NPIMap

Organization Active NPI

East Georgia Healthcare Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Mount Vernon, GA
National Provider Identifier
1487892857
Registry record updated Aug 4, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAST GEORGIA HEALTHCARE CENTER, INC.
Practice address
118 E Broad St
Mount Vernon, GA 30445-3018
Phone
(478) 237-2638
Fax
(478) 237-9138
NPI assigned
Jan 23, 2009
Last updated
Aug 4, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 4, 2014

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

Authorized official

Name
Jill R Sorrells
Title
Cfo
Phone
(478) 237-6262

Specialties & licenses 1

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

Addresses

Primary practice location

118 E Broad St
Mount Vernon, GA 30445-3018

Mailing address

128 S Main St
Swainsboro, GA 30401-3618
Phone (478) 237-6262

Other identifiers 1

IdentifierTypeStateIssuer
000632376KMedicaidGA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050722000569 GA Part B Supplier - Clinic/Group Practice 0547228686 Receives reassigned benefits from 49 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wadley, GA; Vidalia, GA; Sylvania, GA; Swainsboro, GA; Mount Vernon, GA; Stillmore, GA; Statesboro, GA; Soperton, GA…
O20090219000122 GA Part A Provider - Federally Qualified Health Center (FQHC) 0547228686 Practice locations: Mount Vernon, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487892857. Details of each certification follow.

Federally qualified health center certification: CCN 111919

Legal name
EAST GEORGIA HEALTHCARE CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 12, 2009
Last certification
Mar 12, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 29, 1992 in GA
Enrollment address
118E Broad St
Mount Vernon, GA 30445-3018

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Other NPIs on the same Medicare enrollment 15

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

View all 15

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
11D1095724East Georgia Healthcare Center Inc118 E Broad Street, Mount Vernon, GA 30445Provider-performed microscopyFeb 16, 2027

National Provider Directory

National Provider Directory
Tax ID family
East Ga Hlthcare Ctr Inc21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

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

View all 20

Locations

128 S Main St
Swainsboro, GA 30401

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
Joel Salgado Individual Corporate Director Jan 1, 2021 10%
Gwendolyn Love Individual Corporate Director Feb 1, 2009
Lynda Morgan Individual Corporate Director Feb 1, 2009
Theron D Faison Individual Corporate Director Feb 1, 2009
Jennie W Denmark Individual Corporate OfficerCeo Feb 1, 2009
W-2 Managing Employee Feb 1, 2009
Elizabeth Hendrix Individual Corporate Director Feb 1, 2009
Cleveland White Individual Corporate DirectorBoard Member Jan 1, 2015 5%
Martin R Sheldon Individual Corporate OfficerChief Medical Officer Aug 1, 2021 5%
Ken Mercer Individual Corporate Officer Mar 1, 2021 10%
Luis Machado Individual Corporate Director Feb 1, 2009
Amanda R Brown Individual Corporate Director Feb 1, 2009
Jill R Sorrells Individual Corporate OfficerCfo Feb 1, 2009

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Statesboro Pediatrics and Family Healthcare CenterStatesboro, GA, CCN 111931 Federally qualified health center Other Mar 12, 2013
East Georgia Healthcare Center, Inc.Baxley, GA, CCN 111977 Federally qualified health center Operational/Managerial Control (100%) Jan 1, 2014
East Georgia Healthcare Center, Inc.Millen, GA, CCN 111063 Federally qualified health center Operational/Managerial Control May 1, 2017

Owned or controlled facilities with NPI records 4

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": "1232668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1407110400000",
    "number": "1487892857",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "128 S MAIN ST",
            "city": "SWAINSBORO",
            "state": "GA",
            "postal_code": "304013618",
            "telephone_number": "478-237-6262",
            "fax_number": "478-237-6221"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "118 E BROAD ST",
            "city": "MOUNT VERNON",
            "state": "GA",
            "postal_code": "304453018",
            "telephone_number": "478-237-2638",
            "fax_number": "478-237-9138"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST GEORGIA HEALTHCARE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-23",
        "last_updated": "2014-08-04",
        "status": "A",
        "authorized_official_last_name": "SORRELLS",
        "authorized_official_first_name": "JILL",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "478-237-6262"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000632376K",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mount Vernon, GA

Sources for this page

Verify at the official NPI Registry.