efile Public Visual Render
ObjectId: 201803199349302650 - Submission: 2018-11-15
TIN: 54-0696355
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
Attach to Form 990.
Go to
www.irs.gov/Form990
for the latest information.
OMB No. 1545-0047
20
17
Open to Public Inspection
Name of the organization
PRINCE WILLIAM HOSPITAL
Employer identification number
54-0696355
Part I
Identification of Disregarded Entities
Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Total income
(e)
End-of-year assets
(f)
Direct controlling
entity
(1)
PRINCE WILLIAM-FAUQUIER CANCER CENTER LLC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
05-0570221
HEALTHCARE
VA
10,396,513
30,722,598
PRINCE WILLIAM HOSPITAL
Part II
Identification of Related Tax-Exempt Organizations
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))
(f)
Direct controlling
entity
(g)
Section 512(b)(13) controlled entity?
Yes
No
(1)
AUXILIARY OF FORSYTH MEMORIAL HOSPITAL
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-0862112
HEALTHCARE
NC
501(C)(3)
LINE 10
FORSYTH MEMORIAL HOSPITAL INC
No
(2)
BRUNSWICK NOVANT MEDICAL CENTER FOUNDATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
27-4616751
HEALTHCARE
NC
501(C)(3)
LINE 7
BRUNSWICK COMMUNITY HOSPITAL LLC
No
(3)
CAROLINA MEDICORP ENTERPRISES INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
58-1466368
HEALTHCARE
NC
501(C)(3)
LINE 12B, II
NOVANT MEDICAL GROUP INC
No
(4)
COMMUNITY GENERAL HEALTH PARTNERS INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-0636250
HEALTHCARE
NC
501(C)(3)
LINE 3
NOVANT HEALTH TRIAD REGION LLC
No
(5)
COMMUNITY GENERAL HOSPITAL FOUNDATION INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1828629
HEALTHCARE
NC
501(C)(3)
LINE 7
COMMUNITY GENERAL HEALTH PARTNERS INC
No
(6)
FORSYTH MEDICAL CENTER FOUNDATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-2120959
HEALTHCARE
NC
501(C)(3)
LINE 7
FORSYTH MEMORIAL HOSPITAL INC
No
(7)
FORSYTH MEMORIAL HOSPITAL INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-0928089
HEALTHCARE
NC
501(C)(3)
LINE 3
NOVANT HEALTH TRIAD REGION LLC
No
(8)
FOUNDATION HEALTH SYSTEMS CORP
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1373175
HEALTHCARE
NC
501(C)(3)
LINE 10
NOVANT HEALTH INC
No
(9)
MEDICAL PARK HOSPITAL INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1340424
HEALTHCARE
NC
501(C)(3)
LINE 3
NOVANT HEALTH TRIAD REGION LLC
No
(10)
NMG SERVICES INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-2098809
HEALTHCARE
NC
501(C)(3)
LINE 10
NOVANT HEALTH INC
No
(11)
NOVANT HEALTH INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1376950
HEALTHCARE
NC
501(C)(3)
LINE 12C, III-FI
N/A
No
(12)
NOVANT MEDICAL GROUP INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
58-1728803
HEALTHCARE
NC
501(C)(3)
LINE 3
NMG SERVICES INC
No
(13)
PERSONAL CARE SERVICES
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
54-1291284
HEALTHCARE
VA
501(C)(3)
LINE 10
PRINCE WILLIAM HEALTH SYSTEM
No
(14)
PRESBYTERIAN HOSPITAL FOUNDATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
58-1413074
HEALTHCARE
NC
501(C)(3)
LINE 7
NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC
No
(15)
PRESBYTERIAN MEDICAL CARE CORPORATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1376368
HEALTHCARE
NC
501(C)(3)
LINE 3
NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC
No
(16)
PRINCE WILLIAM HEALTH SYSTEM
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
54-1278944
HEALTHCARE
VA
501(C)(3)
LINE 12C, III-FI
NOVANT HEALTH UVA HEALTH SYSTEM
No
(17)
PWHS FOUNDATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
54-1307595
HEALTHCARE
VA
501(C)(3)
LINE 7
PRINCE WILLIAM HEALTH SYSTEM
No
(18)
ROWAN HEALTH SERVICES CORPORATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1424814
HEALTHCARE
NC
501(C)(3)
LINE 12C, III-FI
NOVANT HEALTH INC
No
(19)
ROWAN REGIONAL MEDICAL CENTER AUXILIARY
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
23-7022472
HEALTHCARE
NC
501(C)(3)
LINE 10
ROWAN REGIONAL MEDICAL CENTER INC
No
(20)
ROWAN REGIONAL MEDICAL CENTER FOUNDATION INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1424818
HEALTHCARE
NC
501(C)(3)
LINE 7
ROWAN REGIONAL MEDICAL CENTER INC
No
(21)
ROWAN REGIONAL MEDICAL CENTER INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-0547479
HEALTHCARE
NC
501(C)(3)
LINE 3
ROWAN HEALTH SERVICES CORPORATION
No
(22)
SELF INSURANCE FUND - NOVANT HEALTH INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
58-1867242
HEALTHCARE
NC
501(C)(3)
LINE 12C, III-FI
NOVANT HEALTH INC
No
(23)
THE PRESBYTERIAN HOSPITAL
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-0554230
HEALTHCARE
NC
