NPIMap

Organization Active NPI

Neighborhood Healthsource

Doing business as North Metro Clinic

  • Federally Qualified Health Center (FQHC)
  • Coon Rapids, MN
National Provider Identifier
1659323459
Registry record updated Jun 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NEIGHBORHOOD HEALTHSOURCE
Doing business as
North Metro Clinic
Practice address
10081 Dogwood St. NW
Suite 100
Coon Rapids, MN 55448
Phone
(612) 588-9411
Fax
(763) 783-7944
NPI assigned
May 17, 2006
Last updated
Jun 29, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
NEIGHBORHOOD HEALTHSOURCEAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 29, 2023

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

Authorized official

Name
Mr. Steven Jay Knutson
Title
Executive Director
Phone
(612) 287-2428

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208D00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

10081 Dogwood St. NW
Suite 100
Coon Rapids, MN 55448

Mailing address

2301 Central Ave NE
Minneapolis, MN 55418
Phone (612) 588-9411

Other names 1

  • North Metro Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040729000231 MN Part B Supplier - Clinic/Group Practice 9133199953 Receives reassigned benefits from 16 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Coon Rapids, MN; Minneapolis, MN
O20211029000970 MN Part A Provider - Federally Qualified Health Center (FQHC) 9133199953 Practice locations: Coon Rapids, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1659323459. Details of each certification follow.

Federally qualified health center certification: CCN 241896

Legal name
NEIGHBORHOOD HEALTHSOURCE
Doing business as
NORTH METRO CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 1, 2021
Last certification
Nov 1, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 2019 in MN
Enrollment address
10081 Dogwood St NW
Ste 100
Coon Rapids, MN 55448-5282

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 3

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D1041820Neighborhood Health Source North Metro Clinic10081 Dogwood St NW #100, Coon Rapids, MN 55448RegistrationAug 31, 2027

National Provider Directory

National Provider Directory
Tax ID family
Fremont Community HLTH SVCS2 organizations share this tax ID, including this one
Part of
Fremont Community HLTH SVCS

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

10081 Dogwood St NW
Ste 100
Coon Rapids, MN 55448
Phone (763) 783-3722

9574 Foley Blvd NW
Coon Rapids, MN 55433
Phone (763) 783-3722

342 13th Ave NE
Minneapolis, MN 55413
Phone (612) 362-4111

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
Curt J Engels Individual Corporate DirectorFinance Director Jul 24, 2023
W-2 Managing EmployeeFinance Director Jul 24, 2023
Philip Denny Individual Corporate DirectorBoard Member Jun 1, 2024
Mayte Cambara Individual Corporate DirectorBoard Member Jun 1, 2024
Steven J Knutson Individual Corporate DirectorExecutive Director Aug 1, 2019 100%
Operational/Managerial ControlExecutive Director Aug 1, 2019 100%
Gloria J Peterson Individual Corporate DirectorBoard Member Jun 1, 2024
Carroll Barnes Individual Corporate DirectorBoard Member Jun 1, 2024
Nathan Ebnet Individual Corporate DirectorBoard Member Jun 1, 2024
Mara E Garcia Individual W-2 Managing EmployeePatient Accounting Manager Aug 1, 2019
Doug Christensen Individual Corporate DirectorBoard Member Jun 1, 2024
Victor Wong Individual Corporate DirectorBoard Member Jun 1, 2024
Roberta Ridyn Kelley Individual Corporate DirectorBoard Member Jun 1, 2024

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 28

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 28

NPI Registry JSON

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

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687996800000",
    "number": "1659323459",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2301 CENTRAL AVE NE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "55418",
            "telephone_number": "612-588-9411",
            "fax_number": "612-781-3837"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10081 DOGWOOD ST. NW",
            "address_2": "SUITE 100",
            "city": "COON RAPIDS",
            "state": "MN",
            "postal_code": "55448",
            "telephone_number": "612-588-9411",
            "fax_number": "763-783-7944"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NEIGHBORHOOD HEALTHSOURCE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NEIGHBORHOOD HEALTHSOURCE",
        "enumeration_date": "2006-05-17",
        "last_updated": "2023-06-29",
        "certification_date": "2023-06-29",
        "status": "A",
        "authorized_official_last_name": "KNUTSON",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_middle_name": "JAY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "612-287-2428",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "General Practice",
            "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": "North Metro Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Coon Rapids, MN

Sources for this page

Verify at the official NPI Registry.