NPIMap

Organization Active NPI

Crusaders Central Clinic Association

Doing business as Crusader Community Health

  • Federally Qualified Health Center (FQHC)
  • Loves Park, IL
National Provider Identifier
1891082194
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Doing business as
Crusader Community Health
Practice address
6115 N 2ND St
Loves Park, IL 61111-4155
Phone
(815) 490-1600
Fax
(815) 490-1625
NPI assigned
Jul 7, 2011
Last updated
Aug 24, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
CRUSADER CENTRAL CLINIC ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Mr. Samuel Miller
Title
President and Ceo
Phone
(815) 490-1737

Specialties & licenses 1

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

Addresses

Primary practice location

6115 N 2ND St
Loves Park, IL 61111-4155

Mailing address

6115 N 2ND St
Loves Park, IL 61111-4155
Phone (815) 490-1600

Other names 1

  • Crusader Community Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031216000642 IL Part B Supplier - Clinic/Group Practice 5799682993 Receives reassigned benefits from 19 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Belvidere, IL; Loves Park, IL; Rockford, IL; South Beloit, IL
O20110909002867 IL Part A Provider - Federally Qualified Health Center (FQHC) 5799682993 Practice locations: Loves Park, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1891082194. Details of each certification follow.

Federally qualified health center certification: CCN 141148

Legal name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Doing business as
CRUSADER COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 28, 2011
Last certification
Oct 28, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 6, 2011 in IL
Enrollment address
6115 N 2ND St
Loves Park, IL 61111-4155

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 8

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
14D2028558Crusader Community Health6115 N 2ND St, Loves Park, IL 61111Provider-performed microscopyMay 31, 2027

National Provider Directory

National Provider Directory
Tax ID family
John Coffey MD10 organizations share this tax ID, including this one
Part of
John Coffey MD

Other organizations with this tax ID 9

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

Locations

6115 N 2nd St
Loves Park, IL 61111
Phone (815) 516-0040

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Catherine L Brown Individual Corporate Director Jan 1, 2019
James R Millikin Individual Corporate Director Oct 1, 2016
Noel D Nickel Individual W-2 Managing Employee Dec 1, 2025
Richard P Walsh Individual Corporate OfficerOfficer Jul 1, 2016
Samuel Miller Individual Corporate OfficerPresident & Ceo Sep 6, 2011
W-2 Managing EmployeePresident & Ceo Jan 1, 2020

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": "1309996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1891082194",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6115 N 2ND ST",
            "city": "LOVES PARK",
            "state": "IL",
            "postal_code": "611114155",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6115 N 2ND ST",
            "city": "LOVES PARK",
            "state": "IL",
            "postal_code": "611114155",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRUSADER CENTRAL CLINIC ASSOCIATION",
        "enumeration_date": "2011-07-07",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-11",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PRESIDENT AND CEO",
        "authorized_official_telephone_number": "815-490-1737",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crusader Community Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Crusader Community Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Loves Park, IL

Sources for this page

Verify at the official NPI Registry.