NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Chesterton, IN
National Provider Identifier
1740887298
Registry record updated Nov 5, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHSHORE HEALTH CENTERS, INC.
Practice address
651 W Morgan Ave RM F168
Chesterton, IN 46304-2243
Phone
(219) 763-8112
Fax
(219) 764-5380
NPI assigned
Oct 7, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 5, 2020

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

Authorized official

Name
David Hall
Title
Ceo
Phone
(219) 763-8112

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

651 W Morgan Ave RM F168
Chesterton, IN 46304-2243

Mailing address

PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112

Other names 1

  • NorthShore Chesterton Middle School Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040827000220 IN Part B Supplier - Clinic/Group Practice 5799671236 Receives reassigned benefits from 128 practitioners
25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Station, IN; Merrillville, IN; Michigan City, IN; Portage, IN; Saint John, IN; Crown Point, IN; Schererville, IN; Valparaiso, IN…
O20201221000791 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 Practice locations: Chesterton, IN

Federally qualified health center certification: CCN 151091

Legal name
NORTHSHORE HEALTH CENTERS INC
Doing business as
NORTHSHORE CHESTERTON MIDDLE SCHOOL HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 10, 2020
Last certification
Dec 10, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
651 W Morgan Ave
RM F168
Chesterton, IN 46304-2243

Other NPIs with the same Medicare PAC ID 22

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

View all 22

Other NPIs on the same Medicare enrollment 24

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

View all 24

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
15D2241185Northshore Health Centers - Chesterton Teen Clinic651 W Morgan Avenue, Chesterton, IN 46304Certificate of waiverOct 25, 2027

National Provider Directory

National Provider Directory
Tax ID family
Northshore Health CTRS Inc28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

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

View all 27

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
Steven C Disney Individual Corporate OfficerBoard Member Dec 18, 2018
David Hall Individual Corporate OfficerCeo Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Roman Bronson Individual Corporate OfficerBoard Member Apr 28, 2020
Thomas Mosley Individual Corporate OfficerSecretary/Treasurer Dec 18, 2018
Scott V Cherry Individual Corporate OfficerBoard Member Aug 1, 2011
Denneese Concepcion Individual Corporate OfficerBoard Member Jun 26, 2018
Isis McCann Individual Corporate Officer Jun 1, 2023
Thomas Cripliver Individual Corporate OfficerBoard Member Feb 25, 2020
Wilma Vazquez Individual Corporate OfficerBoard Member Dec 1, 2013
Connie Rudd Individual Corporate OfficerBoard Member Sep 16, 2016
Jena Bellezza Individual Corporate OfficerBoard Member Sep 16, 2016
Tom Aldrich Individual Corporate OfficerChairman Dec 18, 2018

Practitioners & affiliated clinicians

Practitioners 32

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

View all 32

NPI Registry JSON

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

{
    "created_epoch": "1602028800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1604534400000",
    "number": "1740887298",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1430",
            "city": "PORTAGE",
            "state": "IN",
            "postal_code": "463689230",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "651 W MORGAN AVE RM F168",
            "city": "CHESTERTON",
            "state": "IN",
            "postal_code": "463042243",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-07",
        "last_updated": "2020-11-05",
        "certification_date": "2020-11-05",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-763-8112"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NorthShore Chesterton Middle School Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chesterton, IN

Sources for this page

Verify at the official NPI Registry.