NPIMap

Organization Active NPI

Northshore Health Centers, Inc.

Doing business as NorthShore Edison Senior High School

  • Federally Qualified Health Center (FQHC)
  • Lake Station, IN
National Provider Identifier
1972895647
Registry record updated Sep 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHSHORE HEALTH CENTERS, INC.
Doing business as
NorthShore Edison Senior High School
Practice address
3304 Parkside Ave
Lake Station, IN 46405-1143
Phone
(219) 763-8112
Fax
(219) 962-1860
NPI assigned
May 12, 2011
Last updated
Sep 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 22, 2020

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

Authorized official

Name
David Hall
Title
Ceo
Phone
(219) 763-8112

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

3304 Parkside Ave
Lake Station, IN 46405-1143

Mailing address

PO Box 1430
Portage, IN 46368-9230
Phone (219) 763-8112

Other identifiers 3

IdentifierTypeStateIssuer
191360OtherINMEDICARE PART B PTAN
151874OtherINMEDICARE PART A PTAN
200331170FMedicaidIN

Other names 1

  • NorthShore Edison Senior High School Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040827000220 IN Part B Supplier - Clinic/Group Practice 5799671236 Receives reassigned benefits from 128 practitioners
25 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Station, IN; Merrillville, IN; Michigan City, IN; Portage, IN; Saint John, IN; Crown Point, IN; Schererville, IN; Valparaiso, IN…
O20110817000200 IN Part A Provider - Federally Qualified Health Center (FQHC) 5799671236 Practice locations: Lake Station, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972895647. Details of each certification follow.

Federally qualified health center certification: CCN 151874

Legal name
NORTHSHORE HEALTH CENTERS INC
Doing business as
NORTHSHORE EDISON SENIOR HIGH SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 4, 2011
Last certification
Oct 4, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 1997 in IN
Enrollment address
3304 Parkside Ave
Lake Station, IN 46405-1143

Other NPIs with the same Medicare PAC ID 22

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

View all 22

Other NPIs on the same Medicare enrollment 24

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

View all 24

National Provider Directory

National Provider Directory
Tax ID family
Northshore Health Centers Inc28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

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

View all 27

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Steven C Disney Individual Corporate OfficerBoard Member Dec 16, 2014
David Hall Individual Corporate OfficerCeo Jan 23, 2020
W-2 Managing EmployeeCeo Jan 23, 2020
Thomas Mosley Individual Corporate OfficerBoard Member Oct 20, 2015
Scott V Cherry Individual Corporate OfficerChairman Aug 1, 2011
Scott E Fritz Individual Corporate OfficerVice Chairman Aug 1, 2011
Wilma Vazquez Individual Corporate OfficerBoard Member Apr 26, 2016
Connie Rudd Individual Corporate OfficerBoard Member Aug 1, 2011
Corporate Director Aug 1, 2011
Jena Bellezza Individual Corporate OfficerBoard Member May 24, 2016
Tom Aldrich Individual Corporate OfficerBoard Member Aug 1, 2011

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": "1305158400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1600732800000",
    "number": "1972895647",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1430",
            "city": "PORTAGE",
            "state": "IN",
            "postal_code": "463689230",
            "telephone_number": "219-763-8112",
            "fax_number": "219-764-5380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3304 PARKSIDE AVE",
            "city": "LAKE STATION",
            "state": "IN",
            "postal_code": "464051143",
            "telephone_number": "219-763-8112",
            "fax_number": "219-962-1860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSHORE HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-12",
        "last_updated": "2020-09-22",
        "certification_date": "2020-09-22",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-763-8112"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B PTAN",
            "identifier": "191360",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A PTAN",
            "identifier": "151874",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200331170F",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NorthShore Edison Senior High School",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "NorthShore Edison Senior High School",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Station, IN

Sources for this page

Verify at the official NPI Registry.