Bridge Hospice LLC
Organization Active NPI Community Based Hospice Care Agency · Pooler, GA
NPI 1104221209 · NPPES record last updated Sep 20, 2022
Key facts
- NPI
- 1104221209
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- Legal business name
- BRIDGE HOSPICE LLC
- Practice address
- 119 Canal St Ste 103
Pooler, GA 31322 - Phone
- (912) 417-4571
- Fax
- (912) 417-4370
- NPI assigned
- Oct 31, 2014
- Organization subpart
- No
Authorized official
- Name
- Mr. Aaron J Musselman
- Title
- Owner/President
- Phone
- (912) 417-4571
Owners & managing parties with NPI records 1
Affiliated clinicians 2
-
Michael Todd Peacock, M.D.
-
Leslie Birdsong Sizemore, M.D.
Medicare Care Compare: Hospice
- Listed as
- Bridge Hospice, LLC
- Ownership
- For-Profit
- Certified
- Aug 21, 2015
- Medicare certification status
- Active
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Hospice certification: CCN 111772
- Legal name
- BRIDGE HOSPICE LLC
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- Aug 21, 2015
- Last certification
- Jul 29, 2020
- Ownership / control type
- Proprietary - Partnership
- Organization structure
- LLC · Proprietary
- Incorporated
- Dec 26, 2013 in GA
- Enrollment address
- 119 Canal St
Ste 103
Pooler, GA 31322-4094
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Kari Baer |
5% Or Greater Direct Ownership Interest | Mar 16, 2016 | 20% |
| Corporate Officer |
Mar 16, 2016 | ||
| Aaron James Musselman |
5% Or Greater Direct Ownership Interest | Mar 16, 2016 | 31% |
| Corporate Officer |
Mar 16, 2016 | ||
| James Jividen |
W-2 Managing Employee |
Nov 1, 2019 | |
| Jeffrey R Dugas |
5% Or Greater Direct Ownership Interest | Mar 16, 2016 | 10% |
| Kristin R Chase |
5% Or Greater Direct Ownership Interest | Mar 16, 2016 | 34% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150115000561 | GA | Part a Provider - Hospice | 3971827296 | Practice locations: Pooler, GA |
National Provider Directory
Locations
911 N Tennessee St
Ste 209
Cartersville, GA 30120
Phone (770) 334-8811
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | Yes | ||
| Inpatient Hospice | 315D00000X |
Addresses
Primary practice location
119 Canal St Ste 103
Pooler, GA 31322
Mailing address
119 Canal St Ste 103
Pooler, GA 31322-4094
Phone (912) 417-4571
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 003189404A | Medicaid | GA |
Other providers in Pooler, GA
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- Heidi Marlies Braun
- Brave Tomorrow Counseling and Consulting
- Caitlin Breitweiser
- Arion Imani Brevard
- Linda Camille Brinson
- Alexandria Copeland Brooks
- Faberge Brooks
- Arreyona Amea Rana Brown
- Donna Marie Brown
All providers in Pooler, GA · Community Based Hospice Care Agency in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 20, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.