NPIMap

Organization Active NPI

East Georgia Healthcare Center Inc

  • Federally Qualified Health Center (FQHC)
  • Soperton, GA
National Provider Identifier
1700820917
Registry record updated May 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAST GEORGIA HEALTHCARE CENTER INC
Practice address
4357 E Louisiana Ave
Soperton, GA 30457-3661
Phone
(478) 488-4234
Fax
(478) 237-9138
NPI assigned
Jun 16, 2006
Last updated
May 1, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2023

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

Authorized official

Name
Jill R Sorrells
Title
Cfo
Phone
(478) 419-1641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

4357 E Louisiana Ave
Soperton, GA 30457-3661

Mailing address

215 N Coleman St
Swainsboro, GA 30401-3530
Phone (478) 237-2638

Other identifiers 1

IdentifierTypeStateIssuer
000632376GMedicaidGA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041223000205 GA Part A Provider - Federally Qualified Health Center (FQHC) 0547228686 Practice locations: Soperton, GA
O20050722000569 GA Part B Supplier - Clinic/Group Practice 0547228686 Receives reassigned benefits from 49 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wadley, GA; Vidalia, GA; Sylvania, GA; Swainsboro, GA; Mount Vernon, GA; Stillmore, GA; Statesboro, GA; Soperton, GA…

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1700820917. Details of each certification follow.

Federally qualified health center certification: CCN 111889

Legal name
EAST GEORGIA HEALTHCARE CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 28, 2005
Last certification
Jan 28, 2005
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
May 29, 1992 in GA
Enrollment address
4357 E Louisiana Ave
Soperton, GA 30457-3661

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Other NPIs on the same Medicare enrollment 15

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

View all 15

National Provider Directory

National Provider Directory
Tax ID family
E Ga Healthcare Ctr 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

Locations

4357 E Louisiana Ave
Soperton, GA 30457
Phone (478) 488-4234

4393 E Louisiana Ave
Soperton, GA 30457

452 Second St
Soperton, GA 30457
Phone (912) 529-5533

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Joel Salgado Individual Corporate Officer Jan 1, 2021 10%
Pat Gunn Individual Corporate DirectorBoard Member Apr 1, 2005
Gwendolyn Love Individual Corporate DirectorBoard Member Nov 3, 2003
Lynda Morgan Individual Corporate DirectorBoard Member Apr 1, 1998
Theron D Faison Individual Corporate DirectorBoaard Member Jan 1, 2009
Jennie W Denmark Individual Corporate OfficerCeo Mar 15, 1993
W-2 Managing EmployeeCeo Jan 1, 2009
Elizabeth Hendrix Individual Corporate DirectorBoard Member Nov 1, 1999
Cleveland White Individual Corporate DirectorBoard Member Jun 1, 2010
Ken Mercer Individual Corporate Officer Mar 1, 2021 10%
Luis Machado Individual Corporate Director Jan 1, 2009
Amanda R Brown Individual Corporate DirectorBoard Member Aug 1, 2003
Jill R Sorrells Individual Corporate OfficerCfo May 26, 1988
W-2 Managing EmployeeCfo Jan 1, 2009

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Statesboro Pediatrics and Family Healthcare CenterStatesboro, GA, CCN 111931 Federally qualified health center Other Mar 12, 2013
East Georgia Healthcare Center, Inc.Baxley, GA, CCN 111977 Federally qualified health center Operational/Managerial Control (100%) Jan 1, 2014
East Georgia Healthcare Center, Inc.Millen, GA, CCN 111063 Federally qualified health center Operational/Managerial Control May 1, 2017

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 6

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": "1150416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682899200000",
    "number": "1700820917",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 N COLEMAN ST",
            "city": "SWAINSBORO",
            "state": "GA",
            "postal_code": "304013530",
            "telephone_number": "478-237-2638",
            "fax_number": "478-237-9138"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4357 E LOUISIANA AVE",
            "city": "SOPERTON",
            "state": "GA",
            "postal_code": "304573661",
            "telephone_number": "478-488-4234",
            "fax_number": "478-237-9138"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST GEORGIA HEALTHCARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-16",
        "last_updated": "2023-05-01",
        "certification_date": "2023-05-01",
        "status": "A",
        "authorized_official_last_name": "SORRELLS",
        "authorized_official_first_name": "JILL",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "478-419-1641"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000632376G",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Soperton, GA

Sources for this page

Verify at the official NPI Registry.