Covered Entity Details

DSH110001 HAMILTON MEDICAL CENTER INC. (Active) - information as of 6/25/2025 12:50:50 AM

Main Details

Name

HAMILTON MEDICAL CENTER INC.

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110001

Medicare Provider Number

110001

Additional Details

Current Program Status

Active

Registration Date

7/1/2005

Participating Start Date

7/1/2005

Participating Approval Date

5/16/2005

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Hamilton Medical Center
Randall Foster, Vice President-Finance
(706) 272-6124 Ext: 6124

Primary Contact

Hamilton Medical Center
Gregory K. Stinnett, Director of Pharmacy
(706) 272-6020

Addresses

Street Address

1200 Memorial Dr
DALTON, GA 30720

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
2/29/12 add NPI NEW ADD 7/05	02/29/2012
NEW ADD 7/05	05/16/2005

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	000000899A,003118335A	1821247164,1528056066
TN	110001	1528056066

Shipping Addresses

Shipping Address 1

Hamilton Medical Center
1200 Memorial Dr
Dalton, GA 30720

Shipping Address 2

HMC Rx Care
1200 Memorial Dr
Dalton, GA 30720

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/18/2023	07/01/2023	04/01/2025	04/07/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/18/2023	07/01/2023		03/07/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/18/2023	07/01/2023		03/07/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/18/2023	07/01/2023		03/07/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/18/2023	07/01/2023		03/07/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/18/2023	07/01/2023		03/07/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	07/14/2023	10/01/2023		03/07/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	07/14/2023	10/01/2023		03/07/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110001B	Child	DSH	HAMILTON MEDICAL CENTER INC.	Peeples Cancer Institute - Oncology	1215 Memorial Dr	Dalton	GA	Active
DSH110001C	Child	DSH	HAMILTON MEDICAL CENTER INC.	Hamilton Diagnostics Center - Radiology-Diagnostic	1407 N Thornton Ave	Dalton	GA	Active
DSH110001D	Child	DSH	HAMILTON MEDICAL CENTER INC.	Hamilton Diagnostics Center - MRI	1407 N Thornton Ave	Dalton	GA	Active
DSH110001E	Child	DSH	HAMILTON MEDICAL CENTER INC.	Hamilton Diagnostics Center - CT Scan	1407 N Thornton Ave	Dalton	GA	Active
DSH110001F	Child	DSH	HAMILTON MEDICAL CENTER INC.	Hamilton Diagnostics Center - Electrocardiology	1407 N Thornton Ave	Dalton	GA	Terminated
DSH110001G	Child	DSH	HAMILTON MEDICAL CENTER INC.	HDC - Neurodiagnostic - Neurodiagnostic Services	1407 N Thornton Ave	Dalton	GA	Active
DSH110001H	Child	DSH	HAMILTON MEDICAL CENTER INC.	Ambulatory Infusion Center - Oncology	1215 Memorial Dr	Dalton	GA	Active
DSH110001J	Child	DSH	HAMILTON MEDICAL CENTER INC.	HDC - Ultrasound - Ultrasound	1407 N Thornton Ave	Dalton	GA	Active
DSH110001K	Child	DSH	HAMILTON MEDICAL CENTER INC.	Hamilton Diabetes and Endocrinology Center - Diabetes and Endocrinology	475 Reed Rd	Dalton	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Foster, Randall Executive Director, Financial Services Hamilton Medical Center 7062726124-6124	Foster, Randall Vice President-Finance Hamilton Medical Center 7062726124-6124	3/10/2025 6:18 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	4/1/2025 12:00:00 AM		3/7/2025 3:21 PM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	3/7/2025 3:21 PM
Terminations	Termination Date	Update	OPA Cancel Termination Request	4/1/2025 12:00:00 AM		3/7/2025 3:21 PM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	4/1/2025 12:00:00 AM		3/7/2025 3:21 PM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	Change of covered entity type		3/7/2025 3:21 PM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/17/2025 7:27 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	1/17/2025 7:27 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/17/2025 7:27 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/17/2025 7:27 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	1/17/2025 7:27 AM
Details	Last Recertification Date	Update	Recertification	8/24/2023 3:08:50 PM	8/22/2024 8:37:02 AM	8/22/2024 8:37 AM
Contacts	Authorizing Official	Update	Profile Change Request	Foster, Randall Interim Chief Financial Officer Hamilton Medical Center 7062726124-6124	Foster, Randall Executive Director, Financial Services Hamilton Medical Center 7062726124-6124	6/20/2024 6:47 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 12:45:47 PM	8/24/2023 3:08:50 PM	8/24/2023 3:08 PM
Addresses	Main Address	Update	Change Request	1200 MEMORIAL DRIVE DALTON, GA 30720	1200 Memorial Dr DALTON, GA 30720	1/19/2023 7:24 AM
Addresses	Shipping Address	Insert	Change Request		Hamilton Medical Center 1200 Memorial Dr Dalton, GA 30720	1/19/2023 7:24 AM
