NPIMap

Organization Active NPI

Covenant House, Inc

  • Federally Qualified Health Center (FQHC)
  • Philadelphia, PA
National Provider Identifier
1528392008
Registry record updated Dec 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
032220 Issued in PA
Legal business name
COVENANT HOUSE, INC
Doing business as
Covenant House Medical Center
Practice address
8125 Stenton Ave
Philadelphia, PA 19150-3530
Phone
(215) 248-7560
Fax
(215) 248-7564
NPI assigned
Sep 30, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 20, 2023

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

Authorized official

Name
Dr. Susan Denise Stukes
Title
Chief Executive Officer
Phone
(215) 844-1020

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 032220 PA Primary

Addresses

Primary practice location

8125 Stenton Ave
Philadelphia, PA 19150-3530

Mailing address

8125 Stenton Ave
Philadelphia, PA 19150-3530
Phone (215) 248-7560

Other names 1

  • Covenant House Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111107000566 PA Part A Provider - Federally Qualified Health Center (FQHC) 3476591686 1 other NPI on this enrollment
Practice locations: Philadelphia, PA

Federally qualified health center certification: CCN 391018

Legal name
COVENANT HOUSE INC
Doing business as
COVENANT HOUSE MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 15, 2011
Last certification
Nov 15, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 10, 1966 in PA
Enrollment address
8125 Stenton Ave
Philadelphia, PA 19150-3530

Other NPIs with the same Medicare PAC ID 3

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
Tax ID family
Covenant House HLTH SVC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Francine Fulton Individual Corporate Director Dec 10, 2021
Gwendolyn Starks Individual Corporate DirectorBoard Member Sep 29, 2010
Sam Chukwueze Individual Corporate OfficerCfo Dec 5, 2012
W-2 Managing EmployeeChief Financial Officer Sep 1, 2016
Bertha R Finney Individual Corporate DirectorBoard Member Sep 26, 2001
Kathleen Card Individual Corporate DirectorBoard Member Feb 8, 2017
Susan D Stukes Individual Corporate OfficerCeo Jul 1, 2023
W-2 Managing Employee Jul 1, 2023
Phyllis L Niblack Individual Corporate DirectorBoard Member Sep 26, 2001
Richard a Kolb Individual Corporate DirectorBoard Member Mar 29, 1995
Carolyn Richardson Individual Corporate Director Jan 12, 2009
W-2 Managing EmployeeDirector Reimbursement Sevices Jan 12, 2009
Cory Clark Individual Corporate DirectorBoard Member Apr 25, 2018
Charlene Shuler Individual W-2 Managing EmployeeDirector Revenue Management Apr 6, 2022

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1254268800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703030400000",
    "number": "1528392008",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8125 STENTON AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191503530",
            "telephone_number": "215-248-7560",
            "fax_number": "215-248-7564"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8125 STENTON AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191503530",
            "telephone_number": "215-248-7560",
            "fax_number": "215-248-7564"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT HOUSE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-09-30",
        "last_updated": "2023-12-20",
        "certification_date": "2023-12-20",
        "status": "A",
        "authorized_official_last_name": "STUKES",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "DENISE",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "215-844-1020",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "PA",
            "license": "032220",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Covenant House Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, PA

Sources for this page

Verify at the official NPI Registry.