NPIMap

Organization Active NPI

Cherry Street Services Inc

  • Federally Qualified Health Center (FQHC)
  • Grand Rapids, MI
National Provider Identifier
1982279428
Registry record updated Aug 31, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHERRY STREET SERVICES INC
Practice address
2303 Kalamazoo Ave SE Ste 200
Grand Rapids, MI 49507-3780
Phone
(616) 965-8379
Fax
(616) 940-5354
NPI assigned
May 26, 2021
Organization subpart
Yes
Parent organization
CHERRY STREET SERVICES INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 31, 2021

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

Authorized official

Name
Tasha Blackmon
Title
Ceo
Phone
(616) 965-8200

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Addiction (Substance Use Disorder) PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TA0400X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Anesthesiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207L00000X
Addiction Medicine (Anesthesiology) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207LA0401X
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

2303 Kalamazoo Ave SE Ste 200
Grand Rapids, MI 49507-3780

Mailing address

100 Cherry St SE
Grand Rapids, MI 49503-4526
Phone (616) 965-8209

Other names 1

  • Cherry Health - Southside Health Center Suite 200 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211213000519 MI Part A Provider - Federally Qualified Health Center (FQHC) 6800707647 Practice locations: Grand Rapids, MI

Federally qualified health center certification: CCN 231176

Legal name
CHERRY STREET SERVICES INC
Doing business as
SOUTHSIDE HEALTH CENTER SUITE 200
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 13, 2021
Last certification
Dec 13, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 26, 2021 in MI
Enrollment address
2303 Kalamazoo Ave SE
Ste 200
Grand Rapids, MI 49507-3780

Other NPIs with the same Medicare PAC ID 19

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

View all 19

National Provider Directory

National Provider Directory
Tax ID family
Employee Assistance Center Fulton29 organizations share this tax ID, including this one
Part of
Employee Assistance Center Fulton

Other organizations with this tax ID 28

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

View all 28

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Elizabeth Triezenberg Individual Corporate DirectorBoard Member Nov 1, 2021
Allen Tenhoor Individual Corporate DirectorBoard Member Nov 1, 2021
Ziyadah Shakir Individual Corporate DirectorBoard Member Nov 1, 2021
Allison Swets Individual Corporate DirectorBoard Member Nov 1, 2021
Esperanza Degnan Individual Corporate DirectorBoard Member Nov 1, 2021
Richard Stevens Individual Corporate DirectorBoard Member Nov 1, 2021
Tasha Blackmon Individual Corporate OfficerCeo Nov 1, 2021
W-2 Managing EmployeeCeo Nov 1, 2021
Margaret McGuiness Individual Corporate DirectorBoard Member Nov 1, 2021
David Smith Individual Corporate DirectorBoard Member Nov 1, 2021
Barbara Wybrecht Individual Corporate DirectorBoard Member Nov 1, 2021
Gwynn Bult Individual Corporate DirectorBoard Member Apr 25, 2023
Evelyn Esparza-Gonzales Individual Corporate DirectorBoard Member Apr 25, 2023
Francena Purchase-Owens Individual Corporate DirectorBoard Member Nov 1, 2021
Kimberly Lavender Individual Corporate DirectorBoard Member Nov 1, 2021
Leslie King Individual Corporate DirectorBoard Member Apr 25, 2023
Scott David Alfree Individual Corporate DirectorBoard Member Nov 1, 2021
Carol Dickinson Individual Corporate DirectorBoard Member Nov 1, 2021

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Barry Community Health CenterHastings, MI, CCN 231122 Federally qualified health center Operational/Managerial Control Dec 1, 2017

Owned or controlled facilities with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1621987200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1630368000000",
    "number": "1982279428",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CHERRY ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495034526",
            "telephone_number": "616-965-8209",
            "fax_number": "616-940-5366"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2303 KALAMAZOO AVE SE STE 200",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495073780",
            "telephone_number": "616-965-8379",
            "fax_number": "616-940-5354"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHERRY STREET SERVICES INC",
        "enumeration_date": "2021-05-26",
        "last_updated": "2021-08-31",
        "certification_date": "2021-08-31",
        "status": "A",
        "authorized_official_last_name": "BLACKMON",
        "authorized_official_first_name": "TASHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-965-8200"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207LA0401X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology, Addiction Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal 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
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cherry Health - Southside Health Center Suite 200",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Cherry Health - Southside Health Center Suite 200",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.