Northshore Health Centers, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Lake Station, IN
NPI 1861636664 · NPPES record last updated Nov 12, 2020
Key facts
- NPI
- 1861636664
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- NORTHSHORE HEALTH CENTERS, INC.
- Practice address
- 2490 Central Ave
Lake Station, IN 46405-2122 - Phone
- (219) 763-8112
- Fax
- (219) 962-1580
- NPI assigned
- Apr 23, 2009
- Organization subpart
- No
Authorized official
- Name
- David Hall
- Title
- Ceo
- Phone
- (219) 763-8112
Owners & managing parties with NPI records 1
-
David W. Parks, PSY.D.
Other NPIs on the same Medicare enrollment 24
Other NPIs with the same Medicare PAC ID 22
Practitioners 49
-
Ronald Samuel Lemon II, O.D.
-
Megan E App, M.D.
-
Andi Arnautovic, MD
-
Daniel Raleigh Dewar, D.C.
-
Michael D Foster, M.D.
-
Sharon Greiner, MSN, CNM ,FNP-BC
-
Soyong Lee, M.D.
-
Lee Jennifer Murphy, MD FACOG
-
Bala Rangaswami, MD
-
Aditya Shah, M.D.
-
Cheryl D Short, MD, FACOG
-
Dennis W Smith, D.P.M.
-
Crystal A Strickland, MD FACOG
-
Matthew Jason Tipton, M.D.
-
Simona Maria Toader, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IN
Federally qualified health center certification: CCN 151846
- Legal name
- NORTHSHORE HEALTH CENTERS INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 2, 2008
- Last certification
- Jan 2, 2008
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 1, 1997 in IN
- Enrollment address
- 2490 Central Ave
Lake Station, IN 46405-2122
All disclosed owners & managing parties 19
| Name | Role | Since | Share |
|---|---|---|---|
| Steven C Disney |
Corporate Officer |
Dec 16, 2014 | |
| David Hall |
Corporate Officer |
Jan 23, 2020 | |
| W-2 Managing Employee |
Jan 23, 2020 | ||
| Scott V Cherry |
Corporate Officer |
Aug 11, 2011 | |
| Sarah Himmelsbach |
Corporate Director | Dec 1, 2007 | |
| Deborah Soderquist |
Corporate Officer |
Aug 11, 2011 | |
| Shirley Wadding |
Corporate Officer |
Aug 11, 2011 | |
| David Parks |
Corporate Director | Dec 1, 2007 | |
| Davetta M Haywood |
Corporate Officer |
Mar 1, 2013 | |
| Arthur Vasquez |
Corporate Officer |
May 20, 2014 | |
| Anthony J Stofko |
Corporate Officer |
Aug 1, 2011 | |
| Andre Joseph |
Corporate Director | Dec 1, 2007 | |
| Scott E Fritz |
Corporate Officer |
Aug 1, 2011 | |
| William Poe |
Corporate Officer |
Aug 1, 2011 | |
| John C Johnson |
Corporate Director | Dec 1, 2007 | |
| Terrell Taylor |
Corporate Officer |
Mar 1, 2013 | |
| Ruth Needleman |
Corporate Officer |
Nov 1, 2014 | |
| Olgie Havens |
Corporate Director | Dec 1, 2007 | |
| Connie Rudd |
Corporate Officer |
Aug 11, 2011 | |
| Tom Aldrich |
Corporate Officer |
Aug 1, 2011 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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… |
| O20071102000372 | IN | Part a Provider - Federally Qualified Health Center (FQHC) | 5799671236 |
1 other NPI on this enrollment Practice locations: Lake Station, IN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor |
101YA0400X | |||
| Clinical Social Worker |
1041C0700X | |||
| Optometrist |
152W00000X | |||
| Family Medicine Physician |
207Q00000X | |||
| Obstetrics & Gynecology Physician |
207V00000X | |||
| Pediatrics Physician |
208000000X | |||
| Psychiatry Physician |
2084P0800X | |||
| Child & Adolescent Psychiatry Physician |
2084P0804X | |||
| Diagnostic Radiology Physician |
2085R0202X | |||
| Diagnostic Ultrasound Physician |
2085U0001X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Nurse Practitioner |
363L00000X | |||
| Family Nurse Practitioner |
363LF0000X | |||
| Women's Health Nurse Practitioner |
363LW0102X | |||
| Advanced Practice Midwife |
367A00000X |
Addresses
Primary practice location
2490 Central Ave
Lake Station, IN 46405-2122
Mailing address
PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 151846 | Other | IN | MEDICARE PART A PTAN |
| 191360 | Other | IN | MEDICARE PART B PTAN |
| 200331170D | Medicaid | IN |
Other providers in Lake Station, IN
- Jennifer Niemeyer
- Nikki a Wargo DDS
- Northshore Health Centers
- Northshore Health Centers, Inc.
- Northshore Health Centers, Inc.
- Northshore Health Centers, Inc.
- Rayann Nowacki
- Peggy Ruth Payonk
- Kari Payton
- Keith Minton Ramsey
All providers in Lake Station, IN · Federally Qualified Health Center (FQHC) in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 12, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.