NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

Doing business as Merrillville Health Center

  • Federally Qualified Health Center (FQHC)
  • Merrillville, IN
National Provider Identifier
1477810315
Registry record updated Nov 12, 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.
Doing business as
Merrillville Health Center
Practice address
6091 Broadway
Merrillville, IN 46410-2619
Phone
(219) 763-8112
Fax
(219) 884-2547
NPI assigned
Apr 17, 2012
Last updated
Nov 12, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 12, 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 10

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Nurse Practitioner 363LF0000X NU
Clinical Social Worker 1041C0700X NU
General Practice Dentistry 1223G0001X NU
Dental Hygienist 124Q00000X NU
Family Medicine Physician 207Q00000X NU
Obstetrics & Gynecology Physician 207V00000X NU
Pediatrics Physician 208000000X NU
Psychiatry Physician 2084P0800X NU
Child & Adolescent Psychiatry Physician 2084P0804X NU

Addresses

Primary practice location

6091 Broadway
Merrillville, IN 46410-2619

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
191360OtherINMEDICARE PART B PTAN
151880OtherINMEDICARE PART A PTAN
200331170GMedicaidIN

Other names 1

  • Merrillville Health Center Doing business as

Medicare participation

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

Enrollment records 2

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…
O20120601000538 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 Practice locations: Merrillville, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477810315. Details of each certification follow.

Federally qualified health center certification: CCN 151880

Legal name
NORTHSHORE HEALTH CENTERS INC
Doing business as
MERRILLVILLE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 9, 2012
Last certification
Jul 9, 2012
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
6091 Broadway
Merrillville, IN 46410-2619

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
Tax ID family
Northshore Health Centers Inc28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Ownership & related parties

All disclosed owners & managing parties 12

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
Roman Bronson Individual Corporate OfficerBoard Member Apr 28, 2020
Thomas Mosley Individual Corporate OfficerBoard Member Oct 20, 2015
Scott V Cherry Individual Corporate OfficerBoard Member Aug 1, 2011
Denneese Concepcion Individual Corporate OfficerBoard Member Jul 24, 2018
Thomas Cripliver Individual Corporate OfficerBoard Member Feb 25, 2020
Wilma Vazquez Individual Corporate OfficerBoard Member Apr 26, 2016
Connie Rudd Individual Corporate OfficerBoard Member Jan 1, 2001
Jena Bellezza Individual Corporate OfficerBoard Member May 24, 2016
Matt Claussen Individual Corporate OfficerBoard Member Jun 1, 2023
Tom Aldrich Individual Corporate OfficerBoard Member Aug 1, 2011

Practitioners & affiliated clinicians

Practitioners 7

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.

NPI Registry JSON

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

{
    "created_epoch": "1334620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605139200000",
    "number": "1477810315",
    "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": "6091 BROADWAY",
            "city": "MERRILLVILLE",
            "state": "IN",
            "postal_code": "464102619",
            "telephone_number": "219-763-8112",
            "fax_number": "219-884-2547"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-17",
        "last_updated": "2020-11-12",
        "certification_date": "2020-11-12",
        "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": "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": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "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": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B PTAN",
            "identifier": "191360",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A PTAN",
            "identifier": "151880",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200331170G",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Merrillville Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Merrillville Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Merrillville, IN

Sources for this page

Verify at the official NPI Registry.