NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Portage, IN
National Provider Identifier
1407061336
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
6050 Sterling Creek Rd
Portage, IN 46368-7752
Phone
(219) 763-8112
Fax
(219) 764-5380
NPI assigned
May 14, 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 15

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Nurse Practitioner 363LF0000X NU
Women's Health Nurse Practitioner 363LW0102X NU
Addiction (Substance Use Disorder) Counselor 101YA0400X NU
Clinical Social Worker 1041C0700X NU
Chiropractor 111N00000X NU
Dentist 122300000X NU
Optometrist 152W00000X NU
Family Medicine Physician 207Q00000X NU
Endocrinology, Diabetes & Metabolism Physician 207RE0101X NU
Obstetrics & Gynecology Physician 207V00000X NU
Pediatrics Physician 208000000X NU
Psychiatry Physician 2084P0800X NU
Diagnostic Radiology Physician 2085R0202X NU
Diagnostic Ultrasound Physician 2085U0001X NU

Addresses

Primary practice location

6050 Sterling Creek Rd
Portage, IN 46368-7752

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
191360OtherINMEDICARE PART B PTAN
200331170BMedicaidIN
151834OtherINMERICARE PART A PTAN

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040603001258 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 1 other NPI on this enrollment
Practice locations: Portage, IN
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…

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407061336. Details of each certification follow.

Federally qualified health center certification: CCN 151834

Legal name
NORTHSHORE HEALTH CENTERS INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 13, 2004
Last certification
Jun 13, 2004
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 1997 in IN
Enrollment address
6050 Sterling Creek Rd
Portage, IN 46368-7752
Related CCNs
151829

Facilities connected through Provider of Services related, parent or unit certification numbers.

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

3564 Scottsdale St
Portage, IN 46368

Ownership & related parties

All disclosed owners & managing parties 13

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 Officer Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Roman Bronson Individual Corporate OfficerTreasurer Apr 28, 2020
Thomas Mosley Individual Corporate OfficerVice Chairman Dec 18, 2018
Scott V Cherry Individual Corporate OfficerBoard Member Aug 1, 2011
Denneese Concepcion Individual Corporate OfficerBoard Member Jun 26, 2018
Scott E Fritz Individual Corporate OfficerBoard Member Dec 1, 2013
Thomas Cripliver Individual Corporate OfficerBoard Member Feb 25, 2020
Wilma Vazquez Individual Corporate OfficerBoard Member Sep 16, 2016
Lauren Trumbo Individual Corporate OfficerChairman Dec 18, 2018
Connie Rudd Individual Corporate OfficerBoard Member Aug 1, 2011
Jena Bellezza Individual Corporate OfficerBoard Member Sep 16, 2016
Tom Aldrich Individual Corporate OfficerBoard Member Dec 18, 2018

Practitioners & affiliated clinicians

Practitioners 48

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 48

NPI Registry JSON

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

{
    "created_epoch": "1179100800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1600732800000",
    "number": "1407061336",
    "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": "6050 STERLING CREEK RD",
            "city": "PORTAGE",
            "state": "IN",
            "postal_code": "463687752",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-14",
        "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": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LW0102X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Women's Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2085U0001X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Ultrasound",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B PTAN",
            "identifier": "191360",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200331170B",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MERICARE PART A PTAN",
            "identifier": "151834",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portage, IN

Sources for this page

Verify at the official NPI Registry.