NPIMap

Organization Active NPI

Primary Health Care Center of Dade, Inc.

  • Federally Qualified Health Center (FQHC)
  • Summerville, GA
National Provider Identifier
1457770612
Registry record updated Apr 15, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PRIMARY HEALTH CARE CENTER OF DADE, INC.
Practice address
11638 Highway 27
Suite 8
Summerville, GA 30747-8514
Phone
(706) 657-7575
NPI assigned
Apr 15, 2014
Last updated
Apr 15, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 15, 2014

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

Authorized official

Name
Amy L Buffington
Title
Administrative Services Manager
Phone
(706) 657-7575

Specialties & licenses 1

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

Addresses

Primary practice location

11638 Highway 27
Suite 8
Summerville, GA 30747-8514

Mailing address

13570 N Main St
Trenton, GA 30752-2012
Phone (706) 657-7575

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060607000231 GA Part B Supplier - Clinic/Group Practice 0547272650 Receives reassigned benefits from 10 practitioners
12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Summerville, GA; Tunnel Hill, GA; Trenton, GA; Rossville, GA; Ringgold, GA; La Fayette, GA; Fort Oglethorpe, GA
O20140904002621 GA Part A Provider - Federally Qualified Health Center (FQHC) 0547272650 Practice locations: Summerville, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1457770612. Details of each certification follow.

Federally qualified health center certification: CCN 111985

Legal name
PRIMARY HEALTH CARE CENTER OF DADE, INC
Doing business as
PRIMARY HEALTH CARE CENTER SUMMERVILLE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 25, 2014
Last certification
Sep 25, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 2, 1980 in GA
Enrollment address
11638 Hwy 27 Suite 8
Summerville, GA 30747-8514

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 12

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

National Provider Directory

National Provider Directory
Tax ID family
Primary Health Care Center of Dade Inc10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Maritza McKinney Individual OtherBoard Member Apr 15, 2026
Kay Henderson Individual OtherBoard Member Jul 12, 2024
Susan Wells Individual OtherBoard Member Jul 12, 2024
Norman Menard Individual OtherBoard Member Apr 15, 2026
Andrew Plisko Individual OtherBoard Member Jul 12, 2024
Dale Thomas Dreiling Individual OtherBoard Member Apr 15, 2026
Ruben Olm Individual OtherBoard Member Apr 15, 2026
Richard Christman Individual W-2 Managing EmployeeAd; Apr 15, 2026 100%
Davis Brown Individual OtherBoard Member Apr 15, 2026
Michael Caldwell Individual OtherBoard Member Apr 15, 2026
Amy Buffington Individual Corporate DirectorCredentialing Director Jun 11, 2010 100%
W-2 Managing EmployeeCredentialing Director Jun 1, 1999
Talisyn Ridley Individual OtherBoard Member Jul 30, 2021

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Tiger Creek Elementary SchoolTunnel Hill, GA, CCN 111960 Federally qualified health center Other Mar 1, 2013

Owned or controlled facilities with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1397520000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1397520000000",
    "number": "1457770612",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13570 N MAIN ST",
            "city": "TRENTON",
            "state": "GA",
            "postal_code": "307522012",
            "telephone_number": "706-657-7575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11638 HIGHWAY 27",
            "address_2": "SUITE 8",
            "city": "SUMMERVILLE",
            "state": "GA",
            "postal_code": "307478514",
            "telephone_number": "706-657-7575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY HEALTH CARE CENTER OF DADE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-15",
        "last_updated": "2014-04-15",
        "status": "A",
        "authorized_official_last_name": "BUFFINGTON",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "ADMINISTRATIVE SERVICES MANAGER",
        "authorized_official_telephone_number": "706-657-7575"
    },
    "taxonomies": [
        {
            "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 Summerville, GA

Sources for this page

Verify at the official NPI Registry.