NPIMap

Organization Active NPI

Wayne Memorial Community Health Centers

Doing business as Northern Wayne Health Center

  • Federally Qualified Health Center (FQHC)
  • Lake Como, PA
National Provider Identifier
1669654596
Registry record updated Apr 7, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Doing business as
Northern Wayne Health Center
Practice address
412 Como Road
Lake Como, PA 18437-0000
Phone
(570) 798-2828
Fax
(570) 798-2636
NPI assigned
Dec 3, 2007
Last updated
Apr 7, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 7, 2015

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

Authorized official

Name
Mr. Frederick Jackson
Title
Executive Director
Phone
(570) 253-8450

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Medicine Physician 207Q00000X OS011217 PA
Internal Medicine Physician 207R00000X MD428487 PA

Addresses

Primary practice location

412 Como Road
Lake Como, PA 18437-0000

Mailing address

601 Park St
Honesdale, PA 18431-1445
Phone (570) 253-8226

Other identifiers 1

IdentifierTypeStateIssuer
1007765560005MedicaidPA

Other names 1

  • NORTHERN WAYNE HEALTH CENTER Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080417000660 PA Part A Provider - Federally Qualified Health Center (FQHC) 3072598937 Practice locations: Lake Como, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669654596. Details of each certification follow.

Federally qualified health center certification: CCN 391982

Legal name
WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 18, 2008
Last certification
Apr 18, 2008
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1990 in PA
Enrollment address
412 Como Rd
Lake Como, PA 18437-1020

Other NPIs with the same Medicare PAC ID 16

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

View all 16

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
39D0921485Northern Wayne Family Health Center412 Como Road, Lake Como, PA 18437Certificate of waiverOct 28, 2026

National Provider Directory

National Provider Directory
Tax ID family
Hamlin Family Health Center27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

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

View all 26

Locations

412 Como Rd
Lake Como, PA 18437
Phone (570) 775-7100

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Carrie Demers Individual Corporate Director May 1, 2012
John Brennan Individual Corporate Director Sep 1, 2024
Pamela Sader Treanor Individual Corporate Director Nov 1, 2024
Michelle Louise Wonders Individual Corporate DirectorVice Chairman May 1, 2018
Steven Guccini Individual Corporate DirectorTreasurer Feb 10, 2022
Gregory Capitolo Individual Corporate DirectorChairman Feb 1, 2019
Cinda Tietjen Individual Corporate DirectorSecretary Dec 1, 2023
Robert Fortuner Individual Corporate Director Feb 1, 2015
W-2 Managing Employee Feb 1, 2015
Timothy Knapp Individual Corporate Director Jan 1, 2024
Charles Curtin Individual Corporate Director Jun 1, 2025
Judit Vegh Individual Corporate Director Jan 1, 2024
Teresa Lacey Individual Corporate DirectorCeo Feb 1, 2023
W-2 Managing EmployeeCeo Feb 1, 2023

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 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1196640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1428364800000",
    "number": "1669654596",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "601 PARK ST",
            "city": "HONESDALE",
            "state": "PA",
            "postal_code": "184311445",
            "telephone_number": "570-253-8226"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "412 COMO ROAD",
            "city": "LAKE COMO",
            "state": "PA",
            "postal_code": "184370000",
            "telephone_number": "570-798-2828",
            "fax_number": "570-798-2636"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAYNE MEMORIAL COMMUNITY HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-03",
        "last_updated": "2015-04-07",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "FREDERICK",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "570-253-8450",
        "authorized_official_name_prefix": "Mr."
    },
    "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": "PA",
            "license": "OS011217",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "PA",
            "license": "MD428487",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1007765560005",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NORTHERN WAYNE HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Como, PA

Sources for this page

Verify at the official NPI Registry.