Provider Demographics
NPI:1093754905
Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:WREN
Authorized Official - Last Name:DENMARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-237-2638
Mailing Address - Street 1:215 N COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3530
Mailing Address - Country:US
Mailing Address - Phone:478-237-2638
Mailing Address - Fax:478-237-9138
Practice Address - Street 1:117 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4641
Practice Address - Country:US
Practice Address - Phone:912-557-3300
Practice Address - Fax:912-557-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000632376FMedicaid
111887OtherMEDICARE PROVIDER NUMBER