MEDICARE: EAST GEORGIA HEALTHCARE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487892857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST GEORGIA HEALTHCARE CENTER, INC.

Provider Business Mailing Address
First Line	:	128 S MAIN ST
Second Line	:
City	:	SWAINSBORO
State	:	GA
Zip	:	30401-3618
Country	:	US
Telephone Number	:	478-237-6262
Fax Number	:	478-237-6221

Provider Business Practice Location Address
First Line	:	118 E BROAD ST
Second Line	:
City	:	MOUNT VERNON
State	:	GA
Zip	:	30445-3018
Country	:	US
Telephone Number	:	478-237-2638
Fax Number	:	478-237-9138

Authorized Official
Title or Position	:	CFO
Name	:	JILL R SORRELLS
Credential	:
Telephone Number	:	478-237-6262

Provider Enumeration Date	:	01/23/2009
Last Update Date	:	08/04/2014

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