NPIMap

Organization Active NPI

Raphael Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Indianapolis, IN
National Provider Identifier
1487764759
Registry record updated Jul 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
RAPHAEL HEALTH CENTER, INC
Practice address
401 E 34TH St
Indianapolis, IN 46205
Phone
(317) 926-1507
Fax
(317) 926-1508
NPI assigned
Aug 30, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2018

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

Authorized official

Name
Mr. Hoagland C. Elliott
Title
Executive Director
Phone
(317) 926-1507

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 01051367A IN
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

401 E 34TH St
Indianapolis, IN 46205

Mailing address

401 E 34TH St
Indianapolis, IN 46205-3754
Phone (317) 926-1507

Other identifiers 1

IdentifierTypeStateIssuer
200077460AMedicaidIN

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20021205000023 IN Part A Provider - Federally Qualified Health Center (FQHC) 4486562659 Practice locations: Indianapolis, IN
O20041227000466 IN Part B Supplier - Clinic/Group Practice 4486562659 Receives reassigned benefits from 39 practitioners
1 other NPI on this enrollment
Practice locations: Indianapolis, IN

Federally qualified health center certification: CCN 151823

Legal name
RAPHAEL HEALTH CENTER INC
Doing business as
MAPLETON FALL CREEK CHRISTIAN HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 5, 2003
Last certification
Mar 5, 2003
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Oct 18, 1994 in IN
Enrollment address
401 East 34TH Street
Indianapolis, IN 46205-3754

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Paul Utterback Individual Corporate OfficerCfo Dec 16, 2019 50%
Sherry Gray Individual Corporate OfficerCeo Oct 1, 2017 100%
Heather Cornett Individual W-2 Managing EmployeeHR Director Dec 1, 2017 25%

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Raphael Health Center IncIndianapolis, IN, CCN 151197 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 18, 1994

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 40

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 40

NPI Registry JSON

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

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1532563200000",
    "number": "1487764759",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 E 34TH ST",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462053754",
            "telephone_number": "317-926-1507",
            "fax_number": "317-926-1508"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 E 34TH ST",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "46205",
            "telephone_number": "317-926-1507",
            "fax_number": "317-926-1508"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RAPHAEL HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-30",
        "last_updated": "2018-07-26",
        "status": "A",
        "authorized_official_last_name": "ELLIOTT",
        "authorized_official_first_name": "HOAGLAND",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "317-926-1507",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "01051367A",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200077460A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Indianapolis, IN

Sources for this page

Verify at the official NPI Registry.