NPIMap

Organization Active NPI

The Medical Center of Elberton, LLP

  • Rural Health Clinic/Center
  • Elberton, GA
National Provider Identifier
1891863569
Registry record updated Jan 6, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
11-3958 Issued in GA
Legal business name
THE MEDICAL CENTER OF ELBERTON, LLP
Practice address
109 College Ave
Elberton, GA 30635-1705
Phone
(706) 283-3315
Fax
(706) 283-2159
NPI assigned
Dec 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2010

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

Authorized official

Name
Ms. Brooke S Hall
Title
Practice Administrator
Phone
(706) 283-3315

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 11-3958 GA Primary

Addresses

Primary practice location

109 College Ave
Elberton, GA 30635-1705

Mailing address

109 College Ave
Elberton, GA 30635-1705
Phone (706) 283-3315

Other identifiers 1

IdentifierTypeStateIssuer
85000124GMedicaidGA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040526000768 GA Part B Supplier - Clinic/Group Practice 2062493083 Receives reassigned benefits from 8 practitioners
Practice locations: Elberton, GA
O20050222000641 GA Part A Provider - Rural Health Clinic 2062493083 Practice locations: Elberton, GA

Rural health clinic certification: CCN 113958

Legal name
THE MEDICAL CENTER OF ELBERTON, LLP
Doing business as
THE MEDICAL CENTER OF ELBERTON LLP
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 22, 2005
Last certification
Jul 16, 2024
Ownership / control type
1C
Organization structure
PartnershipProprietary
Incorporated
Jan 1, 1990 in GA
Enrollment address
109 College Avenue
Elberton, GA 30635-1705

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
11D0262047Medical Center LLP109 College Avenue, Elberton, GA 30635AccreditationDec 22, 2027

National Provider Directory

National Provider Directory

Locations

109 College Ave
Elberton, GA 30635
Phone (706) 283-3315

Interoperability endpoints

  • Direct secure messaging: ralph.crowe@gadirect.net
  • Direct secure messaging: james.mcavoy@gadirect.net
  • Direct secure messaging: roger.mize@gadirect.net
  • Direct secure messaging: kerri.wiley@gadirect.net
  • Direct secure messaging: glenn.poon@gadirect.net
  • Direct secure messaging: mark.daniel@gadirect.net
  • Direct secure messaging: jonathan.poon@gadirect.net

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Glenn Poon Individual 5% Or Greater Direct Ownership Interest Aug 1, 1995 16.66%
General Partnership Interest Feb 22, 2005 16.66%
James McAvoy Individual 5% Or Greater Direct Ownership Interest Aug 1, 1995 16.66%
General Partnership Interest Feb 22, 2005 16.66%
Matthew L Jenkins Individual 5% Or Greater Direct Ownership Interest Aug 1, 2016 16.66%
General Partnership Interest Aug 1, 2016 16.66%
Ralph Crowe Individual 5% Or Greater Direct Ownership Interest Aug 1, 2012 16.66%
General Partnership Interest Aug 1, 2012 16.66%
Roger David Mize Individual Contracted Managing Employee Feb 22, 2005
Kimberly Hall Individual Corporate Director May 18, 2008
W-2 Managing Employee May 18, 2008
Mark Daniel Individual 5% Or Greater Direct Ownership Interest Aug 1, 1995 16.66%
General Partnership Interest Feb 22, 2005 16.66%
Jonathan Y Poon Individual 5% Or Greater Direct Ownership Interest Aug 1, 2009 16.66%
General Partnership Interest Aug 1, 2009 16.66%

Owners & managing parties with NPI records 6

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

Practitioners & affiliated clinicians

Practitioners 10

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": "1164931200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1262736000000",
    "number": "1891863569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 COLLEGE AVE",
            "city": "ELBERTON",
            "state": "GA",
            "postal_code": "306351705",
            "telephone_number": "706-283-3315",
            "fax_number": "706-283-2159"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 COLLEGE AVE",
            "city": "ELBERTON",
            "state": "GA",
            "postal_code": "306351705",
            "telephone_number": "706-283-3315",
            "fax_number": "706-283-2159"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE MEDICAL CENTER OF ELBERTON, LLP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-01",
        "last_updated": "2010-01-06",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "BROOKE",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "706-283-3315",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "GA",
            "license": "11-3958",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "85000124G",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Elberton, GA

Sources for this page

Verify at the official NPI Registry.