Addresses	Shipping Address	Insert	Change Request		HMC Rx Care 1200 Memorial Dr Dalton, GA 30720	1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	HMC0001N (AL)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	XHXP33899 (CA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	XHSP43899 (CA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	82758824 (CO)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	107554500 (FL)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	581519911001 (IL)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100039070A (IN)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	*01300383 (KY)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1708321 (LA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300335300 (MD)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	250006068 (NV)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3206677 (NY)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1528056066 (NY)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1100001 (NC)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0222744 (OH)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	103330011-0001 (PA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10950A (SC)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1528056066 (VA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1528056066 (WA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3810005775 (WA)		1/19/2023 7:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3810005775 (WV)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (AL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (AL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (CA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (CA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (CO)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (CO)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (FL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (FL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (IL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (IL)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (IN)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (IN)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (KY)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (KY)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (LA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (LA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (MD)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (MD)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (NV)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (NV)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (NY)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (NY)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (NC)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (NC)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (OH)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (OH)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (PA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (PA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (SC)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (SC)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (TN)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (VA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (VA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (WA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (WA)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528056066 (WV)		1/19/2023 7:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1821247164 (WV)		1/19/2023 7:24 AM
Details	Last Recertification Date	Update	Recertification	9/15/2021 9:02:01 AM	9/16/2022 12:45:47 PM	9/16/2022 12:45 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 9:49:00 AM	9/15/2021 9:02:01 AM	9/15/2021 9:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		HMC0001N	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		XHXP33899	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		XHSP43899	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		82758824	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		107554500	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		581519911001	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100039070A	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		*01300383	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1708321	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300335300	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		250006068	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3206677	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1100001	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0222744	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		103330011-0001	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10950A	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110001	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3810005775	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3810005775	