NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Lake Station, IN
National Provider Identifier
1356530505
Registry record updated Sep 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHSHORE HEALTH CENTERS, INC.
Practice address
3099 Central Ave
Lake Station, IN 46405-2207
Phone
(219) 763-8112
Fax
(219) 962-1189
NPI assigned
Oct 23, 2007
Last updated
Sep 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 22, 2020

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

Authorized official

Name
David Hall
Title
Ceo
Phone
(219) 763-8112

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
General Practice Dentistry 1223G0001X
Dental Hygienist 124Q00000X
Body Imaging Physician 2085B0100X

Addresses

Primary practice location

3099 Central Ave
Lake Station, IN 46405-2207

Mailing address

PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112

Other identifiers 3

IdentifierTypeStateIssuer
200331170CMedicaidIN
151869OtherINMEDICARE PART A PTAN
191360OtherINMEDICARE PART B PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040827000220 IN Part B Supplier - Clinic/Group Practice 5799671236 Receives reassigned benefits from 128 practitioners
25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Station, IN; Merrillville, IN; Michigan City, IN; Portage, IN; Saint John, IN; Crown Point, IN; Schererville, IN; Valparaiso, IN…
O20071102000372 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Station, IN
O20110504000296 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 Practice locations: Lake Station, IN

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1356530505. Details of each certification follow.

Federally qualified health center certification: CCN 151846

Legal name
NORTHSHORE HEALTH CENTERS INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 2, 2008
Last certification
Jan 2, 2008
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 1997 in IN
Enrollment address
2490 Central Ave
Lake Station, IN 46405-2122

Federally qualified health center certification: CCN 151869

Legal name
NORTHSHORE HEALTH CENTERS INC
Doing business as
NORTHSHORE DR. FERNANDO RIVERA DENTAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 9, 2011
Last certification
May 9, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
3099 Central Ave
Lake Station, IN 46405-2207

Other NPIs with the same Medicare PAC ID 22

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

View all 22

Other NPIs on the same Medicare enrollment 24

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

View all 24

National Provider Directory

National Provider Directory

Locations

801 Broadway
Chesterton, IN 46304
Phone (219) 764-5311

10851 Broadway
Crown Point, IN 46307

600 N Wiggs St
Rm A104B
Griffith, IN 46319

3304 Parkside Ave
Lake Station, IN 46405
Phone (219) 962-8531

6091 Broadway
Merrillville, IN 46410

1515 US Highway 41
Schererville, IN 46375

Ownership & related parties

All disclosed owners & managing parties 26

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

NameRoleSinceShare
Steven C Disney Individual Corporate OfficerBoard Member Dec 16, 2014
David Hall Individual Corporate OfficerCeo Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Scott V Cherry Individual Corporate OfficerBoard Member Aug 11, 2011
Corporate OfficerChairman Aug 1, 2011
Sarah Himmelsbach Individual Corporate Director Dec 1, 2007
Deborah Soderquist Individual Corporate OfficerBoard Member Aug 11, 2011
Shirley Wadding Individual Corporate OfficerBoard Member Aug 11, 2011
David Parks Individual Corporate Director Dec 1, 2007
Davetta M Haywood Individual Corporate OfficerBoard Member Mar 1, 2013
Arthur Vasquez Individual Corporate OfficerBoard Member May 20, 2014
Anthony J Stofko Individual Corporate OfficerBoard Member Aug 1, 2011
Andre Joseph Individual Corporate Director Dec 1, 2007
Scott E Fritz Individual Corporate OfficerBoard Member Aug 1, 2011
Corporate OfficerVice Chairman Aug 1, 2011
William Poe Individual Corporate OfficerBoard Member Aug 1, 2011
John C Johnson Individual Corporate Director Dec 1, 2007
Terrell Taylor Individual Corporate OfficerBoard Member Mar 1, 2013
Ruth Needleman Individual Corporate OfficerBoard Member Nov 1, 2014
Olgie Havens Individual Corporate Director Dec 1, 2007
Connie Rudd Individual Corporate OfficerChairman of the Board of Directo Aug 11, 2011
Corporate OfficerBoard Member Aug 1, 2011
Tom Aldrich Individual Corporate OfficerBoard Member Aug 1, 2011
Roman Bronson Individual Corporate Officer Apr 28, 2020
Thomas Mosley Individual Corporate OfficerBoard Member Aug 1, 2011
Denneese Concepcion Individual Corporate Officer Jul 24, 2018
Thomas Cripliver Individual Corporate OfficerTreasurer Feb 25, 2020
Wilma Vazquez Individual Corporate OfficerBoard Member Aug 1, 2011
Jena Bellezza Individual Corporate OfficerBoard Member Aug 1, 2011
Matt Claussen Individual Corporate Officer Jun 1, 2023

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 60

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 60

NPI Registry JSON

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

{
    "created_epoch": "1193097600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1600732800000",
    "number": "1356530505",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1430",
            "city": "PORTAGE",
            "state": "IN",
            "postal_code": "463689230",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3099 CENTRAL AVE",
            "city": "LAKE STATION",
            "state": "IN",
            "postal_code": "464052207",
            "telephone_number": "219-763-8112",
            "fax_number": "219-962-1189"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-23",
        "last_updated": "2020-09-22",
        "certification_date": "2020-09-22",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-763-8112"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085B0100X",
            "taxonomy_group": "",
            "desc": "Radiology, Body Imaging",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200331170C",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A PTAN",
            "identifier": "151869",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B PTAN",
            "identifier": "191360",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Station, IN

Sources for this page

Verify at the official NPI Registry.