501(C)(3)
LINE 3
NOVANT HEALTH SOUTHERN PIEDMONT REGION LLC
No
(24)
CULPEPER MEMORIAL HOSPITAL INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
54-0622371
HEALTHCARE
VA
501(C)(3)
LINE 3
NOVANT HEALTH UVA HEALTH SYSTEM
No
(25)
NOVANT HEALTH UVA HEALTH SYSTEM
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
81-0868533
HEALTHCARE
VA
501(C)(3)
LINE 12A, I
NOVANT HEALTH INC
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2017
Page 2
Schedule R (Form 990) 2017
Page
2
Part III
Identification of Related Organizations Taxable as a Partnership
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
(1)
HAYMARKET SURGERY CENTER LLC
2085 FRONTIS PLAZA BLVD
WINSTONSALEM
,
NC
27103
46-2874962
HEALTHCARE
VA
PRINCE WILLIAM HOSPITAL
RELATED
265,422
2,449,920
No
Yes
51.010 %
(2)
PRINCE WILLIAM AMBULATORY SURGERY CENTER LLC (PWASC)
2085 FRONTIS PLAZA BLVD
WINSTONSALEM
,
NC
27103
77-0594498
HEALTHCARE
VA
PRINCE WILLIAM HOSPITAL
RELATED
796,625
2,365,988
No
Yes
51.000 %
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Percentage
ownership
(i)
Section 512(b)(13) controlled entity?
Yes
No
(1)
ADEPT HEALTH INC FKA NOVANT HEALTH SHARED SERVICES INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-2226937
ADMIN SERVICES
NC
N/A
C
No
(2)
CHOICEHEALTH INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1896065
MANAGED CARE
NC
N/A
C
No
(3)
COMMUNICARE INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1952950
RENTAL REAL ESTATE
NC
N/A
C
No
(4)
KERNERSVILLE MEDICAL CENTER PARK OWNERS' ASSOCIATION
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
47-1511401
RENTAL REAL ESTATE
NC
N/A
C
No
(5)
MEDQUEST INC & SUBSIDIARIES
3480 PRESTON RIDGE RD STE 600
ALPHARETTA
,
GA
30005
22-3860764
DIAGNOSTIC IMAGING
DE
N/A
C
No
(6)
NOVANT HEALTH FOUNDATION INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
81-3895369
INACTIVE
NC
N/A
C
No
(7)
NOVANT HEALTH TRINOVA INSURANCE PROTECTED CELL INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
81-2963143
INSURANCE
NC
N/A
C
No
(8)
ROWAN MEDICAL ALLIANCE INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1992669
INSURANCE
NC
N/A
C
No
(9)
ROWAN MEDICAL FACILITIES INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1424672
MEDICAL SUPPLIES
NC
N/A
C
No
(10)
SALEM DIAGNOSTICS INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1513621
HEALTH RELATED
NC
N/A
C
No
(11)
SALEM HEALTH SERVICES INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
56-1342654
HEALTH RELATED
NC
N/A
C
No
(12)
THE PARK AT MONROE PROPERTY OWNERS ASSOCIATION INC
2085 FRONTIS PLAZA BLVD
WINSTON SALEM
,
NC
27103
46-3910256
RENTAL REAL ESTATE
NC
N/A
C
No
Schedule R (Form 990) 2017
Page 3
Schedule R (Form 990) 2017
Page
3
Part V
Transactions With Related Organizations
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note.
Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1
During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a
Receipt of
(i)
interest,
(ii)
annuities,
(iii)
royalties, or
(iv)
rent from a controlled entity
.....................
1a
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
d
Loans or loan guarantees to or for related organization(s)
............................
1d
No
e
Loans or loan guarantees by related organization(s)
............................
1e
No
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
Yes
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
Yes
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
No
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
No
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
No
o
Sharing of paid employees with related organization(s)
............................
1o
No
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
No
r
Other transfer of cash or property to related organization(s)
............................
1r
Yes
s
Other transfer of cash or property from related organization(s)
............................
1s
Yes
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved
(1)
PRINCE WILLIAM AMBULATORY SURGERY CENTER
S
1,083,504
CASH
(2)
HAYMARKET SURGERY CENTER LLC
S
426,642
CASH
Schedule R (Form 990) 2017
Page 4
Schedule R (Form 990) 2017
Page
4
Part VI
Unrelated Organizations Taxable as a Partnership
Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(e)
Are all partners
section
501(c)(3)
organizations?
(f)
Share of total income
(g)
Share of
end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2017
Page 5
Schedule R (Form 990) 2017
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference
Explanation
Schedule R (Form 990) 2017
Additional Data
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