NPIMap

Organization Active NPI

International Community Health Services

  • Federally Qualified Health Center (FQHC)
  • Seattle, WA
National Provider Identifier
1902983109
Registry record updated Apr 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
INTERNATIONAL COMMUNITY HEALTH SERVICES
Practice address
3815 S Othello St
2ND Floor
Seattle, WA 98118-3510
Phone
(206) 788-3500
Fax
(206) 788-3521
NPI assigned
Nov 1, 2006
Last updated
Apr 7, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
INTERNATIONAL COMMUNITY HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 7, 2021

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

Authorized official

Name
Hermes Shahbazian
Title
Cfo
Phone
(206) 788-3618

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 600436519 WA
Case Management Agency 251B00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

3815 S Othello St
2ND Floor
Seattle, WA 98118-3510

Mailing address

PO Box 3007
Seattle, WA 98114-3007
Phone (206) 788-3600

Other identifiers 1

IdentifierTypeStateIssuer
7125289MedicaidWA

Other names 1

  • Holly Park Medical & Dental Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031024000002 WA Part A Provider - Federally Qualified Health Center (FQHC) 5799695672 Practice locations: Seattle, WA
O20040301000204 WA Part B Supplier - Clinic/Group Practice 5799695672 Receives reassigned benefits from 130 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bellevue, WA; Seattle, WA; Shoreline, WA; Auburn, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902983109. Details of each certification follow.

Federally qualified health center certification: CCN 501874

Legal name
INTERNATIONAL COMMUNITY HEALTH SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 14, 2003
Last certification
Nov 14, 2003
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Aug 28, 1973 in WA
Enrollment address
3815 S Othello St
# 2
Seattle, WA 98118-3510

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 6

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

National Provider Directory

National Provider Directory
Tax ID family
International District33 organizations share this tax ID, including this one
Part of
International District

Other organizations with this tax ID 31

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

View all 31

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Mariam Abarientos Individual Corporate DirectorVolunteer Board Director Mar 22, 2017
Hermes Shahbzian Individual Corporate OfficerCfo Apr 1, 1994
W-2 Managing Employee Apr 1, 1994
Catherine Johnson Individual Corporate DirectorVolunteer Board Director Jul 25, 2012
Gildas Cheung Individual Corporate DirectorVolunteer Board Director Jan 28, 2009
John Foz Individual Corporate DirectorVolunteer Board Director Sep 24, 2008
Chengzhen Dai Individual Corporate DirectorVolunteer Board Director May 27, 2020
Kelli Nomura Individual Corporate OfficerCeo Nov 7, 2022
W-2 Managing EmployeeCeo Nov 7, 2022

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Ichs Bellevue Medical and Dental ClinicBellevue, WA, CCN 501971 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 May 1, 2014
May 1, 2014
Ichs Shoreline Medical and Dental ClinicShoreline, WA, CCN 501974 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 15, 2014
Sep 15, 2014
Ichs International District Vision ClinicSeattle, WA, CCN 941034 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 15, 2017
Sep 15, 2017
Ichs Sound Auburn Medical ClinicAuburn, WA, CCN 501074 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 May 1, 2025
May 1, 2025

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 21

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 21

NPI Registry JSON

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

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617753600000",
    "number": "1902983109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3007",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981143007",
            "telephone_number": "206-788-3600",
            "fax_number": "206-652-5216"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3815 S OTHELLO ST",
            "address_2": "2ND FLOOR",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981183510",
            "telephone_number": "206-788-3500",
            "fax_number": "206-788-3521"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERNATIONAL COMMUNITY HEALTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "INTERNATIONAL COMMUNITY HEALTH SERVICES",
        "enumeration_date": "2006-11-01",
        "last_updated": "2021-04-07",
        "certification_date": "2021-04-07",
        "status": "A",
        "authorized_official_last_name": "SHAHBAZIAN",
        "authorized_official_first_name": "HERMES",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "206-788-3618"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "600436519",
            "primary": false
        },
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7125289",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Holly Park Medical & Dental Clinic",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Holly Park Medical & Dental Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Seattle, WA

Sources for this page

Verify at the official NPI Registry.