NPIMap

Organization Active NPI

Chattanooga Hamilton County Hospital Authority

Doing business as South Side Community Health

  • Federally Qualified Health Center (FQHC)
  • Chattanooga, TN
National Provider Identifier
1962597179
Registry record updated Mar 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
0000000140 Issued in TN
Legal business name
CHATTANOOGA HAMILTON COUNTY HOSPITAL AUTHORITY
Doing business as
South Side Community Health
Southside Community Health Center
Practice address
3800 Tennessee Ave Ste 124
Chattanooga, TN 37409-1260
Phone
(423) 778-4780
Fax
(423) 778-4833
NPI assigned
Oct 4, 2006
Last updated
Mar 10, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 10, 2022

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

Authorized official

Name
Mike Dale Shaver
Title
Director of Reimbursement
Phone
(423) 240-8576

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 0000000140 TN Primary

Addresses

Primary practice location

3800 Tennessee Ave Ste 124
Chattanooga, TN 37409-1260

Mailing address

975 E Third Street
Chattanooga, TN 37403
Phone (423) 778-4780

Other identifiers 1

IdentifierTypeStateIssuer
000451481AMedicaidGA

Other names 2

  • South Side Community Health Doing business as
  • Southside Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040302001086 TN Part B Supplier - Clinic/Group Practice 0547179731 Receives reassigned benefits from 565 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
O20050211000763 TN Part A Provider - Federally Qualified Health Center (FQHC) 0547179731 Practice locations: Chattanooga, TN
O20050421001576 TN Part A Provider - Federally Qualified Health Center (FQHC) 0547179731 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chattanooga, TN

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1962597179. Details of each certification follow.

Federally qualified health center certification: CCN 441899

Legal name
CHATTANOOGA HAMILTON COUNTY HOSPITAL AUTHORITY
Doing business as
SOUTHSIDE COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 25, 2005
Last certification
May 25, 2005
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Jun 24, 1998 in TN
Enrollment address
3800 Tennessee Ave
Ste 124
Chattanooga, TN 37409-1270

Federally qualified health center certification: CCN 441898

Legal name
CHATTANOOGA HAMILTON COUNTY HOSPITAL AUTHORITY
Doing business as
DODSON AVENUE COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 25, 2005
Last certification
May 25, 2005
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Jun 24, 1998 in TN
Enrollment address
1200 Dodson Ave
Chattanooga, TN 37406-3214

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 5

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
44D0310216Southside Community Health Center3800 Tennessee Avenue, Chattanooga, TN 37409Provider-performed microscopyOct 21, 2026

National Provider Directory

National Provider Directory

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
Chattanooga Hamilton County Hospital Authority Organization, Chattanooga, TN 5% Or Greater Direct Ownership Interest Oct 1, 1986 100%
Nakeda Lashae Eady Individual Corporate DirectorBoard Member Nov 17, 2015
Corporate Director Nov 17, 2015
William L Jackson Individual Corporate OfficerCeo Sep 18, 2019
Henry a Hoss Individual Corporate DirectorBoard Member Nov 17, 2015
Corporate Officer Nov 17, 2015
Beverly Maxine Johnson Individual Corporate DirectorBoard Member Nov 17, 2015
Lynn S Dejaco Individual Corporate OfficerCfo May 11, 2021
Rosemary W Geiger Individual Corporate DirectorBoard Member Nov 17, 2015
Corporate Director Nov 17, 2015
Gregg Gentry Individual Corporate OfficerChief Admin Officer Feb 11, 2005
W-2 Managing Employee Apr 21, 2005
Mike Shaver Individual W-2 Managing EmployeeDirector of Reimbursement Jul 5, 2015
W-2 Managing Employee Jul 5, 2015
Robert J Maloney Individual Corporate OfficerCoo Sep 28, 2020
Lemon Clyde Williams Individual Corporate DirectorBoard Member Aug 15, 2021
Warren Ervin McEwen Individual Corporate Director Apr 1, 2021

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Erlanger Health SystemChattanooga, TN, CCN 444026 Hospital 5% Or Greater Direct Ownership Interest (20%) Mar 7, 2016
Dodson Avenue Community Health CenterChattanooga, TN, CCN 441898 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 1, 1986
Erlanger Murphy Medical Group, HayesvilleHayesville, NC, CCN 343460 Rural health clinic Operational/Managerial Control (100%) Mar 29, 2018

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 14

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 14

NPI Registry JSON

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

{
    "created_epoch": "1159920000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646870400000",
    "number": "1962597179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "975 E THIRD STREET",
            "city": "CHATTANOOGA",
            "state": "TN",
            "postal_code": "37403",
            "telephone_number": "423-778-4780",
            "fax_number": "423-778-4833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3800 TENNESSEE AVE STE 124",
            "city": "CHATTANOOGA",
            "state": "TN",
            "postal_code": "374091260",
            "telephone_number": "423-778-4780",
            "fax_number": "423-778-4833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHATTANOOGA HAMILTON COUNTY HOSPITAL AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-04",
        "last_updated": "2022-03-10",
        "certification_date": "2022-03-10",
        "status": "A",
        "authorized_official_last_name": "SHAVER",
        "authorized_official_first_name": "MIKE",
        "authorized_official_middle_name": "DALE",
        "authorized_official_title_or_position": "DIRECTOR OF REIMBURSEMENT",
        "authorized_official_telephone_number": "423-240-8576"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "TN",
            "license": "0000000140",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000451481A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Side Community Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Side Community Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southside Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chattanooga, TN

Sources for this page

Verify at the official NPI Registry.