NPIMap

Organization Active NPI

Clackamas County

Doing business as Sunnyside Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Clackamas, OR
National Provider Identifier
1891042487
Registry record updated Sep 24, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CLACKAMAS COUNTY
Doing business as
Sunnyside Health Clinic
Practice address
9775 SE Sunnyside Rd Ste 200
Clackamas, OR 97015-5721
Phone
(503) 794-3830
Fax
(503) 794-3850
NPI assigned
Aug 14, 2012
Last updated
Sep 24, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 24, 2019

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

Authorized official

Name
Ed Johnson
Title
Cfo
Phone
(503) 742-5325

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

9775 SE Sunnyside Rd Ste 200
Clackamas, OR 97015-5721

Mailing address

2051 Kaen Rd Ste 367
Oregon City, OR 97045-4035
Phone (503) 742-5300

Other identifiers 4

IdentifierTypeStateIssuer
031799MedicaidOR
131607MedicaidOR
500653393MedicaidOR
022710MedicaidOR

Other names 1

  • Sunnyside Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031210000827 OR Part B Supplier - Clinic/Group Practice 9537065560 Receives reassigned benefits from 128 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Oregon City, OR; Sandy, OR; Milwaukie, OR; Clackamas, OR; Happy Valley, OR
O20120614000822 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
Practice locations: Clackamas, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1891042487. Details of each certification follow.

Federally qualified health center certification: CCN 381931

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 14, 2012
Last certification
Jun 14, 2012
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
9775 SE Sunnyside Rd
Ste 200
Clackamas, OR 97015-5721

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Tax ID family
Clackamas Cty MNTL HLTH15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

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

View all 14

Locations

110 Beavercreek Rd
Oregon City, OR 97045
Phone (503) 655-8278

6605 SE Lake Rd
Portland, OR 97222
Phone (503) 982-9300

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Deborah S Cockrell Individual Corporate DirectorFQHC Director Aug 25, 2014 100%
Morgan Fetzer Individual W-2 Managing EmployeeAdministrative Assistant Mar 1, 2015
Ed Johnson Individual Corporate OfficerCfo Jan 1, 2016 100%
Gina Beltran Individual W-2 Managing EmployeePolicy, Perf, Research Analyst May 22, 2019
Sarah Jacobson Individual W-2 Managing EmployeeOffice Manager Fiscal Dec 1, 2014 100%
County of Clackamas Office of County Auditor Organization, Oregon City, OR 5% Or Greater Direct Ownership Interest Jan 1, 2014 100%
Operational/Managerial Control Jan 1, 2014 100%

Owners & managing parties with NPI records 7

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

  • Clackamas County

    dba Clackamas Health Centers - 1011 Courthouse Road

    • Federally Qualified Health Center (FQHC)
    • Oregon City, OR
    • NPI 1447507215

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • Clackamas County

    dba Beavercreek Health Clinic

    • Federally Qualified Health Center (FQHC)
    • Oregon City, OR
    • NPI 1720017809

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • Clackamas County

    dba Sandy Behavioral Health Center

    • Federally Qualified Health Center (FQHC)
    • Sandy, OR
    • NPI 1841442001

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • Clackamas County

    dba DSB Behavioral Health

    • Federally Qualified Health Center (FQHC)
    • Oregon City, OR
    • NPI 1841443587

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • County of Clackamas Office of County Auditor

    dba Sandy Health Clinic

    • Federally Qualified Health Center (FQHC)
    • Sandy, OR
    • NPI 1043566847

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • County of Clackamas Office of County Auditor

    dba Hilltop Behavioral Health Center

    • Mental Health Clinic/Center (Including Community Mental Health Center)
    • Milwaukie, OR
    • NPI 1245269315

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • County of Clackamas Office of County Auditor

    dba Gladstone Health Clinic

    • Federally Qualified Health Center (FQHC)
    • Gladstone, OR
    • NPI 1275880866

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

All facility ownership & control disclosures 6

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

FacilityTypeRoleSince
Clackamas Health Centers - Sandy ClinicSandy, OR, CCN 381870 Federally qualified health center Operational/Managerial Control Dec 13, 2010
Clackamas Health CentersOregon City, OR, CCN 381820 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Jan 1, 2014
Clackamas Health CentersGladstone, OR, CCN 381923 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Sep 1, 2010
Lake Road Health CenterMilwaukie, OR, CCN 381922 Federally qualified health center Operational/Managerial Control (100%) Aug 28, 2006
Clackamas Health Centers - Sandy Health ClinicSandy, OR, CCN 381936 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Jan 28, 2013
Clackamas Health CentersOregon City, OR, CCN 381944 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 1990
Jan 1, 1990

Owned or controlled facilities with NPI records 6

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

Facilities with the same owner 6

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 109

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 109

NPI Registry JSON

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

{
    "created_epoch": "1344902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1569283200000",
    "number": "1891042487",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2051 KAEN RD STE 367",
            "city": "OREGON CITY",
            "state": "OR",
            "postal_code": "970454035",
            "telephone_number": "503-742-5300",
            "fax_number": "503-655-8350"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9775 SE SUNNYSIDE RD STE 200",
            "city": "CLACKAMAS",
            "state": "OR",
            "postal_code": "970155721",
            "telephone_number": "503-794-3830",
            "fax_number": "503-794-3850"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLACKAMAS COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-08-14",
        "last_updated": "2019-09-24",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "ED",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "503-742-5325"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "031799",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "131607",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500653393",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "022710",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sunnyside Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sunnyside Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clackamas, OR

Sources for this page

Verify at the official NPI Registry.