NPIMap

Organization Active NPI

Crusaders Central Clinic Association

Doing business as Crusader Clinic Belvidere

  • Federally Qualified Health Center (FQHC)
  • Belvidere, IL
National Provider Identifier
1780852244
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Doing business as
Crusader Clinic Belvidere
Practice address
1050 Logan Ave
Belvidere, IL 61008-3966
Phone
(815) 547-0282
Fax
(815) 490-1625
NPI assigned
Feb 18, 2008
Last updated
Aug 24, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
CRUSADERS CENTRAL CLINIC ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Samuel Miller
Title
President & Ceo
Phone
(815) 490-1737

Specialties & licenses 1

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

Addresses

Primary practice location

1050 Logan Ave
Belvidere, IL 61008-3966

Mailing address

1050 Logan Ave
Belvidere, IL 61008-3966
Phone (815) 490-1600

Other identifiers 3

IdentifierTypeStateIssuer
106483OtherILDORAL
027548OtherCHAMPUS
1011514778OtherBLUE CROSS BLUE SHIELD

Other names 1

  • Crusader Clinic Belvidere Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031216000642 IL Part B Supplier - Clinic/Group Practice 5799682993 Receives reassigned benefits from 19 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Belvidere, IL; Loves Park, IL; Rockford, IL; South Beloit, IL
O20080812000460 IL Part A Provider - Federally Qualified Health Center (FQHC) 5799682993 Practice locations: Belvidere, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780852244. Details of each certification follow.

Federally qualified health center certification: CCN 141094

Legal name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 7, 2009
Last certification
Apr 7, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1997 in IL
Enrollment address
1050 Logan Ave
Belvidere, IL 61008-3966

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 8

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
14D1022716Crusader Clinic Belvidere1050 Logan Ave, Belvidere, IL 61008Provider-performed microscopyMay 31, 2027

National Provider Directory

National Provider Directory
Tax ID family
Crusaders Central CLN Assoc10 organizations share this tax ID, including this one
Part of
Crusaders Central CLN Assoc

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Catherine L Brown Individual Corporate Director Jan 30, 2014
James R Millikin Individual Corporate Director Oct 1, 2016
Noel D Nickel Individual W-2 Managing Employee Nov 1, 2025
Barbara Williams Individual Corporate Director Jan 30, 2014
Richard P Walsh Individual Corporate Director Jun 1, 2016
Samuel Miller Individual Corporate Director Jan 29, 2009
W-2 Managing Employee Jan 29, 2009

Practitioners & affiliated clinicians

Practitioners 1

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": "1203292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1780852244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1050 LOGAN AVE",
            "city": "BELVIDERE",
            "state": "IL",
            "postal_code": "610083966",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 LOGAN AVE",
            "city": "BELVIDERE",
            "state": "IL",
            "postal_code": "610083966",
            "telephone_number": "815-547-0282",
            "fax_number": "815-490-1625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "enumeration_date": "2008-02-18",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-12",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "815-490-1737"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DORAL",
            "identifier": "106483",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHAMPUS",
            "identifier": "027548",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "1011514778",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crusader Clinic Belvidere",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Belvidere, IL

Sources for this page

Verify at the official NPI Registry.