NPIMap

Organization Active NPI

Tift Regional Health System Inc.

Doing business as Southwell Medical Community Health Center

  • Rural Health Clinic/Center
  • Tifton, GA
National Provider Identifier
1649800111
Registry record updated Jun 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TIFT REGIONAL HEALTH SYSTEM INC.
Doing business as
Southwell Medical Community Health Center
Practice address
2735 Central Ave S
Tifton, GA 31794-5645
Phone
(229) 388-5690
Fax
(229) 388-5685
NPI assigned
Jan 23, 2020
Last updated
Jun 24, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2022

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

Authorized official

Name
Christopher Dorman
Title
President/Ceo
Phone
(229) 353-6104

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

2735 Central Ave S
Tifton, GA 31794-5645

Mailing address

PO Box 2650
Tifton, GA 31793-2650
Phone (229) 353-3422

Other names 1

  • Southwell Medical Community Health Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200717001168 GA Part A Provider - Rural Health Clinic 2062745169 Practice locations: Tifton, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649800111. Details of each certification follow.

Rural health clinic certification: CCN 118576

Legal name
TIFT REGIONAL HEALTH SYSTEM INC
Doing business as
SOUTHWELL MEDICAL COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 21, 2021
Last certification
Jul 21, 2021
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
2735 Central Ave S
Tifton, GA 31794-5645
Related CCNs
110101

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

Other NPIs with the same Medicare PAC ID 12

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

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
11D2010734Tift Regional Health System, Inc2735 South Central Avenue, South, Tifton, GA 31794Certificate of waiverAug 3, 2026

National Provider Directory

National Provider Directory
Tax ID family
Tift Regional Health System 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

Interoperability endpoints

  • Direct secure messaging: kristi.childs@trhs.cernerdirect.com
  • Direct secure messaging: lindsey.fletcher@trhs.cernerdirect.com
  • Direct secure messaging: penny.booth@trhs.cernerdirect.com

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Jessica W Beier Individual Corporate DirectorDirector Mar 1, 2019
George Hunt Individual Corporate DirectorBoard Member Jul 1, 2012
Rubal Patel Individual Corporate Director Sep 30, 2021
Tift Regional Health System Inc Organization, Tifton, GA Corporation 5% Or Greater Direct Ownership Interest Jul 12, 2012
Scott Fulp Individual Corporate DirectorDirector Mar 1, 2019
James W Scott Individual Corporate DirectorDirector Mar 1, 2019
Kristy Gladden Individual W-2 Managing EmployeeProvider Enrollment Manager Apr 6, 2022
Lenton C Daughtrey Individual Corporate DirectorDirector Mar 1, 2019
William Bowen Individual Corporate Director Sep 30, 2021
Troy Brooks Individual Corporate DirectorSVP/Cfo Jun 27, 2022
W-2 Managing Employee Jun 27, 2022
John Brownlee Individual Corporate DirectorBoard Member Jul 1, 2012

Owners & managing parties with NPI records 15

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

View all 15

All facility ownership & control disclosures 7

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

FacilityTypeRoleSince
Southwell Medical Sylvia Barr CenterAdel, GA, CCN 11S101 Hospital Operational/Managerial Control Jul 1, 2012
Tift Regional Health System IncTifton, GA, CCN 110095 Hospital Operational/Managerial Control Mar 1, 2019
Southwell Health and RehabilitationAdel, GA, CCN 115655 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control
Adp of the SNF
Direct Ownership Interest (100%)		 Mar 1, 2019
Mar 1, 2019
May 15, 2025
Mar 1, 2019
Southwell Medical Adel Primary CareAdel, GA, CCN 118528 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 1, 2019
Southwell MedicalSylvester, GA, CCN 118578 Rural health clinic 5% Or Greater Direct Ownership Interest Jul 12, 2012
Southwell Medical Ashburn Primary CareAshburn, GA, CCN 118574 Rural health clinic 5% Or Greater Direct Ownership Interest Jul 12, 2012
Southwell MedicalNashville, GA, CCN 118577 Rural health clinic 5% Or Greater Direct Ownership Interest Jul 12, 2012

Owned or controlled facilities with NPI records 7

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

Facilities with the same owner 7

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

Practitioners & affiliated clinicians

Practitioners 3

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": "1579737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1656028800000",
    "number": "1649800111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2650",
            "city": "TIFTON",
            "state": "GA",
            "postal_code": "317932650",
            "telephone_number": "229-353-3422"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2735 CENTRAL AVE S",
            "city": "TIFTON",
            "state": "GA",
            "postal_code": "317945645",
            "telephone_number": "229-388-5690",
            "fax_number": "229-388-5685"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIFT REGIONAL HEALTH SYSTEM INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-23",
        "last_updated": "2022-06-24",
        "certification_date": "2022-06-24",
        "status": "A",
        "authorized_official_last_name": "DORMAN",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "229-353-6104"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southwell Medical Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southwell Medical Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tifton, GA

Sources for this page

Verify at the official NPI Registry.