Provider Demographics
NPI:1225364524
Name:EAST GEORGIA HEALTHCARE CENTER INC
Entity Type:Organization
Organization Name:EAST GEORGIA HEALTHCARE CENTER INC
Other - Org Name:STATESBORO PEDIATRICS & FAMILY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SORRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-237-6262
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:478-237-6262
Mailing Address - Fax:478-237-9138
Practice Address - Street 1:1570 BRAMPTON AVENUE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0855
Practice Address - Country:US
Practice Address - Phone:478-764-9196
Practice Address - Fax:912-764-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108558AMedicaid
GA111937Medicare Oscar/Certification