NPIMap

Organization Active NPI

Primary Care of Southwest Georgia, Inc

  • Federally Qualified Health Center (FQHC)
  • Thomasville, GA
National Provider Identifier
1407375686
Registry record updated Sep 19, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Practice address
4681 US Highway 84 Byp W
Thomasville, GA 31792-2607
Phone
(229) 227-2936
Fax
(229) 225-5284
NPI assigned
Sep 19, 2017
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Edwin James
Title
Cfo
Phone
(229) 723-2660

Owners & managing parties with NPI records 6

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

Owned or controlled facilities with NPI records 1

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

Other NPIs on the same Medicare enrollment 7

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

Other NPIs with the same Medicare PAC ID 6

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

Facilities with the same owner 1

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

Practitioners 4

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

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
11D2134986Primary Care of Southwest Georgia - TCMS4681 US Highway 84 Bypass, Thomasville, GA 31792Certificate of waiverAug 13, 2027

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060201000362 GA Part B Supplier - Clinic/Group Practice 5496777948 Receives reassigned benefits from 22 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bainbridge, GA; Thomasville, GA; Quitman, GA; Blakely, GA
O20171103001548 GA Part a Provider - Federally Qualified Health Center (FQHC) 5496777948 Practice locations: Thomasville, GA

Federally qualified health center certification: CCN 111072

Medicare enrollment files
Legal name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Doing business as
PRIMARY CARE OF SOUTHWEST GEORGIA - TCMS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 3, 2017
Last certification
Nov 3, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 14, 2005 in GA
Enrollment address
4681 US Highway 84 Byp W
Thomasville, GA 31792-2607

All disclosed owners & managing parties 13

Medicare enrollment files

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

NameRoleSinceShare
Annette Summerset Individual Corporate Director Aug 17, 2021
Natalie Singletary Individual Corporate Director Dec 15, 2020
Wayne Lawson Individual Corporate DirectorBoard Member Jul 1, 2007
Kevin Taylor Individual Corporate DirectorBoard Member Mar 1, 2006
Kenneth Cody Individual Corporate DirectorBoard Member Jan 1, 2014
Janis Barron Individual Corporate DirectorBoard Member Mar 1, 2006
Angela McVey Individual W-2 Managing EmployeeCeo Feb 4, 2019
Operational/Managerial ControlCeo Feb 4, 2019
Joan S Simpson Individual Corporate DirectorBoard Member Jan 1, 2011
Crycynthia Gardner Individual Corporate DirectorBoard Member Aug 20, 2019
Primary Care of Southwest Georgia, Inc. Organization, Blakely, GA 5% Or Greater Direct Ownership Interest Sep 18, 2017 100%
Dan Provence Individual Corporate DirectorBoard Member May 12, 2015
Jackie Watson Individual Corporate DirectorBoard Member Feb 1, 2009
Edwin James Individual W-2 Managing EmployeeCfo May 15, 2006
Operational/Managerial ControlCfo May 15, 2006 100%

All facility ownership & control disclosures 1

Medicare enrollment files

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

FacilityTypeRoleSince
Primary Care of Southwest Georgia, Inc.Quitman, GA, CCN 111060 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 23, 2017

National Provider Directory

National Provider Directory
Tax ID family
Primary Care of Southwest Georgia Inc8 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.

Locations

4681 US Highway 84 Byp W
Thomasville, GA 31792
Phone (229) 227-2936

Specialties & licenses 1

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

Addresses

NPPES NPI Registry

Primary practice location

4681 US Highway 84 Byp W
Thomasville, GA 31792-2607

Mailing address

360 College St
Blakely, GA 39823-2554
Phone (229) 723-2660

Other names 1

NPPES NPI Registry
  • Primary Care of Southwest Georgia-TCMS Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Sep 19, 2017.

{
    "created_epoch": "1505779200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1505779200000",
    "number": "1407375686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "360 COLLEGE ST",
            "city": "BLAKELY",
            "state": "GA",
            "postal_code": "398232554",
            "telephone_number": "229-723-2660"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4681 US HIGHWAY 84 BYP W",
            "city": "THOMASVILLE",
            "state": "GA",
            "postal_code": "317922607",
            "telephone_number": "229-227-2936",
            "fax_number": "229-225-5284"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY CARE OF SOUTHWEST GEORGIA, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-19",
        "last_updated": "2017-09-19",
        "status": "A",
        "authorized_official_last_name": "JAMES",
        "authorized_official_first_name": "EDWIN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "229-723-2660"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Primary Care of Southwest Georgia-TCMS",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Thomasville, GA

Sources for this page

Verify at the official NPI Registry.