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		WA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		WA	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1528056066	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	4/21/2021 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821247164	4/21/2021 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	4/21/2021 11:12 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00803976A (GA)		8/25/2020 9:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 9:49 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000000899A	8/25/2020 9:49 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/25/2020 9:49 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821247164	8/25/2020 9:49 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/25/2020 9:49 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1528056066	8/25/2020 9:49 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/25/2020 9:49 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1821247164 ( )		8/25/2020 9:49 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1528056066 ( )		8/25/2020 9:49 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 6:11:14 AM	8/25/2020 9:49:00 AM	8/25/2020 9:49 AM
Details	Last Recertification Date	Update	Recertification	8/29/2018 1:21:04 PM	9/9/2019 6:11:14 AM	9/9/2019 6:11 AM
Contacts	Authorizing Official	Update	Change Request	McGuire, Joseph L. VP & CFO Hamilton Medical Center 7062726115	Foster, Randall Interim Chief Financial Officer Hamilton Medical Center 7062726124-6124	7/24/2019 2:02 PM
Details	Last Recertification Date	Update	Recertification	11/30/2017 11:32:14 AM	8/29/2018 1:21:04 PM	8/29/2018 1:21 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/30/2017 11:32:14 AM	11/30/2017 11:32 AM
Contacts	Authorizing Official	Update		McGuire, Joseph L. VP & CFO 7062726115	McGuire, Joseph L. VP & CFO Hamilton Medical Center 7062726115	11/15/2017 2:04 PM
Contacts	Primary Contact	Update		Stinnett, Gregory K. Director of Pharmacy 7062726020	Stinnett, Gregory K. Director of Pharmacy Hamilton Medical Center 7062726020	11/15/2017 8:17 AM
Addresses	Main Address	Insert			1200 MEMORIAL DRIVE DALTON, GA 30720	9/1/2016 10:01 AM
Contacts	Primary Contact	Update		CLARK, CRAIG DIRECTOR OF PHARMACY 7062726020	Stinnett, Gregory K. Director of Pharmacy 7062726020	9/1/2016 10:01 AM
Contacts	Authorizing Official	Update		BOWLING, JOHN CEO 7062726105	McGuire, Joseph L. VP & CFO 7062726115	9/1/2016 10:01 AM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2016 3:34 PM
Medicaid Billing	Medicaid: Number	Insert			003118335A	1/11/2016 3:34 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/11/2016 3:34 PM
Medicaid Billing	NPI: Number	Insert			1821247164	1/11/2016 3:34 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/26/2015 11:23 AM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/26/2015 12:00:00 AM	8/26/2015 11:23 AM
Contacts	Primary Contact	Insert			CLARK, CRAIG DIRECTOR OF PHARMACY 7062726020	8/21/2014 12:58 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 12:58 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 2:47 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/3/2012 8:02 AM
Medicaid Billing	NPI: Number	Insert			1528056066	2/29/2012 9:44 AM
Contacts	Authorizing Official	Insert			BOWLING, JOHN CEO 7062726105	2/29/2012 9:44 AM
Dates	Participating Approval Date	Update		5/16/2005 2:28:44 PM	5/16/2005 12:00:00 AM	2/29/2012 9:44 AM
Details	Comments Public	Insert			2/29/12 add NPI NEW ADD 7/05	2/29/2012 9:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	7/1/2005 12:00 AM
Medicaid Billing	Medicaid: Number	Insert			00803976A	7/1/2005 12:00 AM
Medicaid Billing	Medicaid: State	Insert			GA	7/1/2005 12:00 AM
Details	Last Recertification Date	Insert				5/16/2005 2:28 PM
Details	Grant Number	Insert				5/16/2005 2:28 PM
Details	340B ID	Insert			DSH110001	5/16/2005 2:28 PM
Details	Is Authorizing Official EHB Data	Insert				5/16/2005 2:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert				5/16/2005 2:28 PM
Details	Medicare Provider Number	Insert			110001	5/16/2005 2:28 PM
Details	Entity Name	Insert			HAMILTON MEDICAL CENTER INC.	5/16/2005 2:28 PM
Details	Program Code	Insert			DSH	5/16/2005 2:28 PM
Details	Entity Subname	Insert				5/16/2005 2:28 PM
Dates	Participating Approval Date	Insert			5/16/2005 2:28:44 PM	5/16/2005 2:28 PM
Details	State	Insert			Active	5/16/2005 2:28 PM
Dates	Registration Date	Insert			7/1/2005 12:00:00 AM	5/16/2005 2:28 PM
Dates	Signed By Date	Insert			4/25/2005 12:00:00 AM	5/16/2005 2:28 PM
Dates	Start Date	Insert			7/1/2005 12:00:00 AM	5/16/2005 2:28 PM
Terminations	Termination Comments	Insert				5/16/2005 2:28 PM
Terminations	Termination Date	Insert				5/16/2005 2:28 PM
Terminations	Termination Effective Date	Insert				5/16/2005 2:28 PM
Terminations	Termination Reason	Insert				5/16/2005 2:28 PM
Details	Comments Public	Insert			NEW ADD 7/05	5/16/2005 2:28 PM