NPIMap

Organization Active NPI

Upper Room AIDS Ministry, Inc. Adult Day Health Care Center.

  • Clinic/Center
  • New York, NY
National Provider Identifier
1417986340
Registry record updated Sep 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
UPPER ROOM AIDS MINISTRY, INC. ADULT DAY HEALTH CARE CENTER.
Practice address
169 W 133Rd St
New York, NY 10030-3301
Phone
(646) 762-4950
Fax
(646) 762-4953
NPI assigned
Jul 2, 2006
Last updated
Sep 5, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 5, 2019

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

Authorized official

Name
Tamisha McPherson, MBA
Title
Executive Director
Phone
(212) 803-2850

Specialties & licenses 12

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU Primary
Adult Day Care Clinic/Center 261QA0600X NU
Non-Surgical Family Planning Clinic/Center 261QF0050X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU
Podiatric Clinic/Center 261QP1100X NU
Psychiatric/Mental Health Nurse Practitioner 363LP0808X NU
Clinical Psychologist 103TC0700X NU
Social Worker 104100000X NU
Clinical Social Worker 1041C0700X NU
General Practice Dentistry 1223G0001X NU
Psychiatry Physician 2084P0800X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

169 W 133Rd St
New York, NY 10030-3301

Mailing address

306 Lenox Avenue
3Rd Floor
New York, NY 10027-4920
Phone (212) 803-2850

Other practice location 1

123-125 West 124th St
New York, NY 10027-4920
Phone (212) 531-1300

Other identifiers 3

IdentifierTypeStateIssuer
33/1040 AND 33/1041OtherNYMEDICARE PART A
01741726MedicaidNY
A100140369OtherNYMEDICARE PART B

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20100716000164 NY Part A Provider - Federally Qualified Health Center (FQHC) 4981770302 Practice locations: New York, NY
O20160405001922 NY Part B Supplier - Clinic/Group Practice 4981770302 Receives reassigned benefits from 51 practitioners
Practice locations: New York, NY
O20160516000223 NY Part A Provider - Federally Qualified Health Center (FQHC) 4981770302 Practice locations: New York, NY

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1417986340. Details of each certification follow.

Federally qualified health center certification: CCN 331041

Legal name
UPPER ROOM AIDS MINISTRY, INC. ADULT DAY HEALTH CARE CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 16, 2011
Last certification
Aug 16, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1995 in NY
Enrollment address
123-125 West 124TH Street
New York, NY 10027-4920

Federally qualified health center certification: CCN 571012

Legal name
UPPER ROOM AIDS MINISTRY, INC. ADULT DAY HEALTH CARE CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 4, 2016
Last certification
Oct 4, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 16, 2015 in NY
Enrollment address
169 W 133Rd St
New York, NY 10030-3301

National Provider Directory

National Provider Directory

Locations

169 W 133rd St
New York, NY 10030
Phone (646) 762-4950

179 E 116th St
New York, NY 10029
Phone (212) 620-0340

306 Malcolm X Blvd
Fl 3
New York, NY 10027
Phone (212) 803-2850

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
Tamisha McPherson Individual Corporate DirectorExecutive Director Jan 10, 2015
W-2 Managing EmployeeExecutive Director Jan 10, 2015
Raymond Verrey Individual Corporate OfficerCo-Chair/Treasurer Aug 27, 2015
Douglass J. Dukeman Individual Limited Partnership InterestBoard Chair Apr 27, 2010
Vincent Cocito Individual Limited Partnership InterestBoard Treasurer Apr 16, 2014
Rebekah Burford Individual Limited Partnership InterestMember Feb 23, 2015
Gilberto a. Hinds Individual Limited Partnership InterestVice-Chair Jul 9, 1991
Sandra L. Miller Individual Corporate DirectorVP of Finance Feb 2, 2015
W-2 Managing EmployeeVP of Finance Feb 2, 2015
Tamara Benejan-Green Individual Limited Partnership InterestMember Mar 5, 2014
Alan Zuckerman Individual Corporate DirectorCfo Mar 31, 2014
W-2 Managing EmployeeCfo Mar 31, 2014
Jonathan Bodrick Individual Limited Partnership InterestMember Jul 23, 2015

Practitioners & affiliated clinicians

Practitioners 80

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 80

NPI Registry JSON

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

{
    "created_epoch": "1151798400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1567641600000",
    "number": "1417986340",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "306 LENOX AVENUE",
            "address_2": "3RD FLOOR",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100274920",
            "telephone_number": "212-803-2850",
            "fax_number": "212-803-2899"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "169 W 133RD ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100303301",
            "telephone_number": "646-762-4950",
            "fax_number": "646-762-4953"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "123-125 West 124th St",
            "address_purpose": "LOCATION",
            "city": "New York",
            "state": "NY",
            "postal_code": "100274920",
            "country_code": "US",
            "telephone_number": "212-531-1300",
            "fax_number": "212-803-2899",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "UPPER ROOM AIDS MINISTRY, INC. ADULT DAY HEALTH CARE CENTER.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-02",
        "last_updated": "2019-09-05",
        "status": "A",
        "authorized_official_last_name": "MCPHERSON",
        "authorized_official_first_name": "TAMISHA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "212-803-2850",
        "authorized_official_credential": "MBA"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QA0600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Day Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0050X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Family Planning, Non-Surgical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QP1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Podiatric",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A",
            "identifier": "33/1040 AND 33/1041",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01741726",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B",
            "identifier": "A100140369",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in New York, NY

Sources for this page

Verify at the official NPI Registry.