Northshore Health Centers, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Crown Point, IN
NPI 1629649751 · NPPES record last updated Jul 9, 2021
Key facts
- NPI
- 1629649751
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- NORTHSHORE HEALTH CENTERS, INC.
- Practice address
- 10851 Broadway
Clinic Suite, North of Main Entrance
Crown Point, IN 46307-7303 - Phone
- (219) 763-8112
- Fax
- (219) 764-5380
- NPI assigned
- Jul 9, 2021
- Organization subpart
- No
Authorized official
- Name
- David Hall
- Title
- Ceo
- Phone
- (219) 763-8112
Other NPIs on the same Medicare enrollment 24
Other NPIs with the same Medicare PAC ID 22
Corporate family (same tax ID) 27
Practitioners 33
-
Megan E App, M.D.
-
Andi Arnautovic, MD
-
Daniel Raleigh Dewar, D.C.
-
Michael D Foster, M.D.
-
Sharon Greiner, MSN, CNM ,FNP-BC
-
Soyong Lee, M.D.
-
Ronald Samuel Lemon II, O.D.
-
Lee Jennifer Murphy, MD FACOG
-
Bala Rangaswami, MD
-
Aditya Shah, M.D.
-
Cheryl D Short, MD, FACOG
-
Dennis W Smith, D.P.M.
-
Crystal A Strickland, MD FACOG
-
Matthew Jason Tipton, M.D.
-
Simona Maria Toader, O.D.
-
Ijaz Ahmad, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IN
Federally qualified health center certification: CCN 151121
- Legal name
- NORTHSHORE HEALTH CENTERS INC
- Doing business as
- NORTHSHORE CROWN POINT HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 14, 2021
- Last certification
- Sep 14, 2021
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 1, 1997 in IN
- Enrollment address
- 310 W 112TH Ave
Crown Point, IN 46307-7844
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Steven C Disney |
Corporate Officer |
Dec 18, 2018 | |
| David Hall |
Corporate Officer |
Jan 23, 2020 | |
| W-2 Managing Employee |
Jan 23, 2020 | ||
| Roman Bronson |
Corporate Officer |
Apr 28, 2020 | |
| Thomas Mosley |
Corporate Officer |
Dec 18, 2018 | |
| Scott V Cherry |
Corporate Officer |
Aug 1, 2011 | |
| Denneese Concepcion |
Corporate Officer |
Jun 26, 2018 | |
| Scott E Fritz |
Corporate Officer |
Dec 1, 2013 | |
| Thomas Cripliver |
Corporate Officer |
Feb 25, 2020 | |
| Wilma Vazquez |
Corporate Officer |
Sep 16, 2016 | |
| Lauren Trumbo |
Corporate Officer |
Dec 18, 2018 | |
| Connie Rudd |
Corporate Officer |
Aug 1, 2011 | |
| Jena Bellezza |
Corporate Officer |
Sep 16, 2016 | |
| Tom Aldrich |
Corporate Officer |
Dec 18, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040827000220 | IN | Part B Supplier - Clinic/Group Practice | 5799671236 |
Receives reassigned benefits from 128 practitioners 25 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Lake Station, IN; Merrillville, IN; Michigan City, IN; Portage, IN; Saint John, IN; Crown Point, IN; Schererville, IN; Valparaiso, IN… |
| O20210914000276 | IN | Part a Provider - Federally Qualified Health Center (FQHC) | 5799671236 | Practice locations: Crown Point, IN |
National Provider Directory
- Tax ID family
- Northshore Health CTRS Inc
Locations
10851 Broadway
Ste N
Crown Point, IN 46307
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Multi-Specialty Clinic/Center | 261QM1300X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
10851 Broadway
Clinic Suite, North of Main Entrance
Crown Point, IN 46307-7303
Mailing address
PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112
Other names
- NorthShore Crown Point Health Center
Other providers in Crown Point, IN
- Sherlonda Nixon
- Jacqueline Poca Noerenberg
- Northland Hearing Centers, Inc.
- Northshore Health Centers, Inc.
- Northshore Health Centers, Inc.
- Northwest Indiana Eye Associates, PC
- Northwest Indiana Orthopedics LLC
- Northwest Indiana Radiation Oncology, PC
- Northwest Indiana Special Education Cooperative
- Andrea Elizabeth Nosich
All providers in Crown Point, IN · Federally Qualified Health Center (FQHC) in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 9, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.