NPIMap

Organization Active NPI

West Side Community Health Services, Inc.

Doing business as McDonough Homes Clinic

  • Federally Qualified Health Center (FQHC)
  • Saint Paul, MN
National Provider Identifier
1821149964
Registry record updated May 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Doing business as
McDonough Homes Clinic
Practice address
1544 Timberlake Rd
Saint Paul, MN 55117-3946
Phone
(651) 558-2191
Fax
(651) 558-2205
NPI assigned
Jan 16, 2007
Last updated
May 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2024

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

Authorized official

Name
Reuben Moore
Title
Ceo
Phone
(651) 602-7500

Specialties & licenses 1

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

Addresses

Primary practice location

1544 Timberlake Rd
Saint Paul, MN 55117-3946

Mailing address

153 Cesar Chavez St
Saint Paul, MN 55107-2226
Phone (651) 602-7500

Other identifiers 2

IdentifierTypeStateIssuer
173477OtherMNUCARE
072223500MedicaidMN

Other names 1

  • McDonough Homes Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040209000647 MN Part B Supplier - Clinic/Group Practice 2062306434 Receives reassigned benefits from 116 practitioners
18 other NPIs on this enrollment
Practice locations: Saint Paul, MN; Saint Paul Park, MN; Maplewood, MN; St. Paul, MN; Minneapolis, MN
O20061117000425 MN Part A Provider - Federally Qualified Health Center (FQHC) 2062306434 Practice locations: Saint Paul, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821149964. Details of each certification follow.

Federally qualified health center certification: CCN 241842

Legal name
WEST SIDE COMMUNITY HEALTH SERVICES, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 2, 2007
Last certification
Feb 2, 2007
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Feb 1, 1972 in MN
Enrollment address
1544 Timberlake Rd
Saint Paul, MN 55117-3946

Other NPIs with the same Medicare PAC ID 15

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

View all 15

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory
Tax ID family
West Side Community Health Service Inc22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

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

View all 21

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Jeanette Jones Individual Corporate Director Nov 19, 2015
Summer Abdalla Individual Corporate Director May 7, 2018
Peter Surdo Individual Corporate Director May 1, 2009
Roman Cress Individual Corporate Director May 7, 2018
Amelia Hardy Individual Corporate Director May 7, 2018
Blake Darsow Individual Corporate OfficerCfo Aug 26, 2016
W-2 Managing EmployeeCfo Aug 26, 2016
William Thompson Individual Corporate Director Jul 1, 2010
Cordell Hardy Individual Corporate Director May 7, 2018
Reuben Moore Individual Corporate OfficerCeo Oct 3, 2017
W-2 Managing EmployeeCeo Oct 3, 2017
Zachary Hylton Individual Corporate Director May 7, 2018
Eric William Hanson Individual Corporate OfficerRevenue Data & Credentialing Manage Feb 28, 2022
W-2 Managing EmployeeRevenue Cycle Manager Feb 28, 2022
Operational/Managerial ControlRevenue Data & Credentialing Manage Feb 28, 2022
Krisa Ryan Individual Corporate Director May 4, 2018
Raul Noriega Individual Corporate OfficerVP of Revenue and It Sep 25, 2023
W-2 Managing EmployeeAd;VP of Revenue and It Sep 25, 2023
Operational/Managerial ControlVP of Revenue and It Sep 25, 2023
Andreatte E Hames Individual Corporate Director Aug 26, 2013
Janet Zastrow Individual Corporate Director May 7, 2018

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
West Side Community Health Services, Inc.Saint Paul, MN, CCN 241804 Federally qualified health center Operational/Managerial Control Dec 8, 1988
Creative Arts ClinicSaint Paul, MN, CCN 241006 Federally qualified health center Operational/Managerial Control (100%) Nov 1, 2018

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 123

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 123

NPI Registry JSON

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

{
    "created_epoch": "1168905600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715731200000",
    "number": "1821149964",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "153 CESAR CHAVEZ ST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551072226",
            "telephone_number": "651-602-7500",
            "fax_number": "651-602-7513"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1544 TIMBERLAKE RD",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551173946",
            "telephone_number": "651-558-2191",
            "fax_number": "651-558-2205"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST SIDE COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-16",
        "last_updated": "2024-05-15",
        "certification_date": "2024-05-15",
        "status": "A",
        "authorized_official_last_name": "MOORE",
        "authorized_official_first_name": "REUBEN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "651-602-7500"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "173477",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "072223500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "McDonough Homes Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Paul, MN

Sources for this page

Verify at the official NPI Registry.