Covered Entity Details

DSH110076D DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL (Active) - information as of 5/17/2025 10:47:07 PM

Main Details

Name

DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL

Subdivision Name

Emory at Decatur - Hematology & Oncology - Hematology & Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110076D

Medicare Provider Number

110076

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/11/2024

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Emory Decatur, Emory Hillandale
Lisa Urbistondo, Vice President & CFO
(404) 501-5025

Primary Contact

Emory Healthcare
Sydney Kchao, Corporate Director of Pharmacy, Business Operations and Finance
(404) 686-2147

Addresses

Street Address

2675 North Decatur Road
Suite 200
Suite 200
Decatur, GA 30033

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
GA	000000536A	1093716979

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110076A	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	Winship Cancer Institute Decatur	2675 N Decatur Rd	Decatur	GA	Active
DSH110076B	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	WOUND CARE CLINIC	2665 NORTH DECATUR RD	DECATUR	GA	Active
DSH110076C	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	Radiology Diagnostic	2675 North Decatur Rd	Decatur	GA	Active
DSH110076D	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	Emory at Decatur - Hematology & Oncology - Hematology & Oncology	2675 North Decatur Road	Decatur	GA	Active
DSH110076E	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	Emory Decatur Hospital Cardiac Imaging Center - Cardiac Imaging	2665 N Decatur Rd	Decatur	GA	Active
DSH110076F	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	EDH 2665 CARDIOLOGY - EDH 2665 CARDIOLOGY	2665 N Decatur Rd	Decatur	GA	Active
DSH110076G	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	EDH 2675 GASTROENTEROLOGY - EDH 2675 GASTROENTEROLOGY	2675 N Decatur Rd	Decatur	GA	Active
DSH110076H	Child	DSH	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	EDH 2675 RHEUMATOLOGY - EDH 2675 RHEUMATOLOGY	2675 N Decatur Rd	Decatur	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/23/2024 9:27:19 AM	8/23/2024 9:27 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Primary Contact	Update	Group Change Request	Lastrapes, Marcia P 340B Program Manager Emory Healthcare 8633990008	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory Healthcare 4046862147	5/21/2024 9:21 AM
Contacts	Signed By	Insert	New Registration		Urbistondo, Lisa Vice President & CFO Emory Decatur, Emory Hillandale 4045015025	4/11/2024 9:23 AM
Details	340B ID	Update	New Registration		DSH110076D	4/11/2024 9:23 AM
Details	Entity Name	Update	New Registration	EMORY DECATUR HOSPITAL	DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL	4/11/2024 9:23 AM
Details	Entity Subname	Update	New Registration	Emory at Decatur - Hematology & Oncology	Emory at Decatur - Hematology & Oncology - Hematology & Oncology	4/11/2024 9:23 AM
Dates	Participating Approval Date	Update	New Registration		4/11/2024 9:23:36 AM	4/11/2024 9:23 AM
Details	State	Update	New Registration	Pending	Approved	4/11/2024 9:23 AM
Dates	Signed By Date	Update	New Registration		4/10/2024 1:33:55 PM	4/11/2024 9:23 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/11/2024 9:23 AM
Addresses	Main Address	Insert	New Registration		2675 North Decatur Road Suite 200 Suite 200 Decatur, GA 30033	4/10/2024 11:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2024 11:13 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000536A	4/10/2024 11:13 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/10/2024 11:13 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1093716979	4/10/2024 11:13 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	4/10/2024 11:13 AM
Contacts	Primary Contact	Insert	New Registration		Lastrapes, Marcia P 340B Program Manager Emory Healthcare 8633990008	4/10/2024 11:13 AM
Contacts	Authorizing Official	Insert	New Registration		Urbistondo, Lisa Vice President & CFO Emory Decatur, Emory Hillandale 4045015025	4/10/2024 11:13 AM
Details	Assistance Received From Date	Insert	New Registration			4/10/2024 11:13 AM
Details	Assistance Received To Date	Insert	New Registration			4/10/2024 11:13 AM
Details	Last Recertification Date	Insert	New Registration			4/10/2024 11:13 AM
Details	Grant Number	Insert	New Registration			4/10/2024 11:13 AM
Details	340B ID	Insert	New Registration			4/10/2024 11:13 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2024 11:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2024 11:13 AM
Details	Medicare Provider Number	Insert	New Registration		110076	4/10/2024 11:13 AM
Details	Entity Name	Insert	New Registration		EMORY DECATUR HOSPITAL	4/10/2024 11:13 AM
Details	NOFO Number	Insert	New Registration			4/10/2024 11:13 AM
Details	Program Code	Insert	New Registration		DSH	4/10/2024 11:13 AM
Details	Entity Subname	Insert	New Registration		Emory at Decatur - Hematology & Oncology	4/10/2024 11:13 AM
Dates	Participating Approval Date	Insert	New Registration			4/10/2024 11:13 AM
Details	State	Insert	New Registration		Pending	4/10/2024 11:13 AM
Dates	Registration Date	Insert	New Registration		4/10/2024 11:13:08 AM	4/10/2024 11:13 AM
Dates	Signed By Date	Insert	New Registration			4/10/2024 11:13 AM
Dates	Start Date	Insert	New Registration			4/10/2024 11:13 AM
Terminations	Termination Comments	Insert	New Registration			4/10/2024 11:13 AM
Terminations	Termination Date	Insert	New Registration			4/10/2024 11:13 AM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2024 11:13 AM
Terminations	Termination Reason	Insert	New Registration			4/10/2024 11:13 AM