NPIMap

Organization Active NPI

Howard Brown Health Center

Doing business as Broadway Youth Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1699109546
Registry record updated Jun 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
HOWARD BROWN HEALTH CENTER
Doing business as
Broadway Youth Center
Practice address
4009 N Broadway St
Chicago, IL 60613-2110
Phone
(773) 935-3151
NPI assigned
Aug 28, 2013
Last updated
Jun 27, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 27, 2022

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

Authorized official

Name
Mr. Burgundy Johnson
Title
Credentialing
Phone
(872) 629-3491

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

4009 N Broadway St
Chicago, IL 60613-2110

Mailing address

4025 N Sheridan Rd
Chicago, IL 60613-2010
Phone (773) 935-3151

Other names 1

  • Broadway Youth Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130919000409 IL Part A Provider - Federally Qualified Health Center (FQHC) 1052203155 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699109546. Details of each certification follow.

Federally qualified health center certification: CCN 781807

Legal name
HOWARD BROWN HEALTH CENTER
Doing business as
HOWARD BROWN HEALTH BROADWAY YOUTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 13, 2013
Last certification
Nov 13, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1979 in IL
Enrollment address
1023 W Irving Park Rd
Chicago, IL 60613-2913

Other NPIs with the same Medicare PAC ID 8

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

National Provider Directory

National Provider Directory
Tax ID family
Howard Brown Health Cen7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

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
Magda Houlberg Individual Corporate OfficerHealth Center Operations & Coo Oct 1, 2012
Corporate DirectorHealth Center Operations & Coo Oct 1, 2012
W-2 Managing EmployeeHealth Center Operations & Coo Oct 1, 2012
Dwight M Alden Individual Corporate OfficerChair Board Member Jul 1, 2011
Vanessa Ann Griggley-Owens Individual Corporate OfficerBoard Member Oct 18, 2013
David E Munar Individual Corporate OfficerCeo Apr 1, 2014
W-2 Managing Employee Apr 2, 2014
Operational/Managerial ControlCeo Apr 1, 2014
Matthew J Nielson Individual Corporate DirectorBoard Member Jun 1, 2007
Randall B Mims Individual Corporate OfficerVice Chair and Secretary of Boar Sep 1, 2014
Jeffrey P Todd Individual Corporate DirectorVice Chair Board Member Mar 28, 2011
Ryan D Siemers Individual Corporate DirectorBoard Member Sep 1, 2012
Francis L Buttitta Individual Corporate OfficerBoard Member Jun 29, 2010
Robert Fortney Individual Corporate OfficerBoard Member Aug 26, 2013
Mark L Hawkins Individual Corporate OfficerVice Chair Treasurer Board Membe Sep 1, 2012

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1377648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1656288000000",
    "number": "1699109546",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4025 N SHERIDAN RD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606132010",
            "telephone_number": "773-935-3151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4009 N BROADWAY ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606132110",
            "telephone_number": "773-935-3151"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOWARD BROWN HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-08-28",
        "last_updated": "2022-06-27",
        "certification_date": "2022-06-27",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "BURGUNDY",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "872-629-3491",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broadway Youth Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Broadway Youth Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.