NPIMap

Organization Active NPI

Beacon Christian Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Staten Island, NY
National Provider Identifier
1639246358
Registry record updated Apr 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BEACON CHRISTIAN COMMUNITY HEALTH CENTER, INC.
Practice address
2079 Forest Ave
Staten Island, NY 10303-1735
Phone
(718) 815-6560
Fax
(718) 815-6576
NPI assigned
Nov 29, 2006
Last updated
Apr 7, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 7, 2023

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

Authorized official

Name
David Hoi Kim, MDNPI 1013981331
Title
Ceo
Phone
(718) 815-6560

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Medicine Physician 207Q00000X 7004209R NY
Internal Medicine Physician 207R00000X 7004209R NY
Obstetrics & Gynecology Physician 207V00000X 7004209R NY
Pediatrics Physician 208000000X 7004209R NY
Podiatrist 213E00000X 7004209R NY

Addresses

Primary practice location

2079 Forest Ave
Staten Island, NY 10303-1735

Mailing address

2079 Forest Ave
Staten Island, NY 10303-1735
Phone (718) 815-6560

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070803000508 NY Part A Provider - Federally Qualified Health Center (FQHC) 7719078856 Practice locations: Staten Island, NY
O20110504000157 NY Part B Supplier - Clinic/Group Practice 7719078856 Receives reassigned benefits from 28 practitioners
1 other NPI on this enrollment
Practice locations: Staten Island, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639246358. Details of each certification follow.

Federally qualified health center certification: CCN 331969

Legal name
BEACON CHRISTIAN COMMUNITY HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 10, 2007
Last certification
Sep 10, 2007
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Apr 7, 2006 in NY
Enrollment address
2079 Forest Ave
Staten Island, NY 10303-1865

Other NPIs with the same Medicare PAC ID 1

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
Beacon Christian Community Health Center Inc5 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

2031 Forest Ave
Staten Island, NY 10303
Phone (718) 815-6560

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
Robert W Kamphuis Individual Corporate Director Aug 8, 2006
John a Saldanha Individual Corporate DirectorBoard Member Apr 1, 2013
Ledia Kaci Individual Corporate Director Aug 8, 2006
Lora Gaston Individual Corporate DirectorBoard Member Sep 1, 2014 100%
Willy Yuin Individual Corporate Director Aug 8, 2006
David H Kim Individual Corporate DirectorCeo Aug 8, 2006 100%
Debra McCaw Individual Corporate Director Aug 8, 2006
Janet J Kim Individual W-2 Managing EmployeeChief Medical Officer Dec 1, 2006 100%
Seon J Lee Individual Corporate DirectorBoard Member May 1, 2014 100%
Ramon Rosa Individual Corporate DirectorBoard Member Sep 1, 2013 100%
Marco Silva Individual Corporate OfficerBoard Chair Jun 1, 2010 100%

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 34

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 34

NPI Registry JSON

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

{
    "created_epoch": "1164758400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1680825600000",
    "number": "1639246358",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2079 FOREST AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103031735",
            "telephone_number": "718-815-6560",
            "fax_number": "718-815-6570"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2079 FOREST AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103031735",
            "telephone_number": "718-815-6560",
            "fax_number": "718-815-6576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON CHRISTIAN COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-29",
        "last_updated": "2023-04-07",
        "certification_date": "2023-04-07",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "HOI",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "718-815-6560",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NY",
            "license": "7004209R",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NY",
            "license": "7004209R",
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NY",
            "license": "7004209R",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NY",
            "license": "7004209R",
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "NY",
            "license": "7004209R",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Staten Island, NY

Sources for this page

Verify at the official NPI Registry.