NPIMap

Organization Active NPI

Southwest Georgia Healthcare Clinics Inc

  • Federally Qualified Health Center (FQHC)
  • Donalsonville, GA
National Provider Identifier
1396484606
Registry record updated Jun 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHWEST GEORGIA HEALTHCARE CLINICS INC
Practice address
804 N Wiley Ave
Donalsonville, GA 39845-1120
Phone
(229) 524-2808
Fax
(229) 524-1272
NPI assigned
Jun 3, 2022
Last updated
Jun 3, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2022

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

Authorized official

Name
Donna L Williams
Title
Ceo
Phone
(229) 524-1307

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

804 N Wiley Ave
Donalsonville, GA 39845-1120

Mailing address

205 Bresee St
Donalsonville, GA 39845-1134
Phone (229) 524-1307

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170613002024 GA Part B Supplier - Clinic/Group Practice 9739457896 Receives reassigned benefits from 8 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Donalsonville, GA
O20230302000564 GA Part A Provider - Federally Qualified Health Center (FQHC) 9739457896 Practice locations: Donalsonville, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396484606. Details of each certification follow.

Federally qualified health center certification: CCN 111187

Legal name
SOUTHWEST GEORGIA HEALTHCARE CLINICS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 6, 2023
Last certification
Jan 6, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 3, 2015 in GA
Enrollment address
804 N Wiley Ave
Donalsonville, GA 39845-1120

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 3

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

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
11D0266091Southwest Georgia Healthcare Clinics Inc804 N Wiley Avenue, Donalsonville, GA 39845Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Southwest Georgia Healthcare Clinics Inc4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Kemberly Earnest Individual Corporate DirectorTreasurer Sep 1, 2022
Betty Orange Individual Corporate DirectorBoard Member Sep 1, 2022
Brenda Peterson Individual Corporate DirectorBoard Member Sep 1, 2022
Katie Hatcher Individual Contracted Managing EmployeeCfo Sep 1, 2022
William Burke Individual Corporate DirectorBoard Member Sep 1, 2022
Donna L Williams Individual Corporate OfficerCeo Sep 1, 2022
Herman Brookins Individual Corporate DirectorBoard Member Sep 1, 2022
Mitchell Blanks Individual Corporate DirectorCo-Chairman Sep 1, 2022
Dianne Thomas Individual Corporate DirectorChairman Sep 1, 2022
Newton King Individual Corporate DirectorBoard Member Sep 1, 2022
Christina Corvers Individual Corporate DirectorBoard Member Sep 1, 2022
Charles H Orrick Individual Corporate DirectorBoard Member Sep 1, 2022
Southwest Georgia Healthcare Clinics, Inc. Organization, Donalsonville, GA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2022 100%

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Southwest Georgia Healthcare Clinics, Inc.Donalsonville, GA, CCN 111803 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2022

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

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

NPI Registry JSON

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

{
    "created_epoch": "1654214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654214400000",
    "number": "1396484606",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 BRESEE ST",
            "city": "DONALSONVILLE",
            "state": "GA",
            "postal_code": "398451134",
            "telephone_number": "229-524-1307",
            "fax_number": "229-524-6268"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "804 N WILEY AVE",
            "city": "DONALSONVILLE",
            "state": "GA",
            "postal_code": "398451120",
            "telephone_number": "229-524-2808",
            "fax_number": "229-524-1272"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHWEST GEORGIA HEALTHCARE CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-03",
        "last_updated": "2022-06-03",
        "certification_date": "2022-05-25",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "229-524-1307"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "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 Donalsonville, GA

Sources for this page

Verify at the official NPI Registry.