NPIMap

Organization Active NPI

Rural Health Corporation of Northeastern Pennsylvania

Doing business as Black Creek Health Center

  • Federally Qualified Health Center (FQHC)
  • Nuremberg, PA
National Provider Identifier
1871695148
Registry record updated Mar 6, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
RURAL HEALTH CORPORATION OF NORTHEASTERN PENNSYLVANIA
Doing business as
Black Creek Health Center
Practice address
75 Pineapple Street
Nuremberg, PA 18241-0670
Phone
(570) 704-4235
Fax
(570) 384-3454
NPI assigned
Sep 5, 2006
Last updated
Mar 6, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
RURAL HEALTH CORPORATION OF NORTHEASTERN PENNSYLVANIAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 6, 2020

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

Authorized official

Name
Edward McCarthy
Title
Chief Financial Officer
Phone
(570) 825-8741

Specialties & licenses 2

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

Addresses

Primary practice location

75 Pineapple Street
Nuremberg, PA 18241-0670

Mailing address

1084 Route 315
Wilkes-Barre, PA 18702-7012
Phone (570) 825-8741

Other identifiers 1

IdentifierTypeStateIssuer
1007296090014MedicaidPA

Other names 1

  • BLACK CREEK HEALTH CENTER Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050201000488 PA Part B Supplier - Clinic/Group Practice 1052362662 Receives reassigned benefits from 34 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Monroe Township, PA; Wilkes Barre, PA; Shickshinny, PA; Nuremberg, PA; Laporte, PA; Hazleton, PA; Freeland, PA; Falls, PA…
O20100902000237 PA Part A Provider - Federally Qualified Health Center (FQHC) 1052362662 Practice locations: Nuremberg, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871695148. Details of each certification follow.

Federally qualified health center certification: CCN 391855

Legal name
RURAL HEALTH CORPORATION OF NORTHEASTERN PENNSYLVANIA
Doing business as
BLACK CREEK HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 1, 1993
Last certification
Jul 1, 1993
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 19, 1970 in PA
Enrollment address
75 Pineapple St
Nuremberg, PA 18241
Related CCNs
393815

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 9

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
39D0191536Black Creek Health Center75 Pineapple Street, Nuremberg, PA 18241Certificate of waiverApr 20, 2028

National Provider Directory

National Provider Directory
Part of
Rural HLTH Corp of Nort

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Lori Gaffney Individual Corporate Director Aug 1, 2010
Lisa Bealla Individual Corporate Director Aug 1, 2010
Barbara Bellucci Individual Corporate Director Aug 1, 2010
Charles Leo Individual Corporate DirectorCeo Aug 1, 2025
W-2 Managing Employee Aug 1, 2025
Robert Gaffney Individual Corporate Director Aug 1, 2010
Marian Holehan Individual Corporate DirectorDirector Jul 1, 2019
Richard Love Individual Corporate Director Aug 1, 2010
Dona Maladay Individual Corporate Director Jul 1, 2018
Ryan Love Individual Corporate DirectorDirector Jul 1, 2019
Anne E O'Donnell Individual Corporate DirectorDirector Jul 1, 2019
James Palvshock Individual Corporate Director Aug 1, 2010
Emily Havrilla Individual Corporate Director Aug 1, 2010

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Valley MedicalEdwardsville, PA, CCN 391184 Federally qualified health center 5% Or Greater Direct Ownership Interest Jun 19, 1970
Hazleton PediatricsHazleton, PA, CCN 391189 Federally qualified health center 5% Or Greater Direct Ownership Interest Jun 19, 1970

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 3

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": "1157414400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583452800000",
    "number": "1871695148",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1084 ROUTE 315",
            "city": "WILKES-BARRE",
            "state": "PA",
            "postal_code": "187027012",
            "telephone_number": "570-825-8741",
            "fax_number": "570-825-8990"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "75 PINEAPPLE STREET",
            "city": "NUREMBERG",
            "state": "PA",
            "postal_code": "182410670",
            "telephone_number": "570-704-4235",
            "fax_number": "570-384-3454"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RURAL HEALTH CORPORATION OF NORTHEASTERN PENNSYLVANIA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "RURAL HEALTH CORPORATION OF NORTHEASTERN PENNSYLVANIA",
        "enumeration_date": "2006-09-05",
        "last_updated": "2020-03-06",
        "certification_date": "2020-03-06",
        "status": "A",
        "authorized_official_last_name": "MCCARTHY",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "570-825-8741"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1007296090014",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BLACK CREEK HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "BLACK CREEK HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Nuremberg, PA

Sources for this page

Verify at the official NPI Registry.