View all 18

Locations

425 E 5th St
Ste B
Burlington, IN 46915
Phone (765) 566-5055

901 Prince William Rd
Delphi, IN 46923
Phone 7655643016207

901 Prince William Rd
Ste A
Delphi, IN 46923
Phone (765) 494-3789

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Trustees of Purdue University Organization, Wolcott, IN Non-profit 5% Or Greater Direct Ownership Interest Jan 4, 2016 100%
Elizabeth M Burrows Individual Corporate OfficerInterim Executive Director Oct 13, 2023
W-2 Managing EmployeeInterim Executive Director Oct 13, 2023
Operational/Managerial ControlInterim Executive Director Oct 13, 2023
Sherri Gehlhausen Individual Corporate OfficerDir. of Revenue Cycle Management Oct 13, 2023
W-2 Managing EmployeeDir. of Revenue Cycle Management Oct 13, 2023
Operational/Managerial ControlDir. of Revenue Cycle Management Oct 13, 2023

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Family Health Clinic of MononMonon, IN, CCN 151862 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 30, 2018
Family Health Clinic of Carroll CountyDelphi, IN, CCN 151863 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 7, 2010
Family Health Clinic of WolcottWolcott, IN, CCN 151976 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jun 15, 2016

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 14

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.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1442361600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1650240000000",
    "number": "1295104669",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "901 PRINCE WILLIAM RD",
            "address_2": "SUITE A",
            "city": "DELPHI",
            "state": "IN",
            "postal_code": "469231758",
            "telephone_number": "765-564-3016",
            "fax_number": "765-564-2608"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 E 5TH STREET",
            "address_2": "SUITE B",
            "city": "BURLINGTON",
            "state": "IN",
            "postal_code": "46915",
            "telephone_number": "765-564-3016",
            "fax_number": "765-564-2608"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRUSTEES OF PURDUE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-16",
        "last_updated": "2022-04-18",
        "certification_date": "2022-04-18",
        "status": "A",
        "authorized_official_last_name": "LAYMAN",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "765-564-3016",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Health Clinic of Burlington",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Family Health Clinic of Burlington",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Burlington, IN

Sources for this page

Verify at the official NPI Registry.