NPIMap

Organization Active NPI

Marin Community Clinic

  • Community Health Clinic/Center
  • Greenbrae, CA
National Provider Identifier
1780292912
Registry record updated Jul 14, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
MARIN COMMUNITY CLINIC
Practice address
1260 S Eliseo Dr Ste 201
Greenbrae, CA 94904-2009
Phone
(415) 448-1500
Fax
(415) 798-3104
NPI assigned
Jul 14, 2020
Last updated
Jul 14, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 14, 2020

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

Authorized official

Name
Andrea M Skelly, CPC
Title
Revenue Credentialing Manager
Phone
(415) 798-3135

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X Primary

Addresses

Primary practice location

1260 S Eliseo Dr Ste 201
Greenbrae, CA 94904-2009

Mailing address

PO Box 5008
Novato, CA 94948-5008
Phone (415) 798-3135

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20211013000157 CA Part A Provider - Federally Qualified Health Center (FQHC) 0840108031 Practice locations: Greenbrae, CA
O20250611003402 CA Part B Supplier - Clinic/Group Practice 0840108031 Receives reassigned benefits from 15 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: San Rafael, CA; Novato, CA; Greenbrae, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780292912. Details of each certification follow.

Federally qualified health center certification: CCN A01030

Legal name
MARIN COMMUNITY CLINIC
Doing business as
MARIN COMMUNITY CLINICS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 18, 2021
Last certification
Oct 18, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 7, 1974 in CA
Enrollment address
1260 S Eliseo Dr
Ste 201
Greenbrae, CA 94904-2009

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 5

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

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
05D2196314Marin Community Clinic - Greenbrae1260 South Eliseo Dr Ste 201, Greenbrae, CA 94904Provider-performed microscopyOct 14, 2026

National Provider Directory

National Provider Directory
Tax ID family
Marin Community Clinic16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

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

View all 15

Locations

1260 S Eliseo Dr
Ste 201
Greenbrae, CA 94904

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
Andrea Skelly Individual W-2 Managing EmployeeBilling Manager Apr 26, 2016
Freshte Kashani Individual Corporate Director Jan 1, 2020
Martin Weil Individual Corporate Director Jan 1, 2020
Alyssa H Morris Individual Corporate Director Jan 1, 2020
David Klinetobe Individual Corporate Officer Jan 1, 2020 25%
Operational/Managerial ControlCfo Jan 1, 2020 25%
John E Boland Individual Corporate Director Jan 1, 2020 5%
Stacy Scott Individual Corporate Director Jan 1, 2020
Abigail Cadelina Individual Corporate Director Jan 1, 2020
Daniel a Segedin Individual Corporate OfficerChair Elect; Community Member Jan 1, 2020 5%
Mitesh Popat Individual Corporate OfficerChief Executive Officer Dec 1, 2016 25%
Cristina a Mackenzie Individual Corporate Director Jan 1, 2020
Operational/Managerial ControlBoard Chair; Community Member Jan 1, 2020 5%

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 4

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.

NPI Registry JSON

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

{
    "created_epoch": "1594684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1594684800000",
    "number": "1780292912",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5008",
            "city": "NOVATO",
            "state": "CA",
            "postal_code": "949485008",
            "telephone_number": "415-798-3135",
            "fax_number": "415-798-3104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1260 S ELISEO DR STE 201",
            "city": "GREENBRAE",
            "state": "CA",
            "postal_code": "949042009",
            "telephone_number": "415-448-1500",
            "fax_number": "415-798-3104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIN COMMUNITY CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-07-14",
        "last_updated": "2020-07-14",
        "certification_date": "2020-07-14",
        "status": "A",
        "authorized_official_last_name": "SKELLY",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "REVENUE CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "415-798-3135",
        "authorized_official_credential": "CPC"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Greenbrae, CA

Sources for this page

Verify at the official NPI Registry.