Provider Demographics
NPI:1902963580
Name:SOUTHERN HEALTH CORP OF ELLIJAY
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP OF ELLIJAY
Other - Org Name:GILMER NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:706-276-4741
Mailing Address - Street 1:PO BOX 1161
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-0015
Mailing Address - Country:US
Mailing Address - Phone:706-276-4741
Mailing Address - Fax:706-276-4745
Practice Address - Street 1:1362 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-5410
Practice Address - Country:US
Practice Address - Phone:706-276-4741
Practice Address - Fax:706-276-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-061-1232313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00141127AMedicaid
GA501001OtherBLUE CROSS
GA501001OtherBLUE CROSS