Tri-State Community Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Hancock, MD
NPI 1366491201 · NPPES record last updated Aug 3, 2010
Key facts
- NPI
- 1366491201
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- TRI-STATE COMMUNITY HEALTH CENTER, INC
- Practice address
- 130 W High St
Hancock, MD 21750-1143 - Phone
- (301) 678-5187
- Fax
- (301) 678-5797
- NPI assigned
- May 9, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Sheila J Deshong
- Title
- Executive Director
- Phone
- (301) 678-7256
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 6
Related certifications (CCN) 1
Practitioners 26
-
Jorge Roberto Andrade, MD, MBA
-
Raymond E Banfer, MD
-
Teresa Ann Dumpe, CRNP
-
Terry Ellen Harvey, CRNP
-
Chelsea Shoaf, CRNP
-
Janell Sioma, CRNP
-
Jeannette Lois Sweitzer, CRNP
-
Danielle Ayers Destfino, CRNP, FNP-C
-
Stephanie Nicole Jarvis, CRNP
-
Daniel Chris Aukerman, M.D.
-
Meghan L Clayton, CRNP
-
Stephanie Imler, CRNP
-
Sharmila Matippa, M.D.
-
Sarita Elaine Bowers, FNP-BC
-
Latasha A. Rabsatt, M.D.
-
Elizabeth Ann Voit, AGPCNP
-
James W Freeman, MD
-
Ryan M. Hikes, MD
-
Stephen Anthony Hoffman, D.O.
-
Danielle L Houck, PA
-
Kelli Renee Oswald, CRNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 21D0220865 | Tri-State Community Health Center | Provider-performed microscopy | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MD
Federally qualified health center certification: CCN 211809
- Legal name
- TRI-STATE COMMUNITY HEALTH CENTER INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Oct 1, 1991
- Last certification
- Oct 1, 1991
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- May 18, 1987 in MD
- Enrollment address
- 130W High St
Hancock, MD 21750-1143
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Carolyn Lee Clingerman |
Corporate Director |
Aug 6, 2018 | |
| Nancy Forlifer |
Corporate Director |
Jun 6, 2011 | |
| Operational/Managerial Control |
Jun 6, 2011 | ||
| Katherine Ann Salesky |
Corporate Director |
Jun 15, 2017 | |
| Sheila J Deshong |
Corporate Officer |
Apr 14, 1996 | |
| W-2 Managing Employee | Apr 15, 1996 | ||
| Tracy Lynn Salvagno |
Corporate Director | Dec 1, 2008 | |
| Elen L Ott |
Corporate Director |
Oct 1, 2016 | |
| Savin Ramani Pillai |
Corporate Director |
Apr 2, 2018 | |
| Cordelia J Carson |
Corporate Director |
Oct 7, 2013 | |
| Susan B Walter |
W-2 Managing Employee |
Jul 5, 2011 | 100% |
| Satricia a Woodal |
W-2 Managing Employee |
Jul 19, 2004 | |
| Terry Lee Beeman |
Corporate Director |
Oct 7, 2019 | |
| Richard Strait |
Corporate Director |
Apr 1, 2007 | |
| William Britton Garlitz |
Corporate Director |
Mar 4, 2019 | |
| Pamela Jean Sauter Mann |
Corporate Director |
Sep 9, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040219000462 | MD | Part B Supplier - Clinic/Group Practice | 9335057355 |
Receives reassigned benefits from 18 practitioners 2 other NPIs on this enrollment Practice locations: Cumberland, MD; Hancock, MD |
| O20100813000835 | MD | Part a Provider - Federally Qualified Health Center (FQHC) | 9335057355 | Practice locations: Hancock, MD |
National Provider Directory
- Tax ID family
- Tri-State Community Health Center Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
130 W High St
Hancock, MD 21750-1143
Mailing address
109 Rayloc Dr
Hancock, MD 21750-1518
Phone (301) 678-5187
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0035061000 | Medicaid | WV | |
| 1723320/01 | Medicaid | PA | |
| 482501200 | Medicaid | MD |
Other providers in Hancock, MD
- RPHC LLC
- Ralph Thomas Salvagno
- Elijah Christopher Souders
- Tender Loving Home Care
- The Home Center Pharmacy Inc
- War Memorial Hospital, Inc.
- War Memorial Hospital, Inc.
- War Memorial Hospital, Inc.
- Wheeler'S Optical Inc.
- Meredith Minto Williams
All providers in Hancock, MD · Federally Qualified Health Center (FQHC) in Maryland
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 3, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.