NPIMap

Organization Active NPI

Wildwood Sanitarium Incorporated

Doing business as Wildwood Medical Clinic

  • General Acute Care Hospital
  • Wildwood, GA
National Provider Identifier
1902957541
Registry record updated Aug 12, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
41198 Issued in GA
Legal business name
WILDWOOD SANITARIUM INCORPORATED
Doing business as
Wildwood Medical Clinic
Practice address
435 Lifestyle Lane
Wildwood, GA 30757-0129
Phone
(706) 820-1493
NPI assigned
Jan 12, 2007
Last updated
Aug 12, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 12, 2010

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

Authorized official

Name
Mr. Vaughan Harvey Sparrow
Title
Hospital Administrator
Phone
(706) 820-1493

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 41198 GA Primary

Addresses

Primary practice location

435 Lifestyle Lane
Wildwood, GA 30757-0129

Mailing address

P.O Box 129
Wildwood, GA 30757-0129
Phone (706) 820-1493

Other names 1

  • Wildwood Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040504000938 GA Part B Supplier - Clinic/Group Practice 3779571138 Receives reassigned benefits from 4 practitioners
Practice locations: Wildwood, GA

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
11D0021709Wildwood Medical Clinic Laboratory435 Lifestyle Lane, Wildwood, GA 30757Certificate of waiverDec 8, 2027

National Provider Directory

National Provider Directory
Tax ID family
Wildwood Lifestyle Center and Hospital3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Practitioners & affiliated clinicians

Practitioners 8

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": "1168560000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1281571200000",
    "number": "1902957541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O BOX 129",
            "city": "WILDWOOD",
            "state": "GA",
            "postal_code": "307570129",
            "telephone_number": "706-820-1493",
            "fax_number": "706-820-7459"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "435 LIFESTYLE LANE",
            "city": "WILDWOOD",
            "state": "GA",
            "postal_code": "307570129",
            "telephone_number": "706-820-1493"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDWOOD SANITARIUM INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-12",
        "last_updated": "2010-08-12",
        "status": "A",
        "authorized_official_last_name": "SPARROW",
        "authorized_official_first_name": "VAUGHAN",
        "authorized_official_middle_name": "HARVEY",
        "authorized_official_title_or_position": "HOSPITAL ADMINISTRATOR",
        "authorized_official_telephone_number": "706-820-1493",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "GA",
            "license": "41198",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wildwood Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wildwood, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.