NPIMap

Organization Active NPI

Edward M. Kennedy Community Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Worcester, MA
National Provider Identifier
1609842152
Registry record updated Jan 31, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
4039 Issued in MA
Legal business name
EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC
Practice address
19 Tacoma St
Worcester, MA 01605-3516
Phone
(508) 852-1805
Fax
(508) 854-3248
NPI assigned
Feb 24, 2006
Last updated
Jan 31, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 31, 2023

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

Authorized official

Name
Mr. Stephen J. Kerrigan
Title
President & Ceo
Phone
(508) 854-2122

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 4039 MA Primary

Addresses

Primary practice location

19 Tacoma St
Worcester, MA 01605-3516

Mailing address

115 NE Cutoff Ste 200
Worcester, MA 01606-1224
Phone (508) 854-2122

Other identifiers 5

IdentifierTypeStateIssuer
110022061BMedicaidMA
1301071MedicaidMA
1320858MedicaidMA
Y10100OtherMABCBS OF MA
0443891MedicaidMA

Other names 1

  • Great Brook Valley Health Center, Inc Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041004000840 MA Part B Supplier - Clinic/Group Practice 3476512740 Receives reassigned benefits from 146 practitioners
Practice locations: Worcester, MA; Framingham, MA; Milford, MA
O20110413000539 MA Part A Provider - Federally Qualified Health Center (FQHC) 3476512740 Practice locations: Worcester, MA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609842152. Details of each certification follow.

Federally qualified health center certification: CCN 221818

Legal name
EDWARD M KENNEDY COMMUNITY HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Nov 6, 1972 in MA
Enrollment address
19 Tacoma St
Worcester, MA 16053516

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Part of
Kennebec Anesthesia Assoc

Locations

115 NE Cutoff
Bldg 2
Worcester, MA 01606
Phone (508) 854-2122

585 Lincoln St
Fl 2
Worcester, MA 01605

605 Lincoln St
Worcester, MA 01605
Phone (508) 856-0104

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Susan Seppa Individual Corporate DirectorBoard Member Jul 1, 2019
Jennifer Ehrlich Individual Corporate DirectorBoard Member Jul 1, 2019
Valerie Zolezzi-Wyndham Individual Corporate DirectorBoard Member Mar 28, 2011
David J Small Individual Corporate DirectorVice President of Human Reources Jul 1, 2019 100%
W-2 Managing EmployeeVice President of Human Resource Jul 1, 2019 100%
Operational/Managerial ControlVice President of Human Resource Jul 1, 2019 100%
George W Manigault Individual Corporate DirectorBoard Member Jul 1, 2019
Stephen J Kerrigan Individual Corporate OfficerPresident and Ceo Jul 2, 2019 100%
Corporate DirectorPresident and Ceo Jul 1, 2019 100%
W-2 Managing EmployeePresident and Ceo Jul 2, 2019 100%
Operational/Managerial ControlPresident and Ceo Jul 2, 2019 100%
Aivi Nguyen Individual Corporate DirectorBoard Member Jul 1, 2019
Jonna Gifford Individual Corporate DirectorBoard Member Jul 1, 2019
Gail F Hormats Individual Corporate DirectorBoard Member Mar 28, 2011
Christopher J Wilbur Individual Corporate DirectorCfo(Interim) and Director of Acc Mar 3, 2020 100%
W-2 Managing EmployeeCfo(Interim) and Director of Acc Mar 3, 2020 100%
Operational/Managerial ControlCfo(Interim) and Director of Acc Mar 3, 2020 100%
Stuart Pynn Individual Corporate DirectorBoard Member May 1, 2012
Ajayi Harris Individual Corporate DirectorBoard Member Jul 1, 2019
Raul Porras Individual Corporate DirectorBoard Member Jul 1, 2019

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 169

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 169

NPI Registry JSON

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

{
    "created_epoch": "1140739200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675123200000",
    "number": "1609842152",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 NE CUTOFF STE 200",
            "city": "WORCESTER",
            "state": "MA",
            "postal_code": "016061224",
            "telephone_number": "508-854-2122",
            "fax_number": "508-853-8593"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19 TACOMA ST",
            "city": "WORCESTER",
            "state": "MA",
            "postal_code": "016053516",
            "telephone_number": "508-852-1805",
            "fax_number": "508-854-3248"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, INC",
        "enumeration_date": "2006-02-24",
        "last_updated": "2023-01-31",
        "certification_date": "2023-01-31",
        "status": "A",
        "authorized_official_last_name": "KERRIGAN",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "508-854-2122",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MA",
            "license": "4039",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110022061B",
            "state": "MA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1301071",
            "state": "MA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1320858",
            "state": "MA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF MA",
            "identifier": "Y10100",
            "state": "MA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0443891",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great Brook Valley Health Center, Inc",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Great Brook Valley Health Center, Inc",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Worcester, MA

Sources for this page

Verify at the official NPI Registry.