NPIMap

Organization Active NPI

Southern Family Medicine of Georgia, LLC

  • Family Medicine Physician
  • Statesboro, GA
National Provider Identifier
1528299393
Registry record updated Aug 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
43354 Issued in GA
Legal business name
SOUTHERN FAMILY MEDICINE OF GEORGIA, LLC
Practice address
1140 Brampton Ave
Statesboro, GA 30458
Phone
(912) 871-2273
Fax
(912) 872-3374
NPI assigned
Jul 28, 2009
Last updated
Aug 8, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 8, 2023

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

Authorized official

Name
Cindy R Rush
Title
Billing Manager
Phone
(912) 290-5235

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 43354 GA Primary

Addresses

Primary practice location

1140 Brampton Ave
Statesboro, GA 30458

Mailing address

1140 Brampton Ave
Statesboro, GA 30458
Phone (912) 871-2273

Other practice location 1

308 E Long St
Claxton, GA 30417-1412
Phone (912) 290-5235

Other names 2

  • Tri-Care Family Medicine LLC Former legal business name
  • Southern Family Medicine LLC Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091105000378 GA Part B Supplier - Clinic/Group Practice 6608914056 Receives reassigned benefits from 11 practitioners
Practice locations: Claxton, GA; Statesboro, GA

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
11D1104838Southern Family Medicine of Georgia, LLC1140 Brampton Avenue, Statesboro, GA 30458Certificate of waiverSep 10, 2027
11D2064698Southern Family Medicine of Georgia, LLC308 East Long Street, Claxton, GA 30417Certificate of waiverAug 25, 2027

National Provider Directory

National Provider Directory

Locations

1140 Brampton Ave
Statesboro, GA 30458
Phone (912) 871-2273

Practitioners & affiliated clinicians

Practitioners 12

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": "1248739200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1691452800000",
    "number": "1528299393",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1140 BRAMPTON AVE",
            "city": "STATESBORO",
            "state": "GA",
            "postal_code": "30458",
            "telephone_number": "912-871-2273",
            "fax_number": "912-871-2274"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1140 BRAMPTON AVE",
            "city": "STATESBORO",
            "state": "GA",
            "postal_code": "30458",
            "telephone_number": "912-871-2273",
            "fax_number": "912-872-3374"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "308 E Long St",
            "address_purpose": "LOCATION",
            "city": "Claxton",
            "state": "GA",
            "postal_code": "304171412",
            "country_code": "US",
            "telephone_number": "912-290-5235",
            "fax_number": "912-290-5236",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SOUTHERN FAMILY MEDICINE OF GEORGIA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-07-28",
        "last_updated": "2023-08-08",
        "certification_date": "2023-08-08",
        "status": "A",
        "authorized_official_last_name": "RUSH",
        "authorized_official_first_name": "CINDY",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "912-290-5235"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "43354",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri-Care Family Medicine LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Southern Family Medicine LLC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Statesboro, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.