East Georgia Healthcare Center Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Sylvania, GA
NPI 1366089062 · NPPES record last updated Sep 30, 2021
Key facts
- NPI
- 1366089062
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- EAST GEORGIA HEALTHCARE CENTER INC
- Practice address
- 330 Mims Rd
Sylvania, GA 30467-1992 - Phone
- (912) 451-5887
- Fax
- (912) 451-5886
- NPI assigned
- Dec 2, 2019
- Organization subpart
- No
Authorized official
- Name
- Jill R Sorrells
- Title
- Cfo
- Phone
- (478) 237-6262
Owned or controlled facilities with NPI records 4
Other NPIs on the same Medicare enrollment 15
Other NPIs with the same Medicare PAC ID 16
Corporate family (same tax ID) 19
Practitioners 17
-
Michael Austin, M.D.
-
Joseph Chad Clifton, L.C.S.W.
-
Sreevalli Dega, MD
-
Mark Allen Haddock, D.C.
-
Tekisha Jones, FNP
-
Beverly Knighten, LCSW
-
Patrick M Riner, O.D.
-
Martin R Sheldon, MD
-
Phyllis Evon Solomon, FNP
-
Mary L Sparkes, MD
-
Emily Jane Tatum, MD
-
Bob H Barrett, O.D.
-
Jacob Funk, D.C.
-
Pamela Sheldon, LICSW
-
Abhijit Singh, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 11D2177432 | East Georgia Healthcare Center Inc | Certificate of waiver | Jan 9, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in GA
Federally qualified health center certification: CCN 111122
- Legal name
- EAST GEORGIA HEALTHCARE CENTER, INC.
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 15, 2020
- Last certification
- Jan 15, 2020
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Oct 19, 1992 in GA
- Enrollment address
- 330 Mims Rd
Sylvania, GA 30467-1904
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Joel Salgado |
Corporate Director |
Jan 1, 2021 | 10% |
| Pat Gunn |
Corporate Director |
Jan 1, 2020 | |
| Gwendolyn Love |
Corporate Director |
Jan 1, 2020 | |
| Tabitha Johns |
Corporate Director |
Jan 1, 2025 | |
| Lynda Morgan |
Corporate Director |
Jan 1, 2020 | |
| Theron D Faison |
Corporate Director |
Jan 1, 2020 | |
| Jennie W Denmark |
Corporate Officer |
Jan 1, 2020 | |
| W-2 Managing Employee |
Jan 1, 2020 | ||
| Elizabeth Hendrix |
Corporate Director |
Jan 1, 2020 | |
| Kenneth Griffin |
Corporate Director |
Jan 1, 2025 | |
| Barbara Bruno |
Corporate Director |
Jan 1, 2025 | |
| Ken Mercer |
Corporate Officer |
Mar 1, 2021 | 10% |
| Luis Machado |
Corporate Director |
Jan 1, 2020 | |
| Amanda R Brown |
Corporate Director |
Jan 1, 2020 | |
| Herbert Hodges |
Corporate Director |
Jan 1, 2025 | |
| Jill R Sorrells |
Corporate Officer |
Jan 1, 2020 | |
| W-2 Managing Employee |
Jan 1, 2020 |
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| Statesboro Pediatrics and Family Healthcare Center |
Federally qualified health center | Other | Mar 12, 2013 |
| East Georgia Healthcare Center, Inc. |
Federally qualified health center | Operational/Managerial Control (100%) | Jan 1, 2014 |
| East Georgia Healthcare Center, Inc. |
Federally qualified health center | Operational/Managerial Control | May 1, 2017 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050722000569 | GA | Part B Supplier - Clinic/Group Practice | 0547228686 |
Receives reassigned benefits from 49 practitioners 15 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Wadley, GA; Vidalia, GA; Sylvania, GA; Swainsboro, GA; Mount Vernon, GA; Stillmore, GA; Statesboro, GA; Soperton, GA… |
| O20200114002756 | GA | Part a Provider - Federally Qualified Health Center (FQHC) | 0547228686 | Practice locations: Sylvania, GA |
National Provider Directory
- Tax ID family
- East Ga Hlthcare Ctr Inc
Locations
121 N Main St
Sylvania, GA 30467
Phone (912) 531-7465
303 Mims Rd
Sylvania, GA 30467
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
330 Mims Rd
Sylvania, GA 30467-1992
Mailing address
215 N Coleman St
Swainsboro, GA 30401-3530
Phone (478) 237-6262
Other providers in Sylvania, GA
- Community Service Board of Middle Georgia
- Katrina Cooper
- Prissilla Cooper
- Nicolasa Correa
- Anne Davis
- Evergreen Counseling Services, LLC
- Faith Forward Transit, LLC.
- James Cleveland Freeman Jr.
- Ga Opco LLC
- Gerdie and Louise PCH
All providers in Sylvania, GA · Federally Qualified Health Center (FQHC) 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 30, 2021. 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.