NPIMap

Organization Active NPI

Near North Health Service Corporation

Doing business as Near North Health Serv Komed

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1346221553
Registry record updated Jul 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NEAR NORTH HEALTH SERVICE CORPORATION
Doing business as
Near North Health Serv Komed
Practice address
4259 S Berkeley Ave
Chicago, IL 60653-3030
Phone
(773) 268-7600
Fax
(773) 268-9088
NPI assigned
Nov 7, 2005
Last updated
Jul 21, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2021

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

Authorized official

Name
Mrs. Berneice Mills-Thomas
Title
Executive
Phone
(312) 337-1073

Specialties & licenses 1

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

Addresses

Primary practice location

4259 S Berkeley Ave
Chicago, IL 60653-3030

Mailing address

1276 N Clybourn Ave
Chicago, IL 60610-2089
Phone (773) 268-7600

Other names 1

  • Near North Health Serv Komed Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040423000456 IL Part B Supplier - Clinic/Group Practice 9638165749 Receives reassigned benefits from 43 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chicago, IL
O20090423000498 IL Part A Provider - Federally Qualified Health Center (FQHC) 9638165749 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1346221553. Details of each certification follow.

Federally qualified health center certification: CCN 141825

Legal name
NEAR NORTH HEALTH SERVICE CORPORATION
Doing business as
KOMED HOLMAN HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 16, 1992
Last certification
Sep 16, 1992
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 1982 in IL
Enrollment address
4259S Berkeley Ave
Chicago, IL 60653-3030

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 11

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
14D0922453Komed Holman Health Center4259 S Berkeley Ave, Chicago, IL 60653Provider-performed microscopyNov 24, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Evelyn Reid Individual Corporate Director Jan 1, 2010
Triste Smith Individual Corporate OfficerChief Executive Officer Nov 1, 2022
W-2 Managing EmployeeChief Executive Officer Nov 1, 2022
David Delgado Individual Corporate Director Jan 1, 2010
Joyce Tucker Individual Corporate Director Jan 1, 2010
Lisa Cowhey Individual Corporate Officer Aug 21, 2023
Patricia Cornelius Individual Corporate Director Jan 1, 2010
Norman Bolden Individual Corporate Director Jan 1, 2010
Clarence Burch Individual Corporate Director Jan 1, 2010
Norine Rhodes Individual Corporate Director Jan 1, 2010
Kenneth Dunkin Individual Corporate Director Jan 1, 2010

Practitioners & affiliated clinicians

Practitioners 3

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": "1131321600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626825600000",
    "number": "1346221553",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1276 N CLYBOURN AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606102089",
            "telephone_number": "773-268-7600",
            "fax_number": "773-268-9088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4259 S BERKELEY AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606533030",
            "telephone_number": "773-268-7600",
            "fax_number": "773-268-9088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NEAR NORTH HEALTH SERVICE CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-07",
        "last_updated": "2021-07-21",
        "certification_date": "2021-07-21",
        "status": "A",
        "authorized_official_last_name": "MILLS-THOMAS",
        "authorized_official_first_name": "BERNEICE",
        "authorized_official_title_or_position": "EXECUTIVE",
        "authorized_official_telephone_number": "312-337-1073",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Near North Health Serv Komed",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Near North Health Serv Komed",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.