NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

Doing business as NorthShore St. John Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Saint John, IN
National Provider Identifier
1851966089
Registry record updated May 20, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHSHORE HEALTH CENTERS, INC.
Doing business as
NorthShore St. John Community Health Center
Practice address
9825 Wicker Ave Side
Saint John, IN 46373-9413
Phone
(219) 763-8112
Fax
(219) 764-5380
NPI assigned
May 20, 2021
Last updated
May 20, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2021

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

Authorized official

Name
David Hall
Title
Ceo
Phone
(219) 763-8112

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

9825 Wicker Ave Side
Saint John, IN 46373-9413

Mailing address

PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112

Other names 1

  • NorthShore St. John Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040827000220 IN Part B Supplier - Clinic/Group Practice 5799671236 Receives reassigned benefits from 128 practitioners
25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Station, IN; Merrillville, IN; Michigan City, IN; Portage, IN; Saint John, IN; Crown Point, IN; Schererville, IN; Valparaiso, IN…
O20210824001326 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 Practice locations: Saint John, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851966089. Details of each certification follow.

Federally qualified health center certification: CCN 151120

Legal name
NORTHSHORE HEALTH CENTERS INC
Doing business as
NORTHSHORE ST JOHN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 23, 2021
Last certification
Aug 23, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 1997 in IN
Enrollment address
9825 Wicker Ave
Side
Saint John, IN 46373-9413

Other NPIs with the same Medicare PAC ID 22

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

View all 22

Other NPIs on the same Medicare enrollment 24

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

View all 24

National Provider Directory

National Provider Directory
Tax ID family
Northshore Health CTRS Inc28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

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

View all 27

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Steven C Disney Individual Corporate OfficerBoard Member Dec 18, 2018
David Hall Individual Corporate OfficerCeo Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Roman Bronson Individual Corporate OfficerTreasurer Apr 28, 2020
Thomas Mosley Individual Corporate OfficerVice Chairman Dec 18, 2018
Scott V Cherry Individual Corporate OfficerBoard Member Aug 1, 2011
Denneese Concepcion Individual Corporate OfficerBoard Member Jun 26, 2018
Scott E Fritz Individual Corporate OfficerBoard Member Dec 1, 2013
Thomas Cripliver Individual Corporate OfficerBoard Member Feb 25, 2020
Wilma Vazquez Individual Corporate OfficerSecretary Sep 16, 2016
Lauren Trumbo Individual Corporate OfficerChairman Dec 18, 2018
Connie Rudd Individual Corporate OfficerBoard Member Aug 1, 2011
Jena Bellezza Individual Corporate OfficerBoard Member Sep 16, 2016
Tom Aldrich Individual Corporate OfficerBoard Member Dec 18, 2018

NPI Registry JSON

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

{
    "created_epoch": "1621468800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621468800000",
    "number": "1851966089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1430",
            "city": "PORTAGE",
            "state": "IN",
            "postal_code": "463689230",
            "telephone_number": "219-763-8112"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9825 WICKER AVE SIDE",
            "city": "SAINT JOHN",
            "state": "IN",
            "postal_code": "463739413",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-20",
        "last_updated": "2021-05-20",
        "certification_date": "2021-05-20",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-763-8112"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NorthShore St. John Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint John, IN

Sources for this page

Verify at the official NPI Registry.