Southbridge Medical Advisory Council Inc

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC

Doing business as

Henrietta Johnson Medical Center

Practice address

600 N Lombard St
Wilmington, DE 19801-4429

Phone

(302) 761-4610

Fax

(302) 655-6606

NPI assigned

Jan 16, 2013

Last updated

Jan 16, 2013By the provider in NPPES

Organization subpart

Yes

Parent organization

SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INCAs reported in NPPES

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

Authorized official

Name

Ms. Rosa Rivera

Title

Chief Executive Officer

Phone

(302) 427-9696

Specialties & licenses 2

Addresses

Other names 1

• Henrietta Johnson Medical Center Doing business as

Medicare fee-for-service enrollment

Enrolled in DE

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639417280. Details of each certification follow.

• CCN 081814 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 081814

Legal name

HENRIETTA JOHNSON MEDICAL CENTER AT EASTSIDE

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Nov 6, 2013

Last certification

Nov 6, 2013

Ownership / control type

For profit – corporation

Facility address

600 North Lombard
Wilmington, DE 19801

Other NPIs on the same Medicare enrollment 3

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

• Southbridge Medical Advisory Council Inc

  dba Henrietta Johnson Medical Center

  • Federally Qualified Health Center (FQHC)
  • Wilmington, DE
  • NPI 1770699621

  O20040514000340

  Same enrollment
• Southbridge Medical Advisory Council, Inc.

  dba Henrietta Johnson Medical Center Claymont

  • Federally Qualified Health Center (FQHC)
  • Claymont, DE
  • NPI 1760874549

  O20040514000340

  Same enrollment
• Southbridge Medical Advisory Council, Inc.

  dba Henrietta Johnson Medical Center

  • Primary Care Clinic/Center
  • Wilmington, DE
  • NPI 1861925042

  O20040514000340

  Same enrollment

Part of

Southbridge Medical Adv

Locations

Practitioners 3

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.

• Charles G Case, M.D.

  • Family Medicine Physician
  • Wilmington, DE
  • NPI 1710901012
  NPD
• Mary Mbabe Nanjo-Allicock, DNP, FNP-C

  • Family Nurse Practitioner
  • New Castle, DE
  • NPI 1720621501
  NPD
• Yvonne Jean Owens, PMHNP-BC

  • Psychiatric/Mental Health Nurse Practitioner
  • Wilmington, DE
  • NPI 1891380374

  Single Specialty

  NPD

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

{
    "created_epoch": "1358294400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1358294400000",
    "number": "1639417280",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "601 NEW CASTLE AVE",
            "city": "WILMINGTON",
            "state": "DE",
            "postal_code": "198015821",
            "telephone_number": "302-655-6187",
            "fax_number": "302-655-6606"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 N LOMBARD ST",
            "city": "WILMINGTON",
            "state": "DE",
            "postal_code": "198014429",
            "telephone_number": "302-761-4610",
            "fax_number": "302-655-6606"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHBRIDGE MEDICAL ADVISORY COUNCIL INC",
        "enumeration_date": "2013-01-16",
        "last_updated": "2013-01-16",
        "status": "A",
        "authorized_official_last_name": "RIVERA",
        "authorized_official_first_name": "ROSA",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "302-427-9696",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Henrietta Johnson Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Salimatou Soumare
• Sound Communications Resource, Inc.
• Sound Mind Mental Health Services
• Catherine Sophia Sousa, DPT
• South Sound Inpatient Physicians, PLLC (Sound Physicians)
• Southbridge Medical Advisory Council Inc (Henrietta Johnson Medical Center)
• Southbridge Medical Advisory Council, Inc. (Henrietta Johnson Medical Center)
• Janice Southerland, CRNA
• Southern Delaware Sportscare and Rehabilitation, LLC (Pivot Physical Therapy)
• Amya Lashan Sowell

• Federally Qualified Health Center (FQHC) in Wilmington, DE
• Providers in Wilmington, DE by specialty
• Federally Qualified Health Center (FQHC) in Delaware

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.