NPIMap

Organization Active NPI

Primary Care of Southwest Georgia, Inc.

  • Federally Qualified Health Center (FQHC)
  • Blakely, GA
National Provider Identifier
1780607754
Registry record updated May 15, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
May 15, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2014

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

Authorized official

Name
Mr. Edwin V James, BBA MBA
Title
Chief Financial Officer
Phone
(229) 723-2660

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 060068 GA
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 057747 GA
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 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

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780607754. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Nov 14, 2005 in GA
Enrollment address
360 College St
Blakely, GA 39823-2554

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory

Locations

509 Wheat Ave
Bainbridge, GA 39819
Phone (229) 416-4421

360 College St
Blakely, GA 39823
Phone (229) 723-2660

Interoperability endpoints

  • Direct secure messaging: casidy.enfinger@gadirect.net
  • Direct secure messaging: gregory.dodson@gadirect.net
  • Direct secure messaging: jennifer.ross@gadirect.net
  • Direct secure messaging: jennifer.ross@pcswga.gadirect.net
  • Direct secure messaging: jessica.nunez@pcswga.gadirect.net
  • Direct secure messaging: luis.murrain@gadirect.net
  • Direct secure messaging: luis.murrain@pcswga.gadirect.net
  • Direct secure messaging: murali.yelagapuri@pcswga.gadirect.net
  • Direct secure messaging: murdoc.henderson@pcswga.gadirect.net

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Wayne Lawson Individual Corporate Director Aug 1, 2007
Kevin Taylor Individual Corporate Director Jun 16, 2010
Mattie Grimes Individual Corporate Director Jun 16, 2010
Kelly Hanks Individual Corporate Director Jun 1, 2017
Kenneth Cody Individual Corporate Director Jan 21, 2014
Janis Barron Individual Corporate Director Jun 16, 2010
Angela McVey Individual Corporate OfficerCeo Feb 5, 2019
W-2 Managing EmployeeCeo Oct 1, 2008
Joan S Simpson Individual Corporate Director Sep 20, 2011
Dan Provence Individual Corporate Director Oct 1, 2014
Jackie Watson Individual Corporate Director Jan 19, 2010
Ethel Willis Individual Corporate Director Jun 1, 2015
Katheryn Mitchell Individual Corporate Director Jun 16, 2010
Edwin James Individual Corporate OfficerCfo May 6, 2006
W-2 Managing Employee May 15, 2006
Wallace O'Neal Individual Corporate Director Jun 16, 2010
Jay Green Individual Corporate Director May 1, 2017

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Primary Care of Southwest Georgia, Inc.Quitman, GA, CCN 111060 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 23, 2017
Primary Care of Southwest Georgia - TCMSThomasville, GA, CCN 111072 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Sep 18, 2017

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 29

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.

View all 29

NPI Registry JSON

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

{
    "created_epoch": "1153785600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400112000000",
    "number": "1780607754",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "360 COLLEGE STREET",
            "city": "BLAKELY",
            "state": "GA",
            "postal_code": "39823",
            "telephone_number": "229-723-2660",
            "fax_number": "229-723-2663"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "360 COLLEGE STREET",
            "city": "BLAKELY",
            "state": "GA",
            "postal_code": "39823",
            "telephone_number": "229-723-2660",
            "fax_number": "229-723-2663"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY CARE OF SOUTHWEST GEORGIA, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-25",
        "last_updated": "2014-05-15",
        "status": "A",
        "authorized_official_last_name": "JAMES",
        "authorized_official_first_name": "EDWIN",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "229-723-2660",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "BBA MBA"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "060068",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": "057747",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "GA",
            "license": "RN188412",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Blakely, GA

Sources for this page

Verify at the official NPI Registry.