NPIMap

Organization Active NPI

McKinney Medical Center Inc

Doing business as Mckinney Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Nahunta, GA
National Provider Identifier
1871756049
Registry record updated Jun 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MCKINNEY MEDICAL CENTER INC
Doing business as
Mckinney Community Health Center
Practice address
9355 South Main Street
Nahunta, GA 31553-9806
Phone
(912) 462-6222
Fax
(912) 287-0687
NPI assigned
Jul 8, 2008
Last updated
Jun 5, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
MCKINNEY MEDICAL CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 5, 2019

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

Authorized official

Name
Ola Smith
Title
Ceo
Phone
(912) 287-0301

Specialties & licenses 1

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

Addresses

Primary practice location

9355 South Main Street
Nahunta, GA 31553-9806

Mailing address

218 Quarterman St
Waycross, GA 31501-3547
Phone (912) 287-0301

Other identifiers 3

IdentifierTypeStateIssuer
000715415BMedicaidGA
336244OtherGAWELLCARE
10066125OtherAMERIGROUP

Other names 1

  • Mckinney Community Health Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040430000265 GA Part B Supplier - Clinic/Group Practice 3173432226 Receives reassigned benefits from 20 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kingsland, GA; Waycross, GA; Nahunta, GA; Folkston, GA; Alma, GA
O20080820000648 GA Part A Provider - Federally Qualified Health Center (FQHC) 3173432226 Practice locations: Nahunta, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871756049. Details of each certification follow.

Federally qualified health center certification: CCN 111872

Legal name
MCKINNEY MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 19, 2003
Last certification
Oct 19, 2003
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
9355 Main St S
Nahunta, GA 31553-6159

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 6

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
11D1067186McKinney Medical Center, Inc9355 South Main Street, Nahunta, GA 31553Certificate of waiverMay 7, 2028

National Provider Directory

National Provider Directory
Tax ID family
McKinney Medical Center Inc2 organizations share this tax ID, including this one
Part of
McKinney Medical Center Inc

Other organizations with this tax ID 1

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

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Eutracey Adamson Individual Corporate DirectorBoard Member Mar 1, 2022
Clarence E Billups Individual Corporate OfficerTreasure Jul 1, 2021
Corporate DirectorBoard Member Jul 1, 2021
Ola Smith Individual Corporate OfficerCeo Jan 1, 2008
Corporate DirectorCeo Jan 1, 2008
W-2 Managing EmployeeCeo Jan 1, 2008
Kimberly Rodgers Individual Corporate DirectorBoard Member Mar 1, 2022
Linda Perry-Simpson Individual Corporate OfficerChaplain Mar 1, 2022
Corporate DirectorBoard Member Mar 1, 2022
Diane Spearman Individual Corporate OfficerSecretary Jul 1, 2021
Corporate DirectorBoard Member Jul 1, 2021
Tenesa Stokes Lightsey Individual Corporate DirectorBoard Member Mar 1, 2022
Carlos Jaime Individual Corporate OfficerChairman Jun 20, 2007
Corporate DirectorBoard Member Jun 20, 2007
Robert Lynch Individual Corporate DirectorCfo Jul 1, 2021
W-2 Managing EmployeeCfo Jul 1, 2021

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 1

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

FacilityTypeRoleSince
McKinney Medical Center IncAlma, GA, CCN 111047 Federally qualified health center Operational/Managerial Control Oct 12, 2009

Owned or controlled facilities with NPI records 1

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

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1215475200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1559692800000",
    "number": "1871756049",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "218 QUARTERMAN ST",
            "city": "WAYCROSS",
            "state": "GA",
            "postal_code": "315013547",
            "telephone_number": "912-287-0301",
            "fax_number": "912-287-0687"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9355 SOUTH MAIN STREET",
            "city": "NAHUNTA",
            "state": "GA",
            "postal_code": "315539806",
            "telephone_number": "912-462-6222",
            "fax_number": "912-287-0687"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCKINNEY MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MCKINNEY MEDICAL CENTER INC",
        "enumeration_date": "2008-07-08",
        "last_updated": "2019-06-05",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "OLA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-287-0301"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000715415B",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLCARE",
            "identifier": "336244",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERIGROUP",
            "identifier": "10066125",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mckinney Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Nahunta, GA

Sources for this page

Verify at the official NPI Registry.