NPIMap

Organization Active NPI

Primary Care of Southwest Georgia, Inc.

  • Federally Qualified Health Center (FQHC)
  • Bainbridge, GA
National Provider Identifier
1821471277
Registry record updated Jul 2, 2015
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
509 Wheat Ave
Bainbridge, GA 39819-4321
Phone
(229) 416-4421
NPI assigned
Jul 2, 2015
Organization subpart
Yes
Parent organization
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 2, 2015

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

509 Wheat Ave
Bainbridge, GA 39819-4321

Mailing address

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

Other names 1

  • Primary Care of Southwest Georgia- Bainbridge 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
O20150929002437 GA Part A Provider - Federally Qualified Health Center (FQHC) 5496777948 Practice locations: Bainbridge, GA

Federally qualified health center certification: CCN 111016

Legal name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 29, 2015
Last certification
Sep 29, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 14, 2005 in GA
Enrollment address
509 Wheat Ave
Bainbridge, GA 39819-4321

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
11D2099096Primary Care of Southwest Georgia-Bainbridge509 Wheat Avenue, Bainbridge, GA 39819Certificate of waiverJul 20, 2027

National Provider Directory

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

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the 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
Annette Summerset Individual Corporate Director Aug 17, 2021
Wayne Lawson Individual Corporate DirectorBoard Member Aug 1, 2007
Kevin Taylor Individual Corporate DirectorBoard Member Sep 18, 2005
Kenneth Cody Individual Corporate DirectorBoard Member Jan 21, 2014
Janis Barron Individual Corporate DirectorBoard Member Sep 18, 2005
Angela McVey Individual Corporate OfficerCeo Feb 4, 2019
W-2 Managing EmployeeCeo Feb 4, 2019
Joan S Simpson Individual Corporate DirectorBoard Member Sep 20, 2011
Crycynthia Gardner Individual Corporate Director Aug 13, 2019
Dan Provence Individual Corporate DirectorBoard Member May 12, 2015
Jackie Watson Individual Corporate DirectorBoard Member Jan 19, 2010
Edwin James Individual Corporate OfficerCfo May 15, 2006
W-2 Managing EmployeeCfo May 15, 2006

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 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1435795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435795200000",
    "number": "1821471277",
    "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": "229-723-5969"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "509 WHEAT AVE",
            "city": "BAINBRIDGE",
            "state": "GA",
            "postal_code": "398194321",
            "telephone_number": "229-416-4421"
        }
    ],
    "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": "2015-07-02",
        "last_updated": "2015-07-02",
        "status": "A",
        "authorized_official_last_name": "JAMES",
        "authorized_official_first_name": "EDWIN",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "229-723-2660",
        "authorized_official_name_prefix": "Mr."
    },
    "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- Bainbridge",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bainbridge, GA

Sources for this page

Verify at the official NPI Registry.