NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Lake Station, IN
National Provider Identifier
1861636664
Registry record updated Nov 12, 2020
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.
Practice address
2490 Central Ave
Lake Station, IN 46405-2122
Phone
(219) 763-8112
Fax
(219) 962-1580
NPI assigned
Apr 23, 2009
Last updated
Nov 12, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 12, 2020

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 15

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Child & Adolescent Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0804X
Diagnostic Radiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2085R0202X
Diagnostic Ultrasound PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2085U0001X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Women's Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LW0102X
Advanced Practice MidwifeGroup: 193200000X MULTI-SPECIALTY GROUP 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

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…
O20071102000372 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 1 other NPI on this enrollment
Practice locations: Lake Station, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1861636664. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Sep 1, 1997 in IN
Enrollment address
2490 Central Ave
Lake Station, IN 46405-2122

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

Locations

2490 Central Ave
Lake Station, IN 46405

Ownership & related parties

All disclosed owners & managing parties 19

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 16, 2014
David Hall Individual Corporate OfficerCeo Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Scott V Cherry Individual Corporate OfficerBoard Member Aug 11, 2011
Sarah Himmelsbach Individual Corporate Director Dec 1, 2007
Deborah Soderquist Individual Corporate OfficerBoard Member Aug 11, 2011
Shirley Wadding Individual Corporate OfficerBoard Member Aug 11, 2011
David Parks Individual Corporate Director Dec 1, 2007
Davetta M Haywood Individual Corporate OfficerBoard Member Mar 1, 2013
Arthur Vasquez Individual Corporate OfficerBoard Member May 20, 2014
Anthony J Stofko Individual Corporate OfficerBoard Member Aug 1, 2011
Andre Joseph Individual Corporate Director Dec 1, 2007
Scott E Fritz Individual Corporate OfficerBoard Member Aug 1, 2011
William Poe Individual Corporate OfficerBoard Member Aug 1, 2011
John C Johnson Individual Corporate Director Dec 1, 2007
Terrell Taylor Individual Corporate OfficerBoard Member Mar 1, 2013
Ruth Needleman Individual Corporate OfficerBoard Member Nov 1, 2014
Olgie Havens Individual Corporate Director Dec 1, 2007
Connie Rudd Individual Corporate OfficerChairman of the Board of Directo Aug 11, 2011
Tom Aldrich Individual Corporate OfficerBoard Member Aug 1, 2011

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 23

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 23

NPI Registry JSON

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

{
    "created_epoch": "1240444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605139200000",
    "number": "1861636664",
    "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",
            "fax_number": "219-764-5380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2490 CENTRAL AVE",
            "city": "LAKE STATION",
            "state": "IN",
            "postal_code": "464052122",
            "telephone_number": "219-763-8112",
            "fax_number": "219-962-1580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-04-23",
        "last_updated": "2020-11-12",
        "certification_date": "2020-11-12",
        "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": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085U0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Radiology, Diagnostic Ultrasound",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LW0102X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Women's Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "367A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Advanced Practice Midwife",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Station, IN

Sources for this page

Verify at the official NPI Registry.