NPIMap

Organization Active NPI

Prime Healthcare Foundation - Southern Regional, LLC

  • Rehabilitation Hospital Unit
  • Riverdale, GA
National Provider Identifier
1679946669
Registry record updated Nov 12, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation Hospital UnitTaxonomy code 273Y00000X
Legal business name
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Practice address
11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615
Phone
(770) 991-8000
NPI assigned
Nov 12, 2015
Last updated
Nov 12, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 12, 2015

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

Authorized official

Name
Christopher Doan
Title
Chief Compliance Counsel
Phone
(909) 235-4307

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rehabilitation Hospital Unit 273Y00000X GA Primary

Addresses

Primary practice location

11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615

Mailing address

11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615
Phone (770) 991-8000

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160415000184 GA Part A Provider - Hospital 7719285311 Practice locations: Riverdale, GA
O20181113001918 GA Part A Provider - Hospital 7719285311 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Riverdale, GA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1679946669. Details of each certification follow.

Hospital certification: CCN 11T165

Legal name
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL LLC
Doing business as
SOUTHERN REGIONAL MEDICAL CENTER
Organization structure
LLCProprietary
Incorporated
Sep 23, 2015 in DE
Enrollment address
11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615
Hospital Rehabilitation Unit
Hospital subgroups
Rehabilitation unit

Hospital certification: CCN 11S165

Legal name
PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL LLC
Doing business as
SOUTHERN REGIONAL MEDICAL CENTER
Organization structure
LLCNon-profit
Incorporated
Sep 23, 2015 in DE
Enrollment address
11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615
Hospital Psychiatric Unit
Hospital subgroups
Psychiatric unit

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

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Inpatient rehabilitation facility

Medicare Care Compare
Listed as
Southern Regional Medical CtrCCN 11T165 · All quality measures
Ownership
Non-profit
Certified
Jul 1, 2005

National Provider Directory

National Provider Directory
Part of
Prime Healthcare Foundation - Southern Regional LLC

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Prime Healthcare Services, Inc Organization, Ontario, CA Corporation, For-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2016 100%
Paul Damron Individual Corporate OfficerChief Financial Officer Aug 1, 2020
W-2 Managing EmployeeChief Financial Officer Aug 1, 2020
Steven Aleman Individual Corporate OfficerCorporate Chief Financial Officer Jun 1, 2020
Corporate OfficerCorporate Chief Financial Officer Aug 1, 2020
Christopher Doan Individual Corporate OfficerChief Compliane Counsel Jul 1, 2017
Corporate OfficerCompliance Counsel Aug 30, 2018
Prime Healthcare Foundation Inc Organization, Ontario, CA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Feb 1, 2016 100%
Michael Davis Individual Corporate OfficerChief Financial Officer Feb 6, 2023
W-2 Managing EmployeeChief Financial Officer Feb 6, 2023

Owners & managing parties with NPI records 1

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

Facilities with the same owner 95

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

View all 95

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1447286400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447286400000",
    "number": "1679946669",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 UPPER RIVERDALE RD SW",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302742615",
            "telephone_number": "770-991-8000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 UPPER RIVERDALE RD SW",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302742615",
            "telephone_number": "770-991-8000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC",
        "enumeration_date": "2015-11-12",
        "last_updated": "2015-11-12",
        "status": "A",
        "authorized_official_last_name": "DOAN",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_title_or_position": "CHIEF COMPLIANCE COUNSEL",
        "authorized_official_telephone_number": "909-235-4307"
    },
    "taxonomies": [
        {
            "code": "273Y00000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation Unit",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Riverdale, GA

Sources for this page

Verify at the official NPI Registry.