NPIMap

Organization Active NPI

Primary Care of Southwest Georgia, Inc.

Doing business as Primary Care of Southwest Georgia- Quitman

  • Federally Qualified Health Center (FQHC)
  • Quitman, GA
National Provider Identifier
1790223352
Registry record updated Feb 3, 2017
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.
Doing business as
Primary Care of Southwest Georgia- Quitman
Practice address
907 N Court St
Quitman, GA 31643-1315
Phone
(229) 263-4531
Fax
(229) 263-5787
NPI assigned
Feb 3, 2017
Last updated
Feb 3, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 3, 2017

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

Authorized official

Name
Edwin James
Title
Cfo
Phone
(229) 723-2660

Specialties & licenses 1

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

Addresses

Primary practice location

907 N Court St
Quitman, GA 31643-1315

Mailing address

360 College St
Blakely, GA 39823-2554
Phone (229) 723-2660

Other names 1

  • Primary Care of Southwest Georgia- Quitman Doing business as

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
O20170515001757 GA Part A Provider - Federally Qualified Health Center (FQHC) 5496777948 Practice locations: Quitman, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790223352. Details of each certification follow.

Federally qualified health center certification: CCN 111060

Legal name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 15, 2017
Last certification
May 15, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 14, 2005 in GA
Enrollment address
907 N Court St
Quitman, GA 31643-1315

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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D0265680Primary Care of Southwest Georgia - Quitman907 North Court St, Quitman, GA 31643Provider-performed microscopyMar 24, 2028

National Provider Directory

National Provider Directory
Tax ID family
Primary Care of SW Ga Inc8 organizations share this tax ID, including this one
Part of
Primary Care of SW Ga Inc

Other organizations with this tax ID 7

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

Locations

454 Smith Ave
Thomasville, GA 31792
Phone (229) 227-5510

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Annette Summerset Individual Corporate Director Aug 17, 2021
Natalie Singletary Individual Corporate Director Dec 15, 2020
Wayne Lawson Individual Corporate DirectorBoard Member Jul 1, 2007
Kevin Taylor Individual Corporate DirectorBoard Member Mar 1, 2006
Kenneth Cody Individual Corporate DirectorBoard Member Jan 1, 2014
Janis Barron Individual Corporate DirectorBoard Member Mar 1, 2006
Angela McVey Individual W-2 Managing EmployeeCeo Feb 4, 2019
Operational/Managerial ControlCeo Feb 4, 2019
Joan S Simpson Individual Corporate DirectorBoard Member Jan 1, 2011
Crycynthia Gardner Individual Corporate DirectorBoard Member Aug 20, 2019
Primary Care of Southwest Georgia, Inc. Organization, Blakely, GA Non-profit 5% Or Greater Direct Ownership Interest May 23, 2017 100%
Dan Provence Individual Corporate DirectorBoard Member May 1, 2015
Jackie Watson Individual Corporate DirectorBoard Member Feb 1, 2009
Edwin James Individual W-2 Managing EmployeeCfo May 15, 2006
Operational/Managerial ControlCfo May 15, 2006

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
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 1

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

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 5

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": "1486080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1486080000000",
    "number": "1790223352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "360 COLLEGE ST",
            "city": "BLAKELY",
            "state": "GA",
            "postal_code": "398232554",
            "telephone_number": "229-723-2660",
            "fax_number": "229-723-5962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "907 N COURT ST",
            "city": "QUITMAN",
            "state": "GA",
            "postal_code": "316431315",
            "telephone_number": "229-263-4531",
            "fax_number": "229-263-5787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY CARE OF SOUTHWEST GEORGIA, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PRIMARY CARE OF SOUTHWEST GEORGIA, INC.",
        "enumeration_date": "2017-02-03",
        "last_updated": "2017-02-03",
        "status": "A",
        "authorized_official_last_name": "JAMES",
        "authorized_official_first_name": "EDWIN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "229-723-2660"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Primary Care of Southwest Georgia- Quitman",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Quitman, GA

Sources for this page

Verify at the official NPI Registry.