Prime Healthcare Foundation - Southern Regional, LLC
Organization Active NPI Rehabilitation Hospital Unit · Riverdale, GA
NPI 1679946669 · NPPES record last updated Nov 12, 2015
Key facts
- NPI
- 1679946669
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rehabilitation Hospital Unit 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
- Organization subpart
- Yes
- Parent organization (as reported)
- PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
Authorized official
- Name
- Christopher Doan
- Title
- Chief Compliance Counsel
- Phone
- (909) 235-4307
Parent organization (reported in NPPES) 1
Owners & managing parties with NPI records 1
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 2
Member of 1
Related certifications (CCN) 1
Facilities with the same owner 95
Medicare Care Compare: Inpatient rehabilitation facility
- Listed as
- Southern Regional Medical Ctr
- Ownership
- Non-profit
- Certified
- Jul 1, 2005
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in GA
Hospital certification: CCN 11T165
- Legal name
- PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL LLC
- Doing business as
- SOUTHERN REGIONAL MEDICAL CENTER
- Organization structure
- LLC · Proprietary
- Incorporated
- Sep 23, 2015 in DE
- Enrollment address
- 11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615 - 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
- LLC · Non-profit
- Incorporated
- Sep 23, 2015 in DE
- Enrollment address
- 11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615 - Hospital subgroups
- Psychiatric unit
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| Prime Healthcare Services, Inc |
5% Or Greater Indirect Ownership Interest | Feb 1, 2016 | 100% |
| Paul Damron |
Corporate Officer |
Aug 1, 2020 | |
| W-2 Managing Employee |
Aug 1, 2020 | ||
| Steven Aleman |
Corporate Officer |
Jun 1, 2020 | |
| Corporate Officer |
Aug 1, 2020 | ||
| Christopher Doan |
Corporate Officer |
Jul 1, 2017 | |
| Corporate Officer |
Aug 30, 2018 | ||
| Prime Healthcare Foundation Inc |
5% Or Greater Direct Ownership Interest | Feb 1, 2016 | 100% |
| Michael Davis |
Corporate Officer |
Feb 6, 2023 | |
| W-2 Managing Employee |
Feb 6, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Part of
- Prime Healthcare Foundation - Southern Regional LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rehabilitation Hospital Unit | 273Y00000X | GA | Yes |
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
Other providers in Riverdale, GA
- Premier Behavioral Services Inc
- Premier Womens OBGYN, LLC
- Mathilda Prevost
- Prime Healthcare Foundation - Southern Regional, LLC
- Prime Healthcare Foundation - Southern Regional, LLC
- Prime RX Consultant Services Inc
- Primecare Medical Center
- Richard Prokesch
- Promed Ambulance Service
- Padma Niharika Putrevu
All providers in Riverdale, GA · Rehabilitation Hospital Unit in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 12, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.