NPIMap

Organization Active NPI

Marin Community Clinic

  • Federally Qualified Health Center (FQHC)
  • San Rafael, CA
National Provider Identifier
1508514902
Registry record updated Oct 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Oct 3, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 3, 2022

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

Authorized official

Name
Andrea M Skelly, CPC
Title
Billing Manager
Phone
(415) 798-3135

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508514902. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Feb 7, 1974 in CA
Enrollment address
1618 2ND St
San Rafael, CA 94901-2707

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory

Locations

400 Professional Center Dr
Ste 424
Novato, CA 94947
Phone (415) 448-1555

6090 Redwood Blvd
Ste G
Novato, CA 94945
Phone (415) 798-3106

1618 2nd St
San Rafael, CA 94901

3260 Kerner Blvd
#A
San Rafael, CA 94901

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Andrea Skelly Individual W-2 Managing EmployeeCredentialing Manager May 31, 2020
Freshte Kashani Individual Corporate Director Jul 1, 2022
Martin Weil Individual Corporate Director Jul 1, 2022
Alyssa H Morris Individual Corporate Director Jul 1, 2022
David Klinetobe Individual Corporate OfficerCfo Jul 1, 2018 5%
Corporate DirectorChief Financial Officer Jul 1, 2018 5%
Operational/Managerial ControlCfo Jul 1, 2020 25%
Nelson Branco Individual Corporate Director Jul 1, 2022 5%
Mark M Jacobs Individual Corporate Officer Jul 1, 2020 5%
Corporate Director Jul 1, 2020 5%
Daniel a Segedin Individual Corporate DirectorChair Jul 1, 2022
Mitesh Popat Individual Corporate OfficerCeo Jul 1, 2020 5%

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 27

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 27

NPI Registry JSON

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

{
    "created_epoch": "1647302400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1664755200000",
    "number": "1508514902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5008",
            "city": "NOVATO",
            "state": "CA",
            "postal_code": "949485008",
            "telephone_number": "415-448-1500",
            "fax_number": "415-798-3104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1618 2ND ST",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949012707",
            "telephone_number": "415-448-1500",
            "fax_number": "415-798-3104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIN COMMUNITY CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-03-15",
        "last_updated": "2022-10-03",
        "certification_date": "2022-10-03",
        "status": "A",
        "authorized_official_last_name": "SKELLY",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "415-798-3135",
        "authorized_official_credential": "CPC"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Rafael, CA

Sources for this page

Verify at the official NPI Registry.