NPIMap

Organization Active NPI

East Georgia Healthcare Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Metter, GA
National Provider Identifier
1821270323
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
EAST GEORGIA HEALTHCARE CENTER, INC.
Practice address
34 NW Broad St
Metter, GA 30439-4025
Phone
(912) 685-4040
Fax
(912) 685-4041
NPI assigned
Nov 27, 2007
Last updated
Feb 3, 2017By the provider in NPPES
Organization subpart
No

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
Jennie Wren C. Denmark
Title
Ceo
Phone
(478) 237-6262

Specialties & licenses 1

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

Addresses

Primary practice location

34 NW Broad St
Metter, GA 30439-4025

Mailing address

215 N Coleman St
Swainsboro, GA 30401-3530
Phone (478) 237-6262

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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…
O20080107000368 GA Part A Provider - Federally Qualified Health Center (FQHC) 0547228686 Practice locations: Metter, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821270323. Details of each certification follow.

Federally qualified health center certification: CCN 111904

Legal name
EAST GEORGIA HEALTHCARE CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 22, 2008
Last certification
Feb 22, 2008
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 29, 1992 in GA
Enrollment address
34 NW Broad St
Metter, GA 30439-4025

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

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
11D1079761East Georgia Healthcare Center - Metter34 NW Broad Street, Metter, GA 30439Provider-performed microscopyFeb 6, 2028

National Provider Directory

National Provider Directory
Tax ID family
East Ga Hlthcare 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

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%
Gwendolyn Love Individual Corporate Director Jan 2, 2008
Lynda Morgan Individual Corporate Director Jan 2, 2008
Theron D Faison Individual Corporate Director Sep 1, 2009
Jennie W Denmark Individual Corporate Director Jan 2, 2008
W-2 Managing Employee Jan 2, 2008
Elizabeth Hendrix Individual Corporate Director Jan 2, 2008
Cleveland White Individual Corporate Director Jan 1, 2011
Martin R Sheldon Individual Corporate OfficerChief Medical Officer Aug 1, 2021 5%
Ken Mercer Individual Corporate Director Jan 2, 2008
Luis Machado Individual Corporate Director Jan 2, 2008
Amanda R Brown Individual Corporate Director Jan 2, 2008
Jill R Sorrells Individual Corporate Director Jan 2, 2008
W-2 Managing Employee Jan 2, 2008

Owners & managing parties with NPI records 1

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

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 1

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": "1196121600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1486080000000",
    "number": "1821270323",
    "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": "478-237-6262",
            "fax_number": "478-237-9138"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "34 NW BROAD ST",
            "city": "METTER",
            "state": "GA",
            "postal_code": "304394025",
            "telephone_number": "912-685-4040",
            "fax_number": "912-685-4041"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST GEORGIA HEALTHCARE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-27",
        "last_updated": "2017-02-03",
        "status": "A",
        "authorized_official_last_name": "DENMARK",
        "authorized_official_first_name": "JENNIE WREN",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "478-237-6262"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Metter, GA

Sources for this page

Verify at the official NPI Registry.