NPIMap

Organization Active NPI

Portland Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Portland, ME
National Provider Identifier
1609120856
Registry record updated Jun 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PORTLAND COMMUNITY HEALTH CENTER
Practice address
180 Park Ave
Portland, ME 04102-2957
Phone
(207) 874-2141
NPI assigned
Nov 8, 2012
Last updated
Jun 9, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2023

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

Authorized official

Name
Ms. Ann Tucker
Title
Cfo
Phone
(207) 874-2141

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Obstetrics & Gynecology Physician 207V00000X NU

Addresses

Primary practice location

180 Park Ave
Portland, ME 04102-2957

Mailing address

180 Park Ave
Portland, ME 04102-2957
Phone (207) 874-2141

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130109000136 ME Part A Provider - Federally Qualified Health Center (FQHC) 5395998017 Practice locations: Portland, ME
O20130206000120 ME Part B Supplier - Clinic/Group Practice 5395998017 Receives reassigned benefits from 73 practitioners
17 other NPIs on this enrollment
Practice locations: Westbrook, ME; South Portland, ME; Portland, ME

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609120856. Details of each certification follow.

Federally qualified health center certification: CCN 201901

Legal name
PORTLAND COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 11, 2013
Last certification
Jan 11, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 30, 2013 in ME
Enrollment address
180 Park Avenue
Portland, ME 41022957

Other NPIs with the same Medicare PAC ID 17

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

View all 17

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Axel Nimbona Individual Corporate DirectorBoard Member Apr 16, 2024
Ann Tucker Individual Corporate DirectorCeo Mar 1, 2017
W-2 Managing EmployeeCeo Mar 1, 2016
Paul Santomenna Individual Corporate DirectorPresident Dec 26, 2017
Belviga Mpolo Individual Corporate DirectorBoard Member Jan 27, 2026
Christine Caulfield Individual Corporate DirectorSecretary Jan 24, 2023
Connor O'Neill Individual Corporate DirectorBoard Member Apr 16, 2024
Christopher Dana Individual Corporate DirectorBoard Member Jul 27, 2021
Isaac Macdougal Individual Corporate DirectorBoard Member Apr 16, 2024
Marie a Guay Individual Corporate DirectorBoard Member Apr 16, 2024
Richard M White Individual Corporate DirectorBoard Member Jan 24, 2017
Doreen Karigirwa Individual Corporate DirectorBoard Member Jan 27, 2026
John Dearmond Individual Corporate DirectorBoard Member Jan 27, 2026

Practitioners & affiliated clinicians

Practitioners 78

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 78

NPI Registry JSON

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

{
    "created_epoch": "1352332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686268800000",
    "number": "1609120856",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "180 PARK AVE",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041022957",
            "telephone_number": "207-874-2141"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "180 PARK AVE",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041022957",
            "telephone_number": "207-874-2141"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORTLAND COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-08",
        "last_updated": "2023-06-09",
        "certification_date": "2023-06-09",
        "status": "A",
        "authorized_official_last_name": "TUCKER",
        "authorized_official_first_name": "ANN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "207-874-2141",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, ME

Sources for this page

Verify at the official NPI Registry.