Provider Demographics
NPI:1821126400
Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:EAST GEORGIA HEALTHCARE CENTER, INC.
Other - Org Name:STATESBORO PEDIATRICS AND FAMILY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASWELL
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 AVE
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:912-764-9196
Practice Address - Fax:912-764-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA861815107AMedicaid
GA111931Medicare Oscar/Certification