NPIMap

Organization Active NPI

Effingham Hospital, Inc.

Doing business as Effingham Family Medicine at Goshen

  • Rural Health Clinic/Center
  • Rincon, GA
National Provider Identifier
1811020407
Registry record updated Nov 29, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
EFFINGHAM HOSPITAL, INC.
Doing business as
Effingham Family Medicine at Goshen
Practice address
100 Goshen Rd
Rincon, GA 31326-5545
Phone
(912) 826-6000
Fax
(912) 826-6016
NPI assigned
Mar 13, 2007
Last updated
Nov 29, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 29, 2016

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

Authorized official

Name
Mrs. Francine Baker-Witt, RN, MBA, CNHA
Title
Interim Ceo
Phone
(912) 754-0142

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X RN057176NP GA
Clinic/Center 261Q00000X NU
Rural Health Clinic/Center 261QR1300X GA Primary

Addresses

Primary practice location

100 Goshen Rd
Rincon, GA 31326-5545

Mailing address

459 Highway 119 South
Attn: Alia Allen/Medical Staff Office
Springfield, GA 31329
Phone (912) 754-0175

Other names 1

  • Effingham Family Medicine at Goshen Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160930000494 GA Part A Provider - Rural Health Clinic 1254628092 1 other NPI on this enrollment
Practice locations: Rincon, GA
O20170113001163 GA Part B Supplier - Clinic/Group Practice 1254628092 Receives reassigned benefits from 35 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Guyton, GA; Port Wentworth, GA; Rincon, GA; Springfield, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811020407. Details of each certification follow.

Rural health clinic certification: CCN 118542

Legal name
EFFINGHAM HOSPITAL INC
Doing business as
EFFINGHAM FAMILY MEDICINE AT GOSHEN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 22, 2012
Last certification
Jul 27, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Aug 8, 2016 in GA
Enrollment address
100 Goshen Rd
Rincon, GA 31326-5744
Related CCNs
111306

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 14

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

View all 14

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Alia Allen Individual W-2 Managing Employee Nov 1, 2016
Fran Baker-Witt Individual Corporate OfficerInterim Ceo & Nursing Home Administ May 25, 2016
Corporate DirectorInterim Ceo & Nursing Home Administ May 25, 2016
W-2 Managing EmployeeInterim Ceo & Nursing Home Administ May 25, 2016
Operational/Managerial ControlInterim Ceo & Nursing Home Administ May 25, 2016
Corporate OfficerInterim Ceo & Nursing Home Administ May 25, 2016
Corporate DirectorInterim Ceo & Nursing Home Administ May 25, 2016
W-2 Managing EmployeeInterim Ceo & Nursing Home Administ May 25, 2016
Operational/Managerial ControlInterim Ceo & Nursing Home Administ May 25, 2016
Effingham Hospital Inc Organization, Springfield, GA Non-profit 5% Or Greater Direct Ownership Interest Nov 1, 2016 100%
Derrell E Banks Individual Corporate OfficerTrustee Jun 4, 2013
Tommy Exley Individual Corporate Officer Nov 1, 2011
Richard Rafter Individual Corporate Officer Nov 1, 2011
Barry Flonnory Individual Corporate OfficerTrustee Feb 5, 2013
Ronnie Brooks Individual Corporate Officer Nov 1, 2011
Patricia Yarbrough Individual Corporate Officer Nov 1, 2011
Lameisha Hunter Individual Corporate Officer Nov 1, 2011
Robin Massey Ruppe Individual Corporate Officer Nov 1, 2011

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
Effingham Health SystemSpringfield, GA, CCN 111306 Hospital 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2016
Effingham Health SystemSpringfield, GA, CCN 11Z306 Hospital 5% Or Greater Direct Ownership Interest Nov 1, 2016
Effingham Care and Rehabilitation CenterSpringfield, GA, CCN 115106 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2016
Effingham Family Medicine at GuytonGuyton, GA, CCN 118541 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 12, 2025
Effingham Family Medicine at Twenty OneSpringfield, GA, CCN 118540 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2016

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 4

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

Change-of-ownership history 1

DateEventCounterparty
Nov 1, 2016 Change of OwnershipThis provider was the buyer Effingham Family Medicine at GoshenCCN 118542, GA, NPI 1811962756

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1173744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1480377600000",
    "number": "1811020407",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "459 HIGHWAY 119 SOUTH",
            "address_2": "ATTN: ALIA ALLEN/MEDICAL STAFF OFFICE",
            "city": "SPRINGFIELD",
            "state": "GA",
            "postal_code": "31329",
            "telephone_number": "912-754-0175",
            "fax_number": "912-754-6395"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 GOSHEN RD",
            "city": "RINCON",
            "state": "GA",
            "postal_code": "313265545",
            "telephone_number": "912-826-6000",
            "fax_number": "912-826-6016"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EFFINGHAM HOSPITAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-13",
        "last_updated": "2016-11-29",
        "status": "A",
        "authorized_official_last_name": "BAKER-WITT",
        "authorized_official_first_name": "FRANCINE",
        "authorized_official_title_or_position": "INTERIM CEO",
        "authorized_official_telephone_number": "912-754-0142",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN, MBA, CNHA"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "GA",
            "license": "RN057176NP",
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Effingham Family Medicine at Goshen",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rincon, GA

Sources for this page

Verify at the official NPI Registry.