NPIMap

Organization Active NPI

Coastal Community Health Services Inc

  • Federally Qualified Health Center (FQHC)
  • Brunswick, GA
National Provider Identifier
1972223162
Registry record updated Aug 30, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Aug 30, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 30, 2022

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

Authorized official

Name
Kavanaugh Chandler, MD
Title
Ceo
Phone
(912) 275-8028

Specialties & licenses 1

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

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 1

TypeEndpointUseAffiliation
CONNECT URL eClinicalWorks Direct

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171110000169 GA Part A Provider - Federally Qualified Health Center (FQHC) 0345463683 Practice locations: Brunswick, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972223162. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Oct 25, 2012 in GA
Enrollment address
1600 Ellis St
Brunswick, GA 31520-6737

Other NPIs with the same Medicare PAC ID 16

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

View all 16

National Provider Directory

National Provider Directory
Tax ID family
Coastal Community Health Services Inc24 organizations share this tax ID, including this one

Other organizations with this tax ID 23

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

View all 23

Locations

106 Shoppers Way
Ste 114
Brunswick, GA 31525

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Polly Andrews-Bean Individual Corporate DirectorBoard Member Apr 1, 2016
Carolyn Tinkham Individual Corporate DirectorBoard Member Mar 1, 2013
Teria Brown Individual Corporate DirectorBoard Member May 1, 2015
Esther Figueroa Individual Corporate DirectorBoard Member Apr 1, 2017
Kavanaugh Chandler Individual Corporate DirectorCeo Jul 6, 2021 100%
W-2 Managing EmployeeCeo Jul 6, 2021 100%
Greg Jaudon Individual Corporate DirectorBoard Member Aug 1, 2015
Margaret R Tuten Individual Corporate DirectorBoard Member Nov 1, 2014
Stephanie Krause-Jones Individual Corporate DirectorBoard Member May 1, 2014
George Stevens Individual Corporate DirectorBoard Member Apr 1, 2016
John Laws Individual Corporate DirectorBoard Member May 1, 2015
Pamela Rogers Individual Corporate DirectorBoard Member Mar 1, 2013

Practitioners & affiliated clinicians

Practitioners 11

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": "1661817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661817600000",
    "number": "1972223162",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "106 SHOPPERS WAY STE 114",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315250522",
            "telephone_number": "912-574-5075"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 ELLIS ST",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315206737",
            "telephone_number": "912-289-2006",
            "fax_number": "912-289-2014"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL COMMUNITY HEALTH SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-08-30",
        "last_updated": "2022-08-30",
        "certification_date": "2022-08-30",
        "status": "A",
        "authorized_official_last_name": "CHANDLER",
        "authorized_official_first_name": "KAVANAUGH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-275-8028",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "eClinicalWorks",
            "affiliation": "N",
            "endpointDescription": "EMR",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "HTTPS",
            "address_1": "1600 Ellis St",
            "city": "Brunswick",
            "state": "GA",
            "country_code": "US",
            "postal_code": "315206737",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Brunswick, GA

Sources for this page

Verify at the official NPI Registry.