NPIMap

Organization Active NPI

Hospital Authority of Jeff Davis County Georgia

Doing business as Jeff Davis Family Medical Group

  • Rural Health Clinic/Center
  • Hazlehurst, GA
National Provider Identifier
1912379082
Registry record updated Apr 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Doing business as
Jeff Davis Family Medical Group
Practice address
9 Hester St
Hazlehurst, GA 31539-6323
Phone
(912) 375-0418
Fax
(912) 375-5775
NPI assigned
Oct 28, 2015
Last updated
Apr 23, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GERORGIAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 23, 2026

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

Authorized official

Name
Barry Bloom
Title
Ceo
Phone
(912) 375-7781

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

9 Hester St
Hazlehurst, GA 31539-6323

Mailing address

9 Hester St
Hazlehurst, GA 31539-6323
Phone (912) 375-0418

Other names 1

  • Jeff Davis Family Medical Group Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040504000404 GA Part B Supplier - Clinic/Group Practice 4981692472 Receives reassigned benefits from 30 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Hazlehurst, GA; MC Rae Helena, GA
O20220711002042 GA Part A Provider - Rural Health Clinic 4981692472 Practice locations: Hazlehurst, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1912379082. Details of each certification follow.

Rural health clinic certification: CCN 118583

Legal name
HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 2, 2022
Last certification
Nov 2, 2022
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
9 Hester St
Hazlehurst, GA 31539-6323
Related CCNs
111333

Facilities connected through Provider of Services related, parent or unit certification numbers.

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 8

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
11D2104510Jeff Davis Family Medical Group9 Hester Street, Hazlehurst, GA 31539Provider-performed microscopyNov 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Hospital Auth of Jeff D7 organizations share this tax ID, including this one
Part of
Hospital Auth of Jeff D

Other organizations with this tax ID 6

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

Locations

4 S Tallahassee St
Hazlehurst, GA 31539

9 Hester St
Hazlehurst, GA 31539
Phone (912) 375-0418

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
Kimila Wildes Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Barry Bloom Individual Corporate OfficerCeo Apr 1, 2022 100%
W-2 Managing EmployeeCeo Apr 1, 2022 100%
Robert Evans Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Wayne Hall Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Jason R Laney Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Shannon Kight Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Shirley Maley Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%
Keith Yawn Individual Corporate OfficerBoard Member Apr 1, 2022 100%
Corporate DirectorBoard Member Apr 1, 2022 100%
Operational/Managerial ControlBoard Member Apr 1, 2022 100%

Owners & managing parties with NPI records 1

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

  • Jason Laney, M.D.
    • Internal Medicine Physician
    • Hazlehurst, GA
    • NPI 1760708580

    Corporate Director, Corporate Officer, Operational/Managerial Control

    CMS ownership

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Jeff Davis HospitalHazlehurst, GA, CCN 111333 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966

Owned or controlled facilities with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 32

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.

View all 32

NPI Registry JSON

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

{
    "created_epoch": "1445990400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1776902400000",
    "number": "1912379082",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9 HESTER ST",
            "city": "HAZLEHURST",
            "state": "GA",
            "postal_code": "315396323",
            "telephone_number": "912-375-0418",
            "fax_number": "912-375-5775"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9 HESTER ST",
            "city": "HAZLEHURST",
            "state": "GA",
            "postal_code": "315396323",
            "telephone_number": "912-375-0418",
            "fax_number": "912-375-5775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GEORGIA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HOSPITAL AUTHORITY OF JEFF DAVIS COUNTY GERORGIA",
        "enumeration_date": "2015-10-28",
        "last_updated": "2026-04-23",
        "certification_date": "2026-04-23",
        "status": "A",
        "authorized_official_last_name": "BLOOM",
        "authorized_official_first_name": "BARRY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-375-7781"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jeff Davis Family Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hazlehurst, GA

Sources for this page

Verify at the official NPI Registry.