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Progressive Community Health Centers, Inc.

Organization Active NPI Federally Qualified Health Center (FQHC) · Milwaukee, WI

NPI 1720153653 · NPPES record last updated Jan 25, 2017

Key facts

NPI
1720153653
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
PROGRESSIVE COMMUNITY HEALTH CENTERS, INC.
Practice address
3522 W Lisbon Ave
Milwaukee, WI 53208-1953
Phone
(414) 935-8000
Fax
(414) 344-3396
NPI assigned
Nov 24, 2006
Organization subpart
No

Authorized official

Name
Candice Cole
Title
Cfo
Phone
(414) 935-8000

Other NPIs on the same Medicare enrollment 3

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

Other NPIs with the same Medicare PAC ID 2

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

Facilities connected through Provider of Services related, parent or unit certification numbers.

Practitioners 61

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 61

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in WI

Federally qualified health center certification: CCN 521821

Legal name
PROGRESSIVE COMMUNITY HEALTH CENTERS INC
Doing business as
LISBON AVENUE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 27, 2001
Last certification
Feb 27, 2001
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
May 14, 2011 in WI
Enrollment address
3522 W Lisbon Ave
Milwaukee, WI 53208-1953

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Janice Harrell
Individual 		Corporate Director Aug 18, 2015
Barbara Zak
Individual 		W-2 Managing Employee
Coo		 Mar 6, 2018
Albert Cooper
Individual 		Corporate Director Oct 25, 2016
John a Grandberry
Individual 		Corporate Director
Chair		 Aug 28, 2018
Candice L Cole
Individual 		W-2 Managing Employee
Cfo		 Aug 9, 2014

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20031118000358 WI Part B Supplier - Clinic/Group Practice 2466366059 Receives reassigned benefits from 59 practitioners
3 other NPIs on this enrollment
Practice locations: Milwaukee, WI
O20101012001304 WI Part a Provider - Federally Qualified Health Center (FQHC) 2466366059 Practice locations: Milwaukee, WI

National Provider Directory

Locations

1452 N 7th St
Milwaukee, WI 53205
Phone (414) 287-0919

1218 W Kilbourn Ave
Ste 124
Milwaukee, WI 53233
Phone (414) 291-2626

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker
Group: 193200000X MULTI-SPECIALTY GROUP		 1041C0700X
Dentist
Group: 193200000X MULTI-SPECIALTY GROUP		 122300000X
Dental Hygienist
Group: 193200000X MULTI-SPECIALTY GROUP		 124Q00000X
Family Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207Q00000X
Internal Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207R00000X
Obstetrics & Gynecology Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207V00000X
Pediatrics Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 208000000X
Psychiatry Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 2084P0800X
Federally Qualified Health Center (FQHC) 261QF0400X Yes
Family Nurse Practitioner
Group: 193200000X MULTI-SPECIALTY GROUP		 363LF0000X

Addresses

Primary practice location

3522 W Lisbon Ave
Milwaukee, WI 53208-1953

Mailing address

PO Box 080257
Milwaukee, WI 53208-8004
Phone (414) 935-8000

Other identifiers

IdentifierTypeStateIssuer
32957400MedicaidWI

Other names

  • Lisbon Avenue Health Center Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 25, 2017.

{
    "created_epoch": "1164326400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485302400000",
    "number": "1720153653",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 080257",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532088004",
            "telephone_number": "414-935-8000",
            "fax_number": "414-755-0058"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3522 W LISBON AVE",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532081953",
            "telephone_number": "414-935-8000",
            "fax_number": "414-344-3396"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROGRESSIVE COMMUNITY HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-24",
        "last_updated": "2017-01-25",
        "status": "A",
        "authorized_official_last_name": "COLE",
        "authorized_official_first_name": "CANDICE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "414-935-8000"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "32957400",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lisbon Avenue Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Milwaukee, WI

All providers in Milwaukee, WI · Federally Qualified Health Center (FQHC) in Wisconsin

Sources for this page

Verify at the official NPI Registry.