NPIMap

Organization Active NPI

Packard Health, Inc.

  • Federally Qualified Health Center (FQHC)
  • Ann Arbor, MI
National Provider Identifier
1851769053
Registry record updated Dec 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PACKARD HEALTH, INC.
Practice address
312 W Huron St
Ann Arbor, MI 48103-4204
Phone
(734) 662-2829
NPI assigned
Sep 4, 2015
Last updated
Dec 17, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2020

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

Authorized official

Name
Todd Montrief, CPA
Title
Cfo
Phone
(734) 926-4935

Specialties & licenses 1

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

Addresses

Primary practice location

312 W Huron St
Ann Arbor, MI 48103-4204

Mailing address

5200 Venture Dr
Ann Arbor, MI 48108-9561
Phone (734) 926-4935

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050510001120 MI Part B Supplier - Clinic/Group Practice 6204876113 Receives reassigned benefits from 31 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ann Arbor, MI; Ypsilanti, MI
O20151014002587 MI Part A Provider - Federally Qualified Health Center (FQHC) 6204876113 Practice locations: Ann Arbor, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851769053. Details of each certification follow.

Federally qualified health center certification: CCN 231081

Legal name
PACKARD HEALTH INC
Doing business as
SHELTER ASSOCIATION OF WASHTENAW COUNTY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 4, 2015
Last certification
Nov 4, 2015
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Aug 23, 1979 in MI
Enrollment address
312 W Huron St
Ann Arbor, MI 48103-4204

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 2

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
23D2110137Packard Health at Delonis Center312 W Huron Street, Ann Arbor, MI 48103Provider-performed microscopyMar 8, 2028

National Provider Directory

National Provider Directory

Locations

2650 Carpenter Rd
Ann Arbor, MI 48108
Phone (734) 971-1073

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
Jean Callum Individual Corporate OfficerCoo Jun 1, 2019
W-2 Managing EmployeeCoo Jun 1, 2019
Operational/Managerial ControlCoo Jun 1, 2019
Rana Smith Individual Corporate DirectorBoard of Directors Chairman Sep 1, 2019
Douglas Strong Individual Corporate DirectorBoard of Directors Sep 1, 2015
Raymond J Rion Individual Corporate Director Nov 16, 2012
Nora Maloy Individual Corporate DirectorBoard of Directors Secretary Sep 1, 2019
Sharon Moore Individual Corporate DirectorBoard of Directors Sep 1, 2016
Deborah Vandenbroek Individual Corporate DirectorBoard of Directors Vice Chairman Sep 1, 2017
David Hoffman Individual Corporate OfficerCfo Jan 9, 2023
W-2 Managing EmployeeCfo Jan 9, 2023
Thomas Biggs Individual Corporate DirectorBoard of Director Treasurer Mar 1, 2015
Charles Hoffman Individual Corporate DirectorBoard of Directors Sep 1, 2015

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Packard Health IncYpsilanti, MI, CCN C71021 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 12, 1989

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 2

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": "1441324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608163200000",
    "number": "1851769053",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VENTURE DR",
            "city": "ANN ARBOR",
            "state": "MI",
            "postal_code": "481089561",
            "telephone_number": "734-926-4935",
            "fax_number": "734-773-1833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "312 W HURON ST",
            "city": "ANN ARBOR",
            "state": "MI",
            "postal_code": "481034204",
            "telephone_number": "734-662-2829"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PACKARD HEALTH, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-04",
        "last_updated": "2020-12-17",
        "certification_date": "2020-12-17",
        "status": "A",
        "authorized_official_last_name": "MONTRIEF",
        "authorized_official_first_name": "TODD",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "734-926-4935",
        "authorized_official_credential": "CPA"
    },
    "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 Ann Arbor, MI

Sources for this page

Verify at the official NPI Registry.