NPIMap

Organization Active NPI

North Country Healthcare, Inc.

Doing business as Flagstaff Pediatric Care

  • Pediatrics Physician
  • Flagstaff, AZ
National Provider Identifier
1669911764
Registry record updated Jun 30, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
NORTH COUNTRY HEALTHCARE, INC.
Doing business as
Flagstaff Pediatric Care
Practice address
1501 S Yale St
Ste 252
Flagstaff, AZ 86001-7304
Phone
(928) 774-1811
Fax
(928) 774-2001
NPI assigned
Feb 22, 2017
Last updated
Jun 30, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTH COUNTRY HEALTHCARE, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 30, 2021

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

Authorized official

Name
Anne Newland, MDNPI 1336178912
Title
Ceo
Phone
(928) 522-9400

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X
Pediatrics Physician 208000000X Primary

Addresses

Primary practice location

1501 S Yale St
Ste 252
Flagstaff, AZ 86001-7304

Mailing address

PO Box 3630
Flagstaff, AZ 86003-3630
Phone (928) 522-9400

Other names 1

  • Flagstaff Pediatric Care Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170803002838 AZ Part A Provider - Federally Qualified Health Center (FQHC) 8820981053 Practice locations: Flagstaff, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669911764. Details of each certification follow.

Federally qualified health center certification: CCN 031953

Legal name
NORTH COUNTRY HEALTHCARE INC
Doing business as
FLAGSTAFF PEDIATRIC CARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 1, 2017
Last certification
Aug 1, 2017
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Jul 17, 1991 in AZ
Enrollment address
1501 S Yale St
Ste 252
Flagstaff, AZ 86001-7336

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Part of
North Country Healthcare Inc

Locations

1501 S Yale St
Flagstaff, AZ 86001
Phone (928) 527-4325

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
Walter Phelps Individual Corporate DirectorBoard Member Jan 1, 2021
Stephen Nuno Perez Individual Corporate DirectorBoard Member Sep 28, 2021
Paul Ferris Individual Corporate DirectorBoard Member Jan 1, 2012
Mike Oxtoby Individual Corporate DirectorSecretary Sep 28, 2021
Sandra L Ernst Individual Corporate DirectorTreasurer Sep 28, 2021
Teri Diane Sherman Individual Corporate DirectorBoard Member Jan 1, 2021
Patsy Crofford Individual Corporate DirectorPresident Jun 1, 2017
Joshua Butler Individual Corporate DirectorBoard Member Mar 22, 2022
Anne M Newland Individual Corporate OfficerCeo Nov 2, 2015
W-2 Managing EmployeeCeo Nov 1, 2015
Travis L Jones Individual Corporate DirectorPresident Elect Apr 1, 2019
Mary Jo Gregory Individual Corporate DirectorHealth Systems Expert Mar 27, 2018
Timothy Dodt Individual Corporate DirectorFoundation Representative May 1, 2018

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Northcountry Healthcare IncBullhead City, AZ, CCN 031888 Federally qualified health center Operational/Managerial Control Nov 30, 2010

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 16

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 16

NPI Registry JSON

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

{
    "created_epoch": "1487721600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1625011200000",
    "number": "1669911764",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3630",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "860033630",
            "telephone_number": "928-522-9400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1501 S YALE ST",
            "address_2": "STE 252",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "860017304",
            "telephone_number": "928-774-1811",
            "fax_number": "928-774-2001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH COUNTRY HEALTHCARE, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTH COUNTRY HEALTHCARE, INC.",
        "enumeration_date": "2017-02-22",
        "last_updated": "2021-06-30",
        "certification_date": "2021-06-30",
        "status": "A",
        "authorized_official_last_name": "NEWLAND",
        "authorized_official_first_name": "ANNE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "928-522-9400",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Flagstaff Pediatric Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Flagstaff Pediatric Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Flagstaff, AZ

Sources for this page

Verify at the official NPI Registry.