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Crisp Regional Hospital, Inc

Organization Active NPI Rural Health Clinic/Center · Cordele, GA

NPI 1376750976 · NPPES record last updated Mar 11, 2013

Key facts

NPI
1376750976
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
CRISP REGIONAL HOSPITAL, INC
Practice address
216 Hospital Dr
Cordele, GA 31015-3275
Phone
(229) 271-9330
Fax
(229) 271-9245
NPI assigned
May 16, 2007
Organization subpart
Yes
Parent organization (as reported)
CRISP REGIONAL HOSPITAL, INC

Authorized official

Name
James W. Miller
Title
Director Physician Practices
Phone
(229) 271-4676

Owners & managing parties with NPI records 8

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 2

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

Other NPIs with the same Medicare PAC ID 8

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

Facilities connected through Provider of Services related, parent or unit certification numbers.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 65

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 65

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2235401Crisp Regional Convenient Care
216 Hospital Drive, Cordele, GA 31015		Certificate of waiverSep 8, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled in GA

Rural health clinic certification: CCN 118555

Legal name
CRISP REGIONAL HOSPITAL INC
Doing business as
CRISP REGIONAL CONVENIENT CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 8, 2013
Last certification
Aug 2, 2023
Ownership / control type
2B
Organization structure
Corporation · Non-profit
Incorporated
Apr 4, 1995 in GA
Enrollment address
216 Hospital Dr
Cordele, GA 31015-3275
Related CCNs
110104

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Crisp Regional Hospital Inc
Organization · Cordele, GA
Non-profit 		Operational/Managerial Control May 1, 2012
Steven L. Gautney
Individual 		Corporate Officer
Cfo		 Jan 1, 2015
W-2 Managing Employee
Ceo		 May 1, 2012
Jessica Carter
Individual 		Corporate Officer Jan 1, 2015
W-2 Managing Employee
Cfo		 May 1, 2012

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Crisp Regional Hospital
Cordele, GA · CCN 110104		 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Crisp Regional Hospital
Cordele, GA · CCN 11U104		 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Caresouth an Affiliate of Crisp Regional Hospital
Cordele, GA · CCN 117309		 Home health agency 5% Or Greater Direct Ownership Interest Dec 14, 2007

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20120806000162 GA Part a Provider - Rural Health Clinic 5991616336 Practice locations: Cordele, GA

National Provider Directory

Part of
Surgical Associates

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X GA Yes

Addresses

Primary practice location

216 Hospital Dr
Cordele, GA 31015-3275

Mailing address

216 Hospital Dr
Cordele, GA 31015-3275
Phone (229) 276-2000

Other identifiers

IdentifierTypeStateIssuer
11-8907OtherGAMCR CCN

Other names

  • Crisp Regional Convenient Care Doing business as

Other providers in Cordele, GA

All providers in Cordele, GA · Rural Health Clinic/Center in Georgia

Sources for this page

Verify at the official NPI Registry.