NPIMap

Organization Active NPI

Ehs, Inc.

Doing business as Evergreen Health Services

  • Primary Care Clinic/Center
  • Buffalo, NY
National Provider Identifier
1356390918
Registry record updated Nov 29, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
01711366 Issued in NY
Legal business name
EHS, INC.
Doing business as
Evergreen Health Services
Practice address
206 S Elmwood Ave
Buffalo, NY 14201-2398
Phone
(716) 847-0212
Fax
(716) 847-0418
NPI assigned
May 9, 2006
Last updated
Nov 29, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 29, 2022

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

Authorized official

Name
Jessica Anne Stack
Title
Avp of Revenue Cycle MGMT
Phone
(716) 880-7399

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU
Primary Care Clinic/Center 261QP2300X 01711366 NY Primary
Infectious Disease Physician 207RI0200X NU
Case Manager/Care Coordinator 171M00000X 01218524 NY

Addresses

Primary practice location

206 S Elmwood Ave
Buffalo, NY 14201-2398

Mailing address

206 S Elmwood Ave
Buffalo, NY 14201-2398
Phone (716) 847-0212

Other practice location 1

800 Hertel Ave Ste 100
Buffalo, NY 14207-1906
Phone (716) 847-2441

Other practice location 2

3297 Bailey Ave
Buffalo, NY 14215-1139
Phone (716) 847-2441

Other practice location 3

7 Community Dr
Cheektowaga, NY 14225-2523
Phone (716) 847-2441

Other identifiers 2

IdentifierTypeStateIssuer
02995357MedicaidNY
0F332484MedicaidNY

Other names 1

  • Evergreen Health Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY6 enrollments

Enrollment records 6

Enrollment IDStateProvider typePAC IDDetails
O20040929000803 NY Part B Supplier - Clinic/Group Practice 7618946310 Receives reassigned benefits from 55 practitioners
1 other NPI on this enrollment
Practice locations: Buffalo, NY; Cheektowaga, NY; Jamestown, NY
O20210205000835 NY Part A Provider - Federally Qualified Health Center (FQHC) 7618946310 Practice locations: Buffalo, NY
O20230123000392 NY Part A Provider - Federally Qualified Health Center (FQHC) 7618946310 Practice locations: Buffalo, NY
O20230123000574 NY Part A Provider - Federally Qualified Health Center (FQHC) 7618946310 Practice locations: Cheektowaga, NY
O20240627002304 NY Part A Provider - Federally Qualified Health Center (FQHC) 7618946310 Practice locations: Buffalo, NY
O20240627002572 NY Part A Provider - Federally Qualified Health Center (FQHC) 7618946310 Practice locations: Jamestown, NY

NPI to CCN mapping 5

The Medicare certification numbers (CCNs) connected to NPI 1356390918. Details of each certification follow.

Federally qualified health center certification: CCN 571843

Legal name
EHS, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 5, 2021
Last certification
Feb 5, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1983 in NY
Enrollment address
206 S Elmwood Ave
Buffalo, NY 14201-2398

Federally qualified health center certification: CCN 331819

Legal name
EHS, INC
Doing business as
EVERGREEN HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 28, 2022
Last certification
Dec 28, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1983 in NY
Enrollment address
800 Hertel Ave
Ste 100
Buffalo, NY 14207-1906

Federally qualified health center certification: CCN 331813

Legal name
EHS, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 28, 2022
Last certification
Dec 28, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1983 in NY
Enrollment address
7 Community Dr
Ste a
Cheektowaga, NY 14225-2523

Federally qualified health center certification: CCN 571863

Legal name
EHS, INC
Doing business as
EVERGREEN HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 28, 2024
Last certification
Jun 28, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1983 in NY
Enrollment address
3297 Bailey Ave
Buffalo, NY 14215-1139

Federally qualified health center certification: CCN 571862

Legal name
EHS, INC
Doing business as
EVERGREEN HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 28, 2024
Last certification
Jun 28, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1983 in NY
Enrollment address
320 Prather Ave
Ste 200a
Jamestown, NY 14701-6858

