NPIMap

Organization Active NPI

Wellstar Sylvan Grove Hospital, Inc

Doing business as Sylvan Grove Hospital

  • Critical Access Hospital
  • Jackson, GA
National Provider Identifier
1386664779
Registry record updated Oct 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
Legal business name
WELLSTAR SYLVAN GROVE HOSPITAL, INC
Doing business as
Sylvan Grove Hospital
Practice address
1050 McDonough Rd
Jackson, GA 30233-1524
Phone
(770) 775-7861
NPI assigned
Jul 20, 2006
Last updated
Oct 31, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 31, 2024

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

Authorized official

Name
Mr. Anthony J Buzdinski
Title
Evp
Phone
(470) 644-0012

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X Primary

Addresses

Primary practice location

1050 McDonough Rd
Jackson, GA 30233-1524

Mailing address

1800 Parkway PL SE Ste 500
Marietta, GA 30067-8237
Phone (470) 956-4981

Other identifiers 19

IdentifierTypeStateIssuer
00715107TMedicaidGA
152710726OtherKAISER FOUNDATION HEALTH
1703761MedicaidLA
000444OtherHUMANA
00791062EMedicaidGA
111319B000000OtherSECTION 1011
23360OtherCOVENTRY HEALTH CARE GEOR
416159OtherCOVENTRY HEALTH CARE GEOR
00001856AMedicaidGA
00282488BMedicaidGA
00001856SMedicaidGA
010492809(TRR)MedicaidMO
004378OtherBCBS OF GEORGIA
00495382DMedicaidGA
00885024BMedicaidGA
085001319GMedicaidGA
973964590OtherAETNA US HEALTHCARE
00211549EMedicaidGA
00214607FMedicaidGA

Other names 1

  • Sylvan Grove Hospital Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220807000077 GA Part A Provider - Critical Access Hospital 7618266974 Practice locations: Jackson, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386664779. Details of each certification follow.

Hospital certification: CCN 11Z319

Legal name
WELLSTAR SYLVAN GROVE HOSPITAL INC
Doing business as
WELLSTAR SYLVAN GROVE HOSPITAL
Organization structure
CorporationNon-profit
Enrollment address
1050 McDonough Rd
Swing Bed
Jackson, GA 30233-1524
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 22

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

NameRoleSinceShare
William C Brock Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Joseph a Reppert Individual Corporate OfficerSenior Vice President of Finance Apr 4, 2024 100%
W-2 Managing EmployeeSenior Vice President of Finance Aug 3, 2020 100%
Orrin S Swayze Individual Corporate DirectorBoard Member Apr 1, 2016 5%
John C McKibben Individual Corporate DirectorBoard Member Aug 1, 2019 5%
Hiram Speer Burdette Individual Corporate Director Apr 1, 2016 5%
Keith Parker Individual Corporate DirectorBoard Member Jul 1, 2023 5%
Paul Lawrence Douglass Individual Corporate DirectorBoard Member Aug 22, 2016 5%
Mitzi Moore Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Wellstar Health System Inc Organization, Marietta, GA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Apr 1, 2016 100%
Gretchen Corbin Individual Corporate DirectorBoard Member Oct 3, 2024 5%
James Glen Cunningham Individual Corporate DirectorBoard Member Mar 4, 2021 5%
Ebenezer Erzuah Individual W-2 Managing EmployeeExec Director of Reimbursement Apr 1, 2015 100%
Mark Berry Individual Corporate DirectorBoard Member Oct 7, 2021 5%
James Holmes Individual Corporate DirectorBoard Member Apr 4, 2016 5%
Candice Saunders Individual Corporate OfficerPresident & Ceo Apr 1, 2016 100%
Edward Tate Individual Corporate DirectorBoard Member Nov 3, 2023 5%
James Swartz Individual Corporate OfficerVice President of Accounting Apr 4, 2024 100%
W-2 Managing EmployeeVice President of Finance Apr 1, 2016 100%
Greg Morgan Individual Corporate DirectorBoard Member Apr 1, 2016 5%
James L Hornsby Individual Corporate DirectorBoard Member Jul 1, 2018 5%
Edward Richardson Individual Corporate DirectorBoard Member Apr 4, 2019 5%
David Bottoms Individual Corporate DirectorBoard Member Feb 2, 2023 5%
Frank Ros Individual Corporate DirectorBoard Member Apr 1, 2016 5%

Owners & managing parties with NPI records 3

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

Facilities with the same owner 18

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

View all 18

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730332800000",
    "number": "1386664779",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1800 PARKWAY PL SE STE 500",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300678237",
            "telephone_number": "470-956-4981",
            "fax_number": "770-999-2489"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 MCDONOUGH RD",
            "city": "JACKSON",
            "state": "GA",
            "postal_code": "302331524",
            "telephone_number": "770-775-7861"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR SYLVAN GROVE HOSPITAL, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-20",
        "last_updated": "2024-10-31",
        "certification_date": "2024-10-21",
        "status": "A",
        "authorized_official_last_name": "BUZDINSKI",
        "authorized_official_first_name": "ANTHONY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "EVP",
        "authorized_official_telephone_number": "470-644-0012",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00715107T",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "KAISER FOUNDATION HEALTH",
            "identifier": "152710726",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1703761",
            "state": "LA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HUMANA",
            "identifier": "000444",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00791062E",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SECTION 1011",
            "identifier": "111319B000000",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "COVENTRY HEALTH CARE GEOR",
            "identifier": "23360",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "COVENTRY HEALTH CARE GEOR",
            "identifier": "416159",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00001856A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00282488B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00001856S",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010492809(TRR)",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF GEORGIA",
            "identifier": "004378",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00495382D",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00885024B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "085001319G",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA US HEALTHCARE",
            "identifier": "973964590",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00211549E",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00214607F",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Sylvan Grove Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sylvan Grove Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, GA

Sources for this page

Verify at the official NPI Registry.