Coastal Community Health Services Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Brunswick, GA
NPI 1972223162 · NPPES record last updated Aug 30, 2022
Key facts
- NPI
- 1972223162
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COASTAL COMMUNITY HEALTH SERVICES INC
- Practice address
- 1600 Ellis St
Brunswick, GA 31520-6737 - Phone
- (912) 289-2006
- Fax
- (912) 289-2014
- NPI assigned
- Aug 30, 2022
- Organization subpart
- No
Authorized official
- Name
- Kavanaugh Chandler, MD
- Title
- Ceo
- Phone
- (912) 275-8028
Other NPIs with the same Medicare PAC ID 16
Corporate family (same tax ID) 23
Practitioners 57
-
Amie Marie Gardner, APRN, FNP-BC
-
Donna Jean Hooks, FNP-C
-
Emily Nole Knott, PA-C
-
Carla Jeanette Rowe, FNP-BC
-
Rebecca Brooke Skeen, FNP
-
Taylor Louise Bargeloh, PA-C
-
Manouchka L Etienne, PA-C
-
Shameka Jones, MD.
-
Kristin Lee, LAPC
-
Daryl Petersen McCartney, M.D.
-
Jeri L. Miller, M.D.
-
Mary Margaret Schlosser, FNP-BC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Federally qualified health center certification: CCN 111074
- Legal name
- COASTAL COMMUNITY HEALTH SERVICES INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Nov 10, 2017
- Last certification
- Nov 10, 2017
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Oct 25, 2012 in GA
- Enrollment address
- 1600 Ellis St
Brunswick, GA 31520-6737
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Polly Andrews-Bean |
Corporate Director |
Apr 1, 2016 | |
| Carolyn Tinkham |
Corporate Director |
Mar 1, 2013 | |
| Teria Brown |
Corporate Director |
May 1, 2015 | |
| Esther Figueroa |
Corporate Director |
Apr 1, 2017 | |
| Kavanaugh Chandler |
Corporate Director |
Jul 6, 2021 | 100% |
| W-2 Managing Employee |
Jul 6, 2021 | 100% | |
| Greg Jaudon |
Corporate Director |
Aug 1, 2015 | |
| Margaret R Tuten |
Corporate Director |
Nov 1, 2014 | |
| Stephanie Krause-Jones |
Corporate Director |
May 1, 2014 | |
| George Stevens |
Corporate Director |
Apr 1, 2016 | |
| John Laws |
Corporate Director |
May 1, 2015 | |
| Pamela Rogers |
Corporate Director |
Mar 1, 2013 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171110000169 | GA | Part a Provider - Federally Qualified Health Center (FQHC) | 0345463683 | Practice locations: Brunswick, GA |
National Provider Directory
- Tax ID family
- Coastal HLTH Srvcs Inc
Locations
22385 Flora Parke Xing
Fernandina Beach, FL 32034
Phone (904) 404-8641
10804 Highway 82
Nahunta, GA 31553
Phone (912) 342-7281
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
1600 Ellis St
Brunswick, GA 31520-6737
Mailing address
106 Shoppers Way Ste 114
Brunswick, GA 31525-0522
Phone (912) 574-5075
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | eClinicalWorks | Direct |
Other providers in Brunswick, GA
- Coastal Anesthesia Associates, LLC
- Coastal Associates of OB/GYN
- Coastal Cardiology PC
- Coastal Care Solutions LLC
- Coastal Community Health Services Inc
- Coastal Community Health Services, Inc.
- Coastal Community Health Services, Inc.
- Coastal Community Health Services, Inc.
- Coastal Community Health Services, Inc.
- Coastal Community Health Services, Inc.
All providers in Brunswick, GA · Federally Qualified Health Center (FQHC) in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 30, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.