NPIMap

Organization Active NPI

Community Health Centers of Southeastern Iowa Inc

Doing business as Tri-State Medical Group Inc

  • Federally Qualified Health Center (FQHC)
  • Hamilton, IL
National Provider Identifier
1992784300
Registry record updated Jan 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Doing business as
Tri-State Medical Group Inc
Practice address
951 Broadway St
Hamilton, IL 62341-1436
Phone
(217) 847-2112
Fax
(319) 753-2301
NPI assigned
Jan 13, 2006
Last updated
Jan 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2023

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

Authorized official

Name
Mr. Antonio Flores, CEO
Title
Ceo
Phone
(319) 768-5858

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

951 Broadway St
Hamilton, IL 62341-1436

Mailing address

1706 West Agency Road
West Burlington, IA 52655
Phone (319) 768-5858

Other identifiers 3

IdentifierTypeStateIssuer
3422957OtherILBLUE CROSS BLUE SHIELD
0563890MedicaidIA
506089416MedicaidMO

Other names 1

  • Tri-State Medical Group Inc Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20021216000016 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486562527 Practice locations: Hamilton, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1992784300. Details of each certification follow.

Federally qualified health center certification: CCN 141933

Legal name
COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 13, 2002
Last certification
Dec 13, 2002
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 29, 2001 in IA
Enrollment address
951 Broadway St
Hamilton, IL 62341-1436

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory

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
William Staats Individual Corporate OfficerBoard Member Oct 1, 2010
Julie a Schilling Individual Corporate OfficerBoard Member Oct 1, 2010
Angelica Lozano Individual Corporate OfficerBoard Member Aug 22, 2019
David Whitaker Individual Corporate OfficerBoard Member Oct 1, 2010
Kathy Vance Individual Corporate OfficerBoard Member Oct 1, 2010
William Grimm Individual Corporate Director Jan 1, 2025
W-2 Managing Employee Jan 1, 2025
Jeffrey Strause Individual Corporate OfficerBoard Member Jan 25, 2018
Chuck Griffin Individual Corporate Officer Jan 1, 2016

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": "1137110400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674604800000",
    "number": "1992784300",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1706 WEST AGENCY ROAD",
            "city": "WEST BURLINGTON",
            "state": "IA",
            "postal_code": "52655",
            "telephone_number": "319-768-5858",
            "fax_number": "319-753-2301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "951 BROADWAY ST",
            "city": "HAMILTON",
            "state": "IL",
            "postal_code": "623411436",
            "telephone_number": "217-847-2112",
            "fax_number": "319-753-2301"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-13",
        "last_updated": "2023-01-25",
        "certification_date": "2023-01-25",
        "status": "A",
        "authorized_official_last_name": "FLORES",
        "authorized_official_first_name": "ANTONIO",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "319-768-5858",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "3422957",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0563890",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "506089416",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri-State Medical Group Inc",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Tri-State Medical Group Inc",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hamilton, IL

Sources for this page

Verify at the official NPI Registry.