NPIMap

Organization Active NPI

East Georgia Healthcare Center Inc

  • Federally Qualified Health Center (FQHC)
  • Sylvania, GA
National Provider Identifier
1366089062
Registry record updated Sep 30, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Sep 30, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2021

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

Authorized official

Name
Jill R Sorrells
Title
Cfo
Phone
(478) 237-6262

Specialties & licenses 1

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

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366089062. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Oct 19, 1992 in GA
Enrollment address
330 Mims Rd
Sylvania, GA 30467-1904

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

Other NPIs on the same Medicare enrollment 15

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 15

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
11D2177432East Georgia Healthcare Center Inc330 Mims Road, Sylvania, GA 30467Certificate of waiverJan 9, 2028

National Provider Directory

National Provider Directory
Tax ID family
East Ga Hlthcare Inc21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

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

View all 20

Locations

121 N Main St
Sylvania, GA 30467
Phone (912) 531-7465

303 Mims Rd
Sylvania, GA 30467

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Joel Salgado Individual Corporate DirectorBoard Member Jan 1, 2021 10%
Pat Gunn Individual Corporate DirectorBoard Member Jan 1, 2020
Gwendolyn Love Individual Corporate DirectorBoard Member Jan 1, 2020
Tabitha Johns Individual Corporate DirectorAccount Manager Jan 1, 2025
Lynda Morgan Individual Corporate DirectorBoard Chairperson Jan 1, 2020
Theron D Faison Individual Corporate DirectorBoard Member Jan 1, 2020
Jennie W Denmark Individual Corporate OfficerCeo Jan 1, 2020
W-2 Managing EmployeeCeo Jan 1, 2020
Elizabeth Hendrix Individual Corporate DirectorBoard Member Jan 1, 2020
Kenneth Griffin Individual Corporate DirectorBoard Member Jan 1, 2025
Barbara Bruno Individual Corporate DirectorBoard Member Jan 1, 2025
Ken Mercer Individual Corporate OfficerBoard Member Mar 1, 2021 10%
Luis Machado Individual Corporate DirectorBoard Member Jan 1, 2020
Amanda R Brown Individual Corporate DirectorBoard Member Jan 1, 2020
Herbert Hodges Individual Corporate DirectorBoard Member Jan 1, 2025
Jill R Sorrells Individual Corporate OfficerCfo Jan 1, 2020
W-2 Managing EmployeeCfo Jan 1, 2020

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Statesboro Pediatrics and Family Healthcare CenterStatesboro, GA, CCN 111931 Federally qualified health center Other Mar 12, 2013
East Georgia Healthcare Center, Inc.Baxley, GA, CCN 111977 Federally qualified health center Operational/Managerial Control (100%) Jan 1, 2014
East Georgia Healthcare Center, Inc.Millen, GA, CCN 111063 Federally qualified health center Operational/Managerial Control May 1, 2017

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

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

{
    "created_epoch": "1575244800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632960000000",
    "number": "1366089062",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 N COLEMAN ST",
            "city": "SWAINSBORO",
            "state": "GA",
            "postal_code": "304013530",
            "telephone_number": "478-237-6262",
            "fax_number": "478-237-9138"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "330 MIMS RD",
            "city": "SYLVANIA",
            "state": "GA",
            "postal_code": "304671992",
            "telephone_number": "912-451-5887",
            "fax_number": "912-451-5886"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST GEORGIA HEALTHCARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-02",
        "last_updated": "2021-09-30",
        "certification_date": "2021-09-14",
        "status": "A",
        "authorized_official_last_name": "SORRELLS",
        "authorized_official_first_name": "JILL",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "478-237-6262"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sylvania, GA

Sources for this page

Verify at the official NPI Registry.