NPIMap

Organization Active NPI

City of Newark

  • Federally Qualified Health Center (FQHC)
  • Newark, NJ
National Provider Identifier
1972206258
Registry record updated Apr 18, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CITY OF NEWARK
Practice address
701 South Orange Avenue
Newark, NJ 07106-2209
Phone
(800) 734-7083
NPI assigned
Mar 24, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 18, 2024

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

Authorized official

Name
Ketlen Alsbrook
Title
Ceo & Director
Phone
(973) 733-5310

Specialties & licenses 1

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

Addresses

Primary practice location

701 South Orange Avenue
Newark, NJ 07106-2209

Mailing address

110 William St
Newark, NJ 07102-1304
Phone (973) 424-4271

Other identifiers 1

IdentifierTypeStateIssuer
0959961MedicaidNJ

Other names 1

  • Newark Department of Health and Community Wellness/Mary Eliza Mahoney Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100113000101 NJ Part B Supplier - Clinic/Group Practice 8123169182 Receives reassigned benefits from 24 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Newark, NJ
O20240610000283 NJ Part A Provider - Federally Qualified Health Center (FQHC) 8123169182 Practice locations: Newark, NJ

Federally qualified health center certification: CCN 311011

Legal name
CITY OF NEWARK
Doing business as
NEWARK DEPARTMENT OF HEALTH AND COMMUNITY WELLNESS MARY ELIZA MAHONEY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 5, 2024
Last certification
Jun 5, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
701 South Orange Avenue
Newark, NJ 71061300

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

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
31D2280261Mary Eliza Mahoney701 South Orange Avenue, Newark, NJ 07106Certificate of waiverApr 16, 2027

National Provider Directory

National Provider Directory
Tax ID family
City of Newark Dept of Child and Family Well Being Mobile Medical Van14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

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

View all 13

Locations

110 William St
Rm 201
Newark, NJ 07102
Phone (973) 733-7558

701 S Orange Ave
Newark, NJ 07106
Phone (800) 734-7083

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Andrea Mason Individual OtherBoard Member Nov 17, 2023
Atiya Jaha-Rashidi Individual OtherBoard Member Nov 17, 2023
Jason Ndungu Individual Corporate OfficerFinancial Operations Officer Nov 17, 2023
W-2 Managing EmployeeFinancial Operations Officer Nov 17, 2023
Ketlen Alsbrook Individual Corporate OfficerDirector/Ceo Nov 17, 2023
Corporate DirectorDirector/Ceo Nov 17, 2023
W-2 Managing EmployeeDirector/Ceo Nov 17, 2023
Tanisha Ginlock Individual OtherBoard Member Nov 17, 2023
Thaddeus Diggs Individual OtherBoard Member Nov 17, 2023
Thyson Halley Individual OtherBoard Member Nov 17, 2023
Alexandria Massey Individual Corporate OfficerChief Operations Officer Nov 17, 2023
W-2 Managing EmployeeChief Operations Officer Nov 17, 2023

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 24

NPI Registry JSON

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

{
    "created_epoch": "1679616000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713398400000",
    "number": "1972206258",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "110 WILLIAM ST",
            "city": "NEWARK",
            "state": "NJ",
            "postal_code": "071021304",
            "telephone_number": "973-424-4271",
            "fax_number": "973-353-8438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 SOUTH ORANGE AVENUE",
            "city": "NEWARK",
            "state": "NJ",
            "postal_code": "071062209",
            "telephone_number": "800-734-7083"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CITY OF NEWARK",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-03-24",
        "last_updated": "2024-04-18",
        "certification_date": "2023-04-18",
        "status": "A",
        "authorized_official_last_name": "ALSBROOK",
        "authorized_official_first_name": "KETLEN",
        "authorized_official_title_or_position": "CEO & DIRECTOR",
        "authorized_official_telephone_number": "973-733-5310"
    },
    "taxonomies": [
        {
            "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": "0959961",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Newark Department of Health and Community Wellness/Mary Eliza Mahoney",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Newark, NJ

Sources for this page

Verify at the official NPI Registry.