NPIMap

Organization Active NPI

Crisp Regional Hospital, Inc

Doing business as Crisp Regional Hospice

  • Community Based Hospice Care Agency
  • Cordele, GA
National Provider Identifier
1699740498
Registry record updated Jun 12, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
040063H Issued in GA
Legal business name
CRISP REGIONAL HOSPITAL, INC
Doing business as
Crisp Regional Hospice
Practice address
910 N 5TH St
Cordele, GA 31015-3254
Phone
(229) 276-3100
Fax
(229) 276-3297
NPI assigned
Feb 23, 2006
Last updated
Jun 12, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2009

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

Authorized official

Name
Mrs. Susan Wade Wilder
Title
Auditor
Phone
(229) 276-3100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 040063H GA Primary

Addresses

Primary practice location

910 N 5TH St
Cordele, GA 31015-3254

Mailing address

910 N 5TH St
Cordele, GA 31015-3254
Phone (229) 271-9686

Other names 1

  • Crisp Regional Hospice Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090610000093 GA Part A Provider - Hospice 5991616336 Practice locations: Cordele, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699740498. Details of each certification follow.

Hospice certification: CCN 111550

Legal name
CRISP REGIONAL HOSPITAL INC
Doing business as
REFLECTIONS HOSPICE OF CRISP REGIONAL
Certification status
Active
Provider type (POS)
Hospice
Participating since
Mar 21, 1996
Last certification
Dec 12, 2018
Ownership / control type
Other
Organization structure
CorporationNon-profit
Incorporated
Oct 21, 1996 in GA
Enrollment address
202E 4TH Ave
Cordele, GA 31015-3211

Other NPIs with the same Medicare PAC ID 8

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

Care Compare: Hospice

Medicare Care Compare
Listed as
Crisp Regional Hospice and Palliative CareCCN 111550 · All quality measures
Ownership
Other
Certified
Mar 21, 1996
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Surgical Associates22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

Organizations that report the same tax identification number in the National Provider Directory.

View all 21

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Steven L. Gautney Individual Corporate OfficerCeo Oct 1, 2010 100%
W-2 Managing Employee Oct 1, 2010
Jessica Carter Individual Corporate Officer May 25, 2011
W-2 Managing Employee May 25, 2011
Operational/Managerial Control May 25, 2011

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Crisp Regional HospitalCordele, GA, CCN 110104 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Crisp Regional HospitalCordele, GA, CCN 11U104 Hospital Operational/Managerial Control (100%) Feb 1, 1996
Caresouth an Affiliate of Crisp Regional HospitalCordele, GA, CCN 117309 Home health agency 5% Or Greater Direct Ownership Interest Dec 14, 2007
Crisp Regional Convenient CareCordele, GA, CCN 118555 Rural health clinic Operational/Managerial Control May 1, 2012

Owned or controlled facilities with NPI records 3

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

Practitioners & affiliated clinicians

Affiliated clinicians 7

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

NPI Registry JSON

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

{
    "created_epoch": "1140652800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1244764800000",
    "number": "1699740498",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "910 N 5TH ST",
            "city": "CORDELE",
            "state": "GA",
            "postal_code": "310153254",
            "telephone_number": "229-271-9686",
            "fax_number": "229-271-9689"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "910 N 5TH ST",
            "city": "CORDELE",
            "state": "GA",
            "postal_code": "310153254",
            "telephone_number": "229-276-3100",
            "fax_number": "229-276-3297"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRISP REGIONAL HOSPITAL, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-23",
        "last_updated": "2009-06-12",
        "status": "A",
        "authorized_official_last_name": "WILDER",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "WADE",
        "authorized_official_title_or_position": "AUDITOR",
        "authorized_official_telephone_number": "229-276-3100",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "GA",
            "license": "040063H",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crisp Regional Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cordele, GA

Sources for this page

Verify at the official NPI Registry.