Other NPIs with the same Medicare PAC ID 1

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

  • Ehs, Inc.

    dba The Pharmacy at Evergreen

    • Pharmacy
    • Buffalo, NY
    • NPI 1043508179

    7618946310

    Same PAC ID

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
33D0881570Evergreen Health - 800 Hertel800 Hertel Avenue, Buffalo, NY 14207Certificate of waiverMar 26, 2027
33D0953352Evergreen Health Services Inc206 S Elmwood Avenue, Buffalo, NY 14201Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory

Locations

3297 Bailey Ave
Buffalo, NY 14215
Phone (716) 833-3622

800 Hertel Ave
Buffalo, NY 14207
Phone (716) 566-5007

800 Hertel Ave
Ste 100
Buffalo, NY 14207
Phone (716) 847-2441

7 Community Dr
Ste A
Cheektowaga, NY 14225
Phone (716) 847-2441

320 Prather Ave
Ste 100
Jamestown, NY 14701
Phone (716) 338-0022

320 Prather Ave
Ste 200A
Jamestown, NY 14701
Phone (716) 664-7855

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
William Dimming Individual Corporate OfficerCco Sep 28, 2020 20%
Jesse Gasbarro Individual Corporate OfficerCfo Dec 11, 2017 20%
Michael Lee Individual Corporate OfficerCoo Oct 22, 2017 20%
Raymond Ganoe Individual Corporate Officer Sep 29, 2015 100%
Corporate OfficerCeo Dec 1, 2016
Corporate OfficerCeo Dec 1, 2016 20%
Jessica Stack Individual W-2 Managing EmployeeAvp of Revenue Cycle Management Aug 31, 2015 20%
Operational/Managerial ControlAvp of Rev Cycle MGMT Aug 30, 2015
W-2 Managing EmployeeAvp of Rev Cycle MGMT Aug 30, 2015
Operational/Managerial ControlAvp of Revenue Cycle Management Aug 30, 2015 20%
W-2 Managing EmployeeAvp of Revenue Cycle Management Aug 30, 2015 25%

Practitioners & affiliated clinicians

Practitioners 64

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 64

NPI Registry JSON

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

{
    "created_epoch": "1147132800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669680000000",
    "number": "1356390918",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "206 S ELMWOOD AVE",
            "city": "BUFFALO",
            "state": "NY",
            "postal_code": "142012398",
            "telephone_number": "716-847-0212",
            "fax_number": "716-847-0418"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "206 S ELMWOOD AVE",
            "city": "BUFFALO",
            "state": "NY",
            "postal_code": "142012398",
            "telephone_number": "716-847-0212",
            "fax_number": "716-847-0418"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "800 Hertel Ave Ste 100",
            "address_purpose": "LOCATION",
            "city": "Buffalo",
            "state": "NY",
            "postal_code": "142071906",
            "country_code": "US",
            "telephone_number": "716-847-2441",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "3297 Bailey Ave",
            "address_purpose": "LOCATION",
            "city": "Buffalo",
            "state": "NY",
            "postal_code": "142151139",
            "country_code": "US",
            "telephone_number": "716-847-2441",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "7 Community Dr",
            "address_purpose": "LOCATION",
            "city": "Cheektowaga",
            "state": "NY",
            "postal_code": "142252523",
            "country_code": "US",
            "telephone_number": "716-847-2441",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EHS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-09",
        "last_updated": "2022-11-29",
        "certification_date": "2022-11-29",
        "status": "A",
        "authorized_official_last_name": "STACK",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_middle_name": "ANNE",
        "authorized_official_title_or_position": "AVP OF REVENUE CYCLE MGMT",
        "authorized_official_telephone_number": "716-880-7399"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NY",
            "license": "01711366",
            "primary": true
        },
        {
            "code": "207RI0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Infectious Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NY",
            "license": "01218524",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02995357",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0F332484",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Health Services",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Evergreen Health Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Buffalo, NY

Sources for this page

Verify at the official NPI Registry.