NPIMap

Organization Active NPI

Crusaders Central Clinic Association

Doing business as Rosecrance Ware Center

  • Federally Qualified Health Center (FQHC)
  • Rockford, IL
National Provider Identifier
1922358373
Registry record updated Aug 8, 2023
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
Rosecrance Ware Center
Practice address
2704 N Main St
Rockford, IL 61103-3112
Phone
(815) 490-1600
Fax
(815) 490-1845
NPI assigned
Sep 13, 2012
Reactivated
Aug 8, 2023
Last updated
Aug 8, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
CRUSADERS CENTRAL CLINIC ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 8, 2023

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

2704 N Main St
Rockford, IL 61103-3112

Mailing address

1200 W State St
Rockford, IL 61102-2112
Phone (815) 490-1600

Other names 1

  • Rosecrance Ware Center 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
O20231121000625 IL Part A Provider - Federally Qualified Health Center (FQHC) 5799682993 Practice locations: Rockford, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1922358373. Details of each certification follow.

Federally qualified health center certification: CCN C41013

Legal name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 17, 2023
Last certification
Nov 17, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 29, 1970 in IL
Enrollment address
2704 N Main St
Rockford, IL 61103-3112

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.

National Provider Directory

National Provider Directory
Part of
John Coffey MD

Locations

1720 18th Ave
Rockford, IL 61104
Phone 81549016001601

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
Catherine L Brown Individual Corporate Director Aug 8, 2023
David Ruffin Individual Corporate Director Aug 8, 2023
Peter J Mazanec Individual Corporate Director Aug 8, 2023
James R Millikin Individual Corporate Director Aug 8, 2023
Noel D Nickel Individual W-2 Managing Employee Dec 1, 2025
David W Powell Individual Corporate Director Aug 8, 2023
Dennis Roop Individual Corporate Director Aug 8, 2023
Leon E Hansen Individual Corporate Director Aug 8, 2023
Janice Forrest Individual Corporate Director Aug 8, 2023
Richard P Walsh Individual Corporate Director Aug 5, 2023
Samuel Miller Individual Corporate Officer Aug 5, 2023
W-2 Managing EmployeePresident & Ceo Jan 1, 2020

Practitioners & affiliated clinicians

Practitioners 55

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 55

NPI Registry JSON

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

{
    "created_epoch": "1347494400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1691452800000",
    "number": "1922358373",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 W STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611022112",
            "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": "2704 N MAIN ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611033112",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1845"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "enumeration_date": "2012-09-13",
        "last_updated": "2023-08-08",
        "certification_date": "2023-08-08",
        "deactivation_date": "2022-02-25",
        "reactivation_date": "2023-08-08",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "CEO/PRESIDENT",
        "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": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rosecrance Ware Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Rosecrance Ware Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rockford, IL

Sources for this page

Verify at the official NPI Registry.