NPIMap

Organization Active NPI

Beacon Christian Community Health Center Inc

  • Federally Qualified Health Center (FQHC)
  • Staten Island, NY
National Provider Identifier
1750700902
Registry record updated Jun 27, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BEACON CHRISTIAN COMMUNITY HEALTH CENTER INC
Practice address
2031 Forest Ave
Staten Island, NY 10303-1733
Phone
(718) 815-6560
Fax
(718) 815-6576
NPI assigned
Apr 15, 2014
Last updated
Jun 27, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 27, 2016

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

Authorized official

Name
Dr. David H Kim, MD, MBANPI 1013981331
Title
Ceo
Phone
(718) 815-6560

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

2031 Forest Ave
Staten Island, NY 10303-1733

Mailing address

2079 Forest Ave
Staten Island, NY 10303-1865
Phone (718) 815-6560

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110504000157 NY Part B Supplier - Clinic/Group Practice 7719078856 Receives reassigned benefits from 28 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Staten Island, NY
O20170105000162 NY Part A Provider - Federally Qualified Health Center (FQHC) 7719078856 Practice locations: Staten Island, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1750700902. Details of each certification follow.

Federally qualified health center certification: CCN 571057

Legal name
BEACON CHRISTIAN COMMUNITY HEALTH CENTER INC
Organization structure
CorporationNon-profit
Incorporated
Apr 20, 2013 in NY
Enrollment address
2031 Forest Ave
Ste 2
Staten Island, NY 10303-1796

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Beacon Christian Community Health Center Inc5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Locations

2031 Forest Ave
Ste 2
Staten Island, NY 10303
Phone (718) 815-6560

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
John a Saldanha Individual Corporate Director Apr 1, 2014
Lora Gaston Individual Corporate Director May 1, 2014
Annie Cooper Individual Corporate DirectorSecretary Jun 1, 2013
David H Kim Individual Corporate DirectorCeo Apr 1, 2007 100%
Victor O Anjorin Individual Corporate DirectorVice-Chair Mar 1, 2013
Maria E Soto Individual Corporate Director Apr 1, 2014
Janet J Kim Individual W-2 Managing EmployeeChief Medical Officer Apr 1, 2007
Seon J Lee Individual Corporate Director Jun 1, 2013
Ramon Rosa Individual Corporate Director Oct 1, 2012
Marco Silva Individual Corporate DirectorBoard Chair Mar 1, 2010

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 27

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 27

NPI Registry JSON

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

{
    "created_epoch": "1397520000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1466985600000",
    "number": "1750700902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2079 FOREST AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103031865",
            "telephone_number": "718-815-6560",
            "fax_number": "718-815-6576"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2031 FOREST AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103031733",
            "telephone_number": "718-815-6560",
            "fax_number": "718-815-6576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEACON CHRISTIAN COMMUNITY HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-15",
        "last_updated": "2016-06-27",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "718-815-6560",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD, MBA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Staten Island, NY

Sources for this page

Verify at the official NPI Registry.