Primary Care of Southwest Georgia, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Blakely, GA
NPI 1780607754 · NPPES record last updated May 15, 2014
Key facts
- NPI
- 1780607754
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
- Practice address
- 360 College Street
Blakely, GA 39823 - Phone
- (229) 723-2660
- Fax
- (229) 723-2663
- NPI assigned
- Jul 25, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. Edwin V James, BBA MBA
- Title
- Chief Financial Officer
- Phone
- (229) 723-2660
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 7
Other NPIs with the same Medicare PAC ID 6
Practitioners 30
-
Brittany Reichert, LCSW
-
James T Brown Jr., M.D.
-
Michael S Schmidt, M.D.
-
Briana Manley-Hall, PMHNP
-
Gregory E Dodson, PAC
-
Casidy Enfinger, NP-C
-
De'Smond Marquise Henry, M.D.
-
Luis Alberto Murrain, D.O.
-
Jessica Nunez, MD
-
Daneisha Latrell Rogers, DNP, FNP-C
-
Jennifer Ross, PA-C
-
Haley Rykard, LPC
-
Dave Stewart, M.D.
-
Aretha Tinson, NP-C
-
Wayne Henry Friedman, M.D.
-
Candice R. Scurry, LPC-S
-
Emily Conoly, APNP
-
Melanie Hattink, FNP
-
Mary Racheal Havens, ARNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in GA
Federally qualified health center certification: CCN 111893
- Legal name
- PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 9, 2006
- Last certification
- Jan 9, 2006
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Nov 14, 2005 in GA
- Enrollment address
- 360 College St
Blakely, GA 39823-2554
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Wayne Lawson |
Corporate Director | Aug 1, 2007 | |
| Kevin Taylor |
Corporate Director | Jun 16, 2010 | |
| Mattie Grimes |
Corporate Director | Jun 16, 2010 | |
| Kelly Hanks |
Corporate Director | Jun 1, 2017 | |
| Kenneth Cody |
Corporate Director | Jan 21, 2014 | |
| Janis Barron |
Corporate Director | Jun 16, 2010 | |
| Angela McVey |
Corporate Officer |
Feb 5, 2019 | |
| W-2 Managing Employee |
Oct 1, 2008 | ||
| Joan S Simpson |
Corporate Director | Sep 20, 2011 | |
| Dan Provence |
Corporate Director | Oct 1, 2014 | |
| Jackie Watson |
Corporate Director | Jan 19, 2010 | |
| Ethel Willis |
Corporate Director | Jun 1, 2015 | |
| Katheryn Mitchell |
Corporate Director | Jun 16, 2010 | |
| Edwin James |
Corporate Officer |
May 6, 2006 | |
| W-2 Managing Employee | May 15, 2006 | ||
| Wallace O'Neal |
Corporate Director | Jun 16, 2010 | |
| Jay Green |
Corporate Director | May 1, 2017 |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Primary Care of Southwest Georgia, Inc. |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | May 23, 2017 |
| Primary Care of Southwest Georgia - TCMS |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Sep 18, 2017 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060201000362 | GA | Part B Supplier - Clinic/Group Practice | 5496777948 |
Receives reassigned benefits from 22 practitioners 7 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Bainbridge, GA; Thomasville, GA; Quitman, GA; Blakely, GA |
| O20100730000980 | GA | Part a Provider - Federally Qualified Health Center (FQHC) | 5496777948 | Practice locations: Blakely, GA |
National Provider Directory
Interoperability endpoints
- casidy.enfinger@gadirect.net
- luis.murrain@gadirect.net
- jessica.nunez@pcswga.gadirect.net
- murdoc.henderson@pcswga.gadirect.net
- murali.yelagapuri@pcswga.gadirect.net
- gregory.dodson@gadirect.net
- jennifer.ross@gadirect.net
- luis.murrain@pcswga.gadirect.net
- jennifer.ross@pcswga.gadirect.net
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 060068 | GA | |
| Internal Medicine Physician |
207R00000X | 057747 | GA | |
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Family Nurse Practitioner |
363LF0000X | RN188412 | GA |
Addresses
Primary practice location
360 College Street
Blakely, GA 39823
Mailing address
360 College Street
Blakely, GA 39823
Phone (229) 723-2660
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 024893266A | Medicaid | GA |
Other providers in Blakely, GA
- Prchal and Prchal, P.C.
- Alisa Spann Price
- Lindsay Austin Prickett
- Primary Care of Southwest Georgia, Inc
- Primary Care of Southwest Georgia, Inc
- Queen City Home Medical, LLC
- Tina G. Rackley
- Arthur Redding
- Daneisha Latrell Rogers
- Jennifer Ross
All providers in Blakely, GA · Federally Qualified Health Center (FQHC) in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 15, 2014. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.