NPIMap

Organization Active NPI

Centerville Clinics Inc

  • School Social Worker
  • Fredericktown, PA
National Provider Identifier
1871079962
Registry record updated Jul 12, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
School Social WorkerTaxonomy code 1041S0200X
Legal business name
CENTERVILLE CLINICS INC
Practice address
Beth Center Elementary School
194 Crawford Road
Fredericktown, PA 15333
Phone
(724) 267-4944
Fax
(724) 267-4905
NPI assigned
Jul 12, 2018
Last updated
Jul 12, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 12, 2018

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

Authorized official

Name
Mr. Barry Niccolai
Title
Executive Director
Phone
(724) 632-6801

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
School Social WorkerGroup: 193400000X SINGLE SPECIALTY GROUP 1041S0200X PA Primary

Addresses

Primary practice location

Beth Center Elementary School
194 Crawford Road
Fredericktown, PA 15333

Mailing address

Centerville Clinics Inc
1070 Old National Pike Road
Fredericktown, PA 15333-2114
Phone (724) 632-6801

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210525001712 PA Part A Provider - Federally Qualified Health Center (FQHC) 7214837202 Practice locations: Fredericktown, PA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1871079962. Details of each certification follow.

Federally qualified health center certification: CCN 731834

Legal name
CENTERVILLE CLINICS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 14, 2021
Last certification
May 14, 2021
Ownership / control type
For profit – corporation
Organization structure
OtherProprietary
Incorporated
Mar 2, 1953 in PA
Enrollment address
194 Crawford Road
Fredericktown, PA 15333-2012

Federally qualified health center certification: CCN 731833

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
CENTERVILLE CLINICS INC - BETH CENTER ES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 14, 2021
Last certification
May 14, 2021
Ownership / control type
For profit – corporation
Facility address
194 Crawford Road
Fredericktown, PA 15333

Other NPIs with the same Medicare PAC ID 23

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

View all 23

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Daniel L Holt Individual W-2 Managing EmployeeMedical Director Jan 1, 2011
Donna Salvino Individual Corporate DirectorSecretary/Treasurer Aug 25, 2014
Edward J Marotta Individual Corporate DirectorBoard Member Nov 17, 2014
Barry R Niccolai Individual Corporate OfficerExecutive Director Apr 1, 2017
Patricia a Gavazzi Individual Corporate DirectorBoard Member Jun 27, 2017
Darra Tyler-Owens Individual Corporate DirectorBoard Member Sep 29, 2018
Andrew Corfont Individual Corporate DirectorBoard Member Mar 25, 2013
Joseph M Yablonski Individual Corporate DirectorPresident of Board Nov 23, 2004
Patricia Martos Individual W-2 Managing EmployeeDirector of Finance & Personnel Mar 1, 1979
James T Yablonski Individual Corporate DirectorVice-President Jan 23, 1995
Marianne E Gideon Individual Corporate DirectorBoard Member Jun 27, 2016

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1531353600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531353600000",
    "number": "1871079962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "CENTERVILLE CLINICS INC",
            "address_2": "1070 OLD NATIONAL PIKE ROAD",
            "city": "FREDERICKTOWN",
            "state": "PA",
            "postal_code": "153332114",
            "telephone_number": "724-632-6801",
            "fax_number": "724-632-6312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "BETH CENTER ELEMENTARY SCHOOL",
            "address_2": "194 CRAWFORD ROAD",
            "city": "FREDERICKTOWN",
            "state": "PA",
            "postal_code": "15333",
            "telephone_number": "724-267-4944",
            "fax_number": "724-267-4905"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERVILLE CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-12",
        "last_updated": "2018-07-12",
        "status": "A",
        "authorized_official_last_name": "NICCOLAI",
        "authorized_official_first_name": "BARRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "724-632-6801",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "1041S0200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker, School",
            "state": "PA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fredericktown, PA

Sources for this page

Verify at the official NPI Registry.