NPIMap

Organization Active NPI

Georgia Highlands Medical Services, Inc

Doing business as Highlands Medical Plaza

  • Federally Qualified Health Center (FQHC)
  • Cumming, GA
National Provider Identifier
1407306418
Registry record updated May 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
GEORGIA HIGHLANDS MEDICAL SERVICES, INC
Doing business as
Highlands Medical Plaza
Practice address
475 Tribble Gap Rd
Cumming, GA 30040-2478
Phone
(770) 887-1668
Fax
(770) 781-9937
NPI assigned
Oct 13, 2016
Last updated
May 9, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 9, 2022

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

Authorized official

Name
Mr. Todd Shifflet
Title
Ceo
Phone
(770) 887-1668

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Urgent Care Clinic/Center 261QU0200X

Addresses

Primary practice location

475 Tribble Gap Rd
Cumming, GA 30040-2478

Mailing address

PO Box 307
Cumming, GA 30028-0307
Phone (770) 887-1668

Other identifiers 3

IdentifierTypeStateIssuer
GRP1700OtherGAMEDICARE PIN
003183795AMedicaidGA
300022400AMedicaidGA

Other names 1

  • Highlands Medical Plaza Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040302001307 GA Part B Supplier - Clinic/Group Practice 5890682017 Receives reassigned benefits from 26 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Canton, GA; Dawsonville, GA; Cumming, GA; Cartersville, GA; Buford, GA
O20161215000918 GA Part A Provider - Federally Qualified Health Center (FQHC) 5890682017 Practice locations: Cumming, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407306418. Details of each certification follow.

Federally qualified health center certification: CCN 111051

Legal name
GEORGIA HIGHLANDS MEDICAL SERVICES, INC.
Doing business as
HIGHLANDS MEDICAL PLAZA
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 15, 2016
Last certification
Dec 15, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 1979 in GA
Enrollment address
475 Tribble Gap Rd
Cumming, GA 30040-2478

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory
Tax ID family
Georgia Highlands Medic8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Todd Shifflet Individual Corporate OfficerCeo Apr 13, 2014 100%
Corporate DirectorCeo Apr 13, 2014 100%
Stephen Brown Individual Corporate OfficerCfo Apr 19, 2017 99%
Operational/Managerial ControlCfo Apr 19, 2017 99%

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Georgia Highlands Medical Services, Inc.Cumming, GA, CCN 111195 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Nov 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.

Practitioners & affiliated clinicians

Practitioners 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1476316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652054400000",
    "number": "1407306418",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 307",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300280307",
            "telephone_number": "770-887-1668",
            "fax_number": "770-781-9937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "475 TRIBBLE GAP RD",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300402478",
            "telephone_number": "770-887-1668",
            "fax_number": "770-781-9937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GEORGIA HIGHLANDS MEDICAL SERVICES, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-13",
        "last_updated": "2022-05-09",
        "certification_date": "2022-05-09",
        "status": "A",
        "authorized_official_last_name": "SHIFFLET",
        "authorized_official_first_name": "TODD",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "770-887-1668",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PIN",
            "identifier": "GRP1700",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003183795A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300022400A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Highlands Medical Plaza",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Highlands Medical Plaza",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cumming, GA

Sources for this page

Verify at the official NPI Registry.