NPIMap

Organization Active NPI

Masonic Villages of the Grand Lodge of Pennsylvania

Doing business as Masonic Village at Sewickley

  • Skilled Nursing Facility
  • Sewickley, PA
National Provider Identifier
1558615484
Registry record updated May 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
221402 Issued in PA
Legal business name
MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Doing business as
Masonic Village at Sewickley
Practice address
1000 Masonic Dr
Sewickley, PA 15143-2328
Phone
(412) 741-1400
NPI assigned
Oct 30, 2012
Last updated
May 1, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2023

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

Authorized official

Name
Ms. Pamela Formica
Title
Chief Financial Officer
Phone
(717) 367-1121

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 221402 PA Primary

Addresses

Primary practice location

1000 Masonic Dr
Sewickley, PA 15143-2328

Mailing address

1000 Masonic Dr
Sewickley, PA 15143-2328
Phone (412) 741-1400

Other identifiers 1

IdentifierTypeStateIssuer
0579OtherPASECURITY BLUE

Other names 1

  • Masonic Village at Sewickley Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130123000035 PA Part A Provider - Skilled Nursing Facility 9537136916 Practice locations: Sewickley, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558615484. Details of each certification follow.

Skilled nursing facility certification: CCN 395638

Legal name
MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Doing business as
MASSONIC VILLAGE AT SEWICKLEY
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Mar 9, 1984
Last certification
Aug 1, 2024
Beds
128
Ownership / control type
Nonprofit Corporation
Multi-facility organization
Masonic Villages of the Grand Lodge of Pennsylvania
Organization structure
CorporationNon-profit
Incorporated
May 7, 1871 in PA
Enrollment address
1000 Masonic Drive
Masonic Village at Sewickley
Sewickley, PA 15143-2359
Nursing home name
MASONIC VILLAGE AT SEWICKLEY

Other NPIs with the same Medicare PAC ID 3

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

Care Compare: Nursing home

Medicare Care Compare
Listed as
Masonic Village at SewickleyCCN 395638 · All quality measures
Overall star rating
3 of 5
Health inspections
2 of 5
Staffing
5 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Mar 9, 1984
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
12871.0 residents per day on average

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D0907737Masonic Village at Sewickley1000 Masonic Drive, Sewickley, PA 15143Certificate of waiverOct 18, 2027

National Provider Directory

National Provider Directory
Tax ID family
Masonic Home of PA5 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.

Locations

581 Freemason Dr
Elizabethtown, PA 17022
Phone (717) 367-1121

1000 Masonic Dr
Sewickley, PA 15143
Phone (412) 259-5060

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Robert D Brink Individual Corporate DirectorBoard Member Dec 30, 2019
Lynn B Baker Individual Corporate DirectorBoard Member Jan 1, 2024
Mark Haines Individual Corporate DirectorBoard Member Jan 1, 2013
Frederic Collins Wheeler Individual Corporate DirectorBoard Member Sep 21, 2018
Brenda Spence Individual Corporate DirectorDirector of Resident Accounts Jun 1, 2018
W-2 Managing Employee Jun 1, 2018
Robert J Cepielik Individual Corporate DirectorBoard Member Jan 1, 2024
William Kingsbury Individual Corporate OfficerCeo Dec 1, 2019
Paul Jeffrey Roup Individual Corporate DirectorBoard Member Dec 28, 2021
Larry Arthur Derr Individual Corporate DirectorBoard Member Jan 1, 2018
Thomas Bahney Individual Corporate DirectorBoard Member Jun 3, 2024
Robert Carl Snyder Individual Corporate DirectorBoard Member Jan 1, 2018
Pamela Formica Individual Corporate OfficerCfo Jun 1, 2018
Kim Jeffreys Individual Corporate DirectorBoard Member Jan 1, 2017
Adam C Heese Individual Corporate DirectorBoard Member Mar 1, 2017
Chris T Odonnell Individual W-2 Managing EmployeeMD; May 6, 2024
Glenn D Miller Individual Corporate DirectorBoard Member Jan 1, 2023
Tracy Leja Individual W-2 Managing EmployeeAd; May 6, 2024

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
Masonic Villages at Lafayette HillLafayette Hill, PA, CCN 395818 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 Jan 1, 2013
Jan 1, 2013
Masonic Villages at ElizabethtownElizabethtown, PA, CCN 395560 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 Jan 1, 2013
Jan 1, 2013
Masonic Village at WarminsterWarminster, PA, CCN 396054 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 Jan 1, 2013
Jan 1, 2013
Masonic Village Home HealthElizabethtown, PA, CCN 398272 Home health agency 5% Or Greater Direct Ownership Interest (100%) Oct 17, 2016
Masonic Village HospiceElizabethtown, PA, CCN 391721 Hospice 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2017

Owned or controlled facilities with NPI records 5

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

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 8

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1351555200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682899200000",
    "number": "1558615484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1000 MASONIC DR",
            "city": "SEWICKLEY",
            "state": "PA",
            "postal_code": "151432328",
            "telephone_number": "412-741-1400",
            "fax_number": "412-741-0747"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 MASONIC DR",
            "city": "SEWICKLEY",
            "state": "PA",
            "postal_code": "151432328",
            "telephone_number": "412-741-1400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-30",
        "last_updated": "2023-05-01",
        "certification_date": "2023-05-01",
        "status": "A",
        "authorized_official_last_name": "FORMICA",
        "authorized_official_first_name": "PAMELA",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "717-367-1121",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "PA",
            "license": "221402",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SECURITY BLUE",
            "identifier": "0579",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Masonic Village at Sewickley",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Masonic Village at Sewickley",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sewickley, PA

Sources for this page

Verify at the official NPI Registry.