Marin Community Clinic
Organization Active NPI Federally Qualified Health Center (FQHC) · San Rafael, CA
NPI 1508514902 · NPPES record last updated Oct 3, 2022
Key facts
- NPI
- 1508514902
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- MARIN COMMUNITY CLINIC
- Practice address
- 1618 2ND St
San Rafael, CA 94901-2707 - Phone
- (415) 448-1500
- Fax
- (415) 798-3104
- NPI assigned
- Mar 15, 2022
- Organization subpart
- No
Authorized official
- Name
- Andrea M Skelly, CPC
- Title
- Billing Manager
- Phone
- (415) 798-3135
Owners & managing parties with NPI records 2
-
Nelson Branco, MD
-
Mitesh G Popat, MD
Other NPIs on the same Medicare enrollment 5
Other NPIs with the same Medicare PAC ID 6
Practitioners 46
-
Alaric K Akashi, MD
-
Tess Barbach, APRN
-
Rebekah Harding, M.D.
-
Darell Hawley, DO
-
Marie A Kristensen, NURSE PRACTICIONER
-
Jeanette Krolikowski, D.O.
-
Claudia A Levine, MD
-
Viky Morales, FNP
-
John R. Spurzem, MD
-
Claudia Awamleh, FNP
-
Patrick Mulvey Bennett, M.D.
-
Robert H. Byers, M.D.
-
Alissa Anne Detz, MD
-
Douglas Alan Ehrenberg, D.P.M.
-
Ericka Ledesma, RN, NP
-
Kathryn Maclaughlin, NPF
-
Lynette Teresa McLamb, M.D.
-
Christian Reyna, DO
-
Elizabeth Shaw, M.D.
-
Katherine Werbaneth, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
Federally qualified health center certification: CCN A01145
- Legal name
- MARIN COMMUNITY CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 24, 2023
- Last certification
- Jan 24, 2023
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 7, 1974 in CA
- Enrollment address
- 1618 2ND St
San Rafael, CA 94901-2707
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| Andrea Skelly |
W-2 Managing Employee |
May 31, 2020 | |
| Freshte Kashani |
Corporate Director | Jul 1, 2022 | |
| Martin Weil |
Corporate Director | Jul 1, 2022 | |
| Alyssa H Morris |
Corporate Director | Jul 1, 2022 | |
| David Klinetobe |
Corporate Officer |
Jul 1, 2018 | 5% |
| Corporate Director |
Jul 1, 2018 | 5% | |
| Operational/Managerial Control |
Jul 1, 2020 | 25% | |
| Nelson Branco |
Corporate Director | Jul 1, 2022 | 5% |
| Mark M Jacobs |
Corporate Officer | Jul 1, 2020 | 5% |
| Corporate Director | Jul 1, 2020 | 5% | |
| Daniel a Segedin |
Corporate Director |
Jul 1, 2022 | |
| Mitesh Popat |
Corporate Officer |
Jul 1, 2020 | 5% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20230201000211 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 0840108031 | Practice locations: San Rafael, CA |
| O20250611003402 | CA | Part B Supplier - Clinic/Group Practice | 0840108031 |
Receives reassigned benefits from 15 practitioners 5 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: San Rafael, CA; Novato, CA; Greenbrae, CA |
National Provider Directory
Locations
1260 S Eliseo Dr
Ste 201
Greenbrae, CA 94904
400 Professional Center Dr
Ste 424
Novato, CA 94947
Phone (415) 448-1531
6090 Redwood Blvd
Novato, CA 94945
Phone (415) 798-3132
411 4th St
Ste A
San Rafael, CA 94901
Phone (415) 271-8386
1618 2nd St
San Rafael, CA 94901
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Obstetrics & Gynecology Physician |
207V00000X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
1618 2ND St
San Rafael, CA 94901-2707
Mailing address
PO Box 5008
Novato, CA 94948-5008
Phone (415) 448-1500
Other providers in San Rafael, CA
- Marin City Health and Wellness Center
- Marin Community Clinic
- Marin Community Clinic
- Marin Community Clinic
- Marin Community Clinic
- Marin Community Clinic
- Marin Community Clinic
- Marin Community Clinic
- Marin County Community Mental Health Services
- Marin County Health and Human Services
All providers in San Rafael, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 3, 2022. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.