NPIMap

Organization Active NPI

Coastal Community Health Services, Inc.

Doing business as Coastal Community Health County Clinic

  • Federally Qualified Health Center (FQHC)
  • Brunswick, GA
National Provider Identifier
1063282937
Registry record updated Jan 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COASTAL COMMUNITY HEALTH SERVICES, INC.
Doing business as
Coastal Community Health County Clinic
Practice address
2747 4TH St
Brunswick, GA 31520-3714
Phone
(912) 289-2617
NPI assigned
Jan 3, 2024
Last updated
Jan 3, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 3, 2024

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

Authorized official

Name
Kavanaugh Chandler, MD
Title
Ceo
Phone
(912) 275-8028

Specialties & licenses 1

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

Addresses

Primary practice location

2747 4TH St
Brunswick, GA 31520-3714

Mailing address

100 Professional Center Dr
Brunswick, GA 31525-6743
Phone (912) 275-8028

Other names 1

  • Coastal Community Health County Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250528003801 GA Part A Provider - Federally Qualified Health Center (FQHC) 0345463683 Practice locations: Brunswick, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063282937. Details of each certification follow.

Federally qualified health center certification: CCN C21038

Legal name
COASTAL COMMUNITY HEALTH SERVICES INC
Doing business as
CCH-GLYNN COUNTY EMPLOYEE HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 13, 2025
Last certification
May 13, 2025
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 25, 2012 in GA
Enrollment address
2747 4TH St
Brunswick, GA 31520-3714

Other NPIs with the same Medicare PAC ID 16

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

View all 16

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
11D2340192Coastal Community Health- County Clinic2747 Fourth Street, Brunswick, GA 31520Provider-performed microscopyMar 12, 2028

National Provider Directory

National Provider Directory
Tax ID family
Coastal Community Health Services Inc24 organizations share this tax ID, including this one

Other organizations with this tax ID 23

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

View all 23

Locations

22385 Flora Parke Xing
Fernandina Beach, FL 32034
Phone (904) 404-8641

106 Shoppers Way
Ste 101
Brunswick, GA 31525
Phone (912) 275-8208

2321 Pooler Pkwy
Ste 106109
Pooler, GA 31322
Phone (912) 303-7149

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Faye Mathis Individual Corporate DirectorBoard Vice Chair Jan 9, 2020
Kavanaugh Chandler Individual Corporate DirectorCeo Jul 1, 2021 100%
W-2 Managing EmployeeCeo Jul 6, 2021 100%
Jeffery Clark Individual Corporate DirectorBoard Treasurer Jun 17, 2022
Samantha Young Individual Corporate DirectorBoard Member Jun 26, 2023
Josiah Watts Individual Corporate DirectorBoard Chair Aug 30, 2022
D'Jon McNair Individual Corporate DirectorBoard Member Jun 26, 2023

Practitioners & affiliated clinicians

Practitioners 118

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.

View all 118

NPI Registry JSON

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

{
    "created_epoch": "1704240000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704240000000",
    "number": "1063282937",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 PROFESSIONAL CENTER DR",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315256743",
            "telephone_number": "912-275-8028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2747 4TH ST",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315203714",
            "telephone_number": "912-289-2617"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-03",
        "last_updated": "2024-01-03",
        "certification_date": "2024-01-03",
        "status": "A",
        "authorized_official_last_name": "CHANDLER",
        "authorized_official_first_name": "KAVANAUGH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-275-8028",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Coastal Community Health County Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Brunswick, GA

Sources for this page

Verify at the official NPI Registry.