NPIMap

Organization Active NPI

Wellstar Sylvan Grove Hospital, Inc

Doing business as WellStar Sylvan Grove Hospital

  • Critical Access Hospital
  • Jackson, GA
National Provider Identifier
1619997079
Registry record updated Oct 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
018-544 Issued in GA
Legal business name
WELLSTAR SYLVAN GROVE HOSPITAL, INC
Doing business as
WellStar Sylvan Grove Hospital
Practice address
1050 McDonough Rd
Jackson, GA 30233-1524
Phone
(770) 775-7861
NPI assigned
Jul 20, 2006
Last updated
Oct 31, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 31, 2024

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

Authorized official

Name
Mr. Anthony J Budzinski
Title
Evp
Phone
(470) 644-0012

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 018-544 GA Primary

Addresses

Primary practice location

1050 McDonough Rd
Jackson, GA 30233-1524

Mailing address

1800 Parkway PL SE Ste 500
Marietta, GA 30067-8237
Phone (470) 956-4981

Other identifiers 1

IdentifierTypeStateIssuer
000001856AMedicaidGA

Other names 1

  • WellStar Sylvan Grove Hospital Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210525003402 GA Part A Provider - Critical Access Hospital 7618266974 Practice locations: Jackson, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619997079. Details of each certification follow.

Hospital certification: CCN 111319

Legal name
WELLSTAR SYLVAN GROVE HOSPITAL INC
Doing business as
WELLSTAR SYLVAN GROVE HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Aug 28, 2001
Last certification
Nov 18, 2025
Beds
25
Ownership / control type
Private (not for profit)
Most recent change of ownership
Apr 1, 2016 (2 total)
Organization structure
CorporationNon-profit
Enrollment address
1050 McDonough Rd
Jackson, GA 30233-1524
Main/Primary Hospital Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Wellstar Sylvan Grove Medical CenterCCN 111319 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 20

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

NameRoleSinceShare
William C Brock Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Heather Graham Individual Corporate DirectorBoard Member Sep 1, 2025 5%
Joseph a Reppert Individual Corporate OfficerSenior Vice President of Finance Apr 4, 2024 100%
W-2 Managing EmployeeSenior Vice President of Finance Aug 3, 2020 100%
Orrin S Swayze Individual Corporate DirectorBoard Member Apr 1, 2016 5%
John C McKibben Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Keith Parker Individual Corporate DirectorBoard Member Jul 1, 2023 5%
Paul Lawrence Douglass Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Mitzi Moore Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Wellstar Health System Inc Organization, Marietta, GA Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Apr 1, 2016 100%
Gretchen Corbin Individual Corporate DirectorBoard Member Oct 3, 2024 5%
John Kerndl Individual Corporate OfficerEvp & Cfo Feb 17, 2025 100%
W-2 Managing EmployeeEvp & Cfo Feb 17, 2025 100%
James Glen Cunningham Individual Corporate DirectorBoard Member Mar 4, 2021 5%
Ebenezer Erzuah Individual W-2 Managing EmployeeExec Director of Reimbursement Apr 1, 2015 100%
Mark Berry Individual Corporate DirectorBoard Member Oct 7, 2021 5%
James Holmes Individual Corporate DirectorBoard Member Apr 1, 2016 5%
Greg Morgan Individual Corporate DirectorBoard Member Apr 1, 2016 5%
James L Hornsby Individual Corporate DirectorBoard Member Jul 1, 2018 5%
Edward Richardson Individual Corporate DirectorBoard Member Apr 1, 2019 5%
David Bottoms Individual Corporate DirectorBoard Member Feb 2, 2023 5%
Frank Ros Individual Corporate DirectorBoard Member Apr 1, 2016 5%

Owners & managing parties with NPI records 3

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

Facilities with the same owner 18

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

View all 18

Practitioners & affiliated clinicians

Affiliated clinicians 20

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730332800000",
    "number": "1619997079",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1800 PARKWAY PL SE STE 500",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300678237",
            "telephone_number": "470-956-4981",
            "fax_number": "770-999-2489"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1050 MCDONOUGH RD",
            "city": "JACKSON",
            "state": "GA",
            "postal_code": "302331524",
            "telephone_number": "770-775-7861"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR SYLVAN GROVE HOSPITAL, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-20",
        "last_updated": "2024-10-31",
        "certification_date": "2024-10-21",
        "status": "A",
        "authorized_official_last_name": "BUDZINSKI",
        "authorized_official_first_name": "ANTHONY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "EVP",
        "authorized_official_telephone_number": "470-644-0012",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "GA",
            "license": "018-544",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000001856A",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "WellStar Sylvan Grove Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WellStar Sylvan Grove Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, GA

Sources for this page

Verify at the official NPI Registry.