NPIMap

Organization Active NPI

Centerville Clinics Inc

  • School Social Worker
  • Washington, PA
National Provider Identifier
1992203095
Registry record updated Jan 24, 2018
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Key facts

NPPES NPI Registry
Primary specialty
School Social WorkerTaxonomy code 1041S0200X
Legal business name
CENTERVILLE CLINICS INC
Practice address
2500 South Main St Ext.
Trinity South Elementary School
Washington, PA 15301
Phone
(724) 225-7490
NPI assigned
Jan 24, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 24, 2018

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

Authorized official

Name
Mr. Barry Niccolai
Title
Executive Director
Phone
(724) 632-6801

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
School Social WorkerGroup: 193400000X SINGLE SPECIALTY GROUP 1041S0200X PA Primary

Addresses

Primary practice location

2500 South Main St Ext.
Trinity South Elementary School
Washington, PA 15301

Mailing address

1070 Old National Pike Road
Fredericktown, PA 15333-2114
Phone (724) 632-6801

Other identifiers 1

IdentifierTypeStateIssuer
1007288440027MedicaidPA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210503001873 PA Part A Provider - Federally Qualified Health Center (FQHC) 7214837202 Practice locations: Washington, PA

Federally qualified health center certification: CCN 731801

Legal name
CENTERVILLE CLINICS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 28, 2021
Last certification
Apr 28, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 2, 1953 in PA
Enrollment address
2500 S Main Street Ext
Washington, PA 15301-3269

Other NPIs with the same Medicare PAC ID 23

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

View all 23

National Provider Directory

National Provider Directory

Locations

2500 S Main Street Ext
Washington, PA 15301
Phone (724) 225-7490

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
Daniel L Holt Individual W-2 Managing EmployeeMedical Director Jan 1, 2011
Donna Salvino Individual Corporate DirectorSecretary / Treasurer Aug 25, 2014
Edward J Marotta Individual Corporate DirectorBoard Member Nov 17, 2014
Barry R Niccolai Individual Corporate OfficerExecutive Director Apr 1, 2017
W-2 Managing EmployeeManaging Employee Apr 1, 2017
Patricia a Gavazzi Individual Corporate DirectorBoard Member Jun 27, 2017
Darra Tyler-Owens Individual Corporate DirectorBoard Member Sep 29, 2018
Andrew Corfont Individual Corporate DirectorVice President Oct 23, 2023
Joseph M Yablonski Individual Corporate DirectorPresident of Board Nov 23, 2004
Marianne E Gideon Individual Corporate DirectorBoard Member Jun 27, 2016

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1516752000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1516752000000",
    "number": "1992203095",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1070 OLD NATIONAL PIKE ROAD",
            "city": "FREDERICKTOWN",
            "state": "PA",
            "postal_code": "153332114",
            "telephone_number": "724-632-6801",
            "fax_number": "724-632-6312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2500 SOUTH MAIN ST EXT.",
            "address_2": "TRINITY SOUTH ELEMENTARY SCHOOL",
            "city": "WASHINGTON",
            "state": "PA",
            "postal_code": "15301",
            "telephone_number": "724-225-7490"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERVILLE CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-01-24",
        "last_updated": "2018-01-24",
        "status": "A",
        "authorized_official_last_name": "NICCOLAI",
        "authorized_official_first_name": "BARRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "724-632-6801",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "1041S0200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker, School",
            "state": "PA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1007288440027",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Washington, PA

Sources for this page

Verify at the official NPI Registry.