NPIMap

Organization Active NPI

Affinia Healthcare

Doing business as Affinia Healthcare Ferguson

  • Federally Qualified Health Center (FQHC)
  • Saint Louis, MO
National Provider Identifier
1740067719
Registry record updated Nov 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
AFFINIA HEALTHCARE
Doing business as
Affinia Healthcare Ferguson
Practice address
3396 Pershall Rd
Saint Louis, MO 63135-1407
Phone
(314) 814-8700
Fax
(314) 814-8542
NPI assigned
Sep 12, 2023
Last updated
Nov 16, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 16, 2023

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

Authorized official

Name
Leslie O'Connor
Title
VP/Cfo
Phone
(314) 814-8571

Specialties & licenses 1

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

Addresses

Primary practice location

3396 Pershall Rd
Saint Louis, MO 63135-1407

Mailing address

PO Box 551
Saint Louis, MO 63188-0551
Phone (314) 814-8531

Other names 1

  • Affinia Healthcare Ferguson Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20231213001714 MO Part A Provider - Federally Qualified Health Center (FQHC) 1052386919 Practice locations: Saint Louis, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740067719. Details of each certification follow.

Federally qualified health center certification: CCN 261963

Legal name
AFFINIA HEALTHCARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 28, 2023
Last certification
Dec 28, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 16, 2023 in MO
Enrollment address
3396 Pershall Rd
Saint Louis, MO 63135-1407

Other NPIs with the same Medicare PAC ID 7

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

National Provider Directory

National Provider Directory
Tax ID family
Affinia Healthcare21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

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

View all 20

Locations

2028 S 12th St
Saint Louis, MO 63104
Phone (314) 539-9800

2220 Lemp Ave
Saint Louis, MO 63104
Phone (314) 814-8531

2600 Hadley St
Saint Louis, MO 63106
Phone (314) 241-2200

2900 Washington Ave
Ste 100
Saint Louis, MO 63103

3390 Pershall Rd
Saint Louis, MO 63135

3396 Pershall Rd
Saint Louis, MO 63135
Phone (314) 377-4329

3930 S Broadway
Saint Louis, MO 63118
Phone (314) 577-6232

4308N Grand Blvd
Saint Louis, MO 63107
Phone (314) 340-3222

Ownership & related parties

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Araceli Escalante-Gudino Individual Corporate Officer Jan 1, 2022
Riisa Rawlins Individual Corporate Officer Jan 1, 2022
Mary Dambrose Individual Corporate Officer Jan 1, 2022
Kevin Hachegechog Individual Corporate Officer Jan 1, 2022
Robert Jacobson Individual Corporate Officer Jan 1, 2022
Debra Johns Individual Corporate Officer Jan 1, 2022
Kimball McMullin Individual Corporate OfficerChair Jan 1, 2022
Georgia Harris Individual Corporate Officer Jan 1, 2022
Lavonne McClain Individual Corporate Officer Jan 1, 2022
David Walters Individual Corporate OfficerVice Chair Jan 1, 2022
Jean M Frazee Individual Corporate OfficerTreasurer Jan 1, 2022
Tondaleria Curry Individual Corporate Officer Jan 1, 2022
Leslie O'Connor Individual Corporate DirectorCfo/VP Jan 1, 2023 100%
W-2 Managing EmployeeCfo/VP Jan 1, 2023 100%
Mitchell L Baris Individual Corporate Officer Jan 1, 2022
Carrollton Bank Organization, Clayton, MO Created for acquisition, Financial institution 5% Or Greater Direct Ownership Interest Jan 1, 2023 5%
Gwendolyn Hall Individual Corporate Officer Jan 1, 2022
Paula R Davis Individual Corporate Officer Jan 1, 2022
Kendra C Holmes Individual Corporate DirectorCeo/President Jan 1, 2023 100%
W-2 Managing EmployeeCeo/President Jan 1, 2023 100%
Gilbert Peoples Individual Corporate OfficerSecretary Jan 1, 2022

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 66

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 66

NPI Registry JSON

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

{
    "created_epoch": "1694476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700092800000",
    "number": "1740067719",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 551",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631880551",
            "telephone_number": "314-814-8531",
            "fax_number": "314-814-8542"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3396 PERSHALL RD",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631351407",
            "telephone_number": "314-814-8700",
            "fax_number": "314-814-8542"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AFFINIA HEALTHCARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-09-12",
        "last_updated": "2023-11-16",
        "certification_date": "2023-11-16",
        "status": "A",
        "authorized_official_last_name": "O'CONNOR",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "314-814-8571"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Affinia Healthcare Ferguson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Louis, MO

Sources for this page

Verify at the official NPI Registry.