| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Vice President, Clinical Services
John D. Archbold Memorial Hospital
2292282771 | Newman, Chris
Vice President, Clinical and Support Services
John D. Archbold Memorial Hospital
2292282771 | 8/29/2024 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2023 1:10:49 PM | 8/22/2024 4:52:45 PM | 8/22/2024 4:52 PM |
| Addresses | Shipping Address | Insert | Recertification | | Mitchell County Hospital
90 East Stephens Street
Camilla, GA 31730 | 8/23/2023 1:10 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 5:23:44 PM | 8/23/2023 1:10:49 PM | 8/23/2023 1:10 PM |
| Details | Entity Subname | Update | Recertification | MEDICAL GROUP OF MITCHELL COUNTY | ARCHBOLD PRIMARY CARE CAMILLA | 8/23/2023 1:10 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 1:53:42 PM | 9/7/2022 5:23:44 PM | 9/7/2022 5:23 PM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2020 5:37:43 PM | 8/27/2021 1:53:42 PM | 8/27/2021 1:53 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Vice President, Ancillary Services
John D. Archbold Memorial Hospital
2292282771 | Newman, Chris
Vice President, Clinical Services
John D. Archbold Memorial Hospital
2292282771 | 2/17/2021 8:31 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1922211515 | 8/19/2020 5:37 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | GA | 8/19/2020 5:37 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1922211515 ( ) | | 8/19/2020 5:37 PM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2019 12:28:09 PM | 8/19/2020 5:37:43 PM | 8/19/2020 5:37 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 10:25:12 AM | 8/28/2019 12:28:09 PM | 8/28/2019 12:28 PM |
| Addresses | Billing Address | Update | Change Request | MITCHELL COUNTY HOSPITAL
900 CAIRO ROAD
THOMASVILLE, GA 31792 | MITCHELL COUNTY HOSPITAL
920 CAIRO ROAD
THOMASVILLE, GA 31792 | 3/20/2019 10:06 AM |
| Details | Last Recertification Date | Update | Recertification | 11/14/2017 11:31:06 AM | 8/22/2018 10:25:12 AM | 8/22/2018 10:25 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Hembree, Greg S.
CFO
John D. Archboold Memorial Hospital
2292282853 | Hembree, Greg S.
CFO
John D. Archbold Memorial Hospital
2292282853 | 4/26/2018 6:19 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Pharmacy Director
John D. Archbold Memorial Hospital
2292282752 | Newman, Chris
Vice President, Ancillary Services
John D. Archbold Memorial Hospital
2292282771 | 3/29/2018 9:50 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2016 12:00:00 AM | 11/14/2017 11:31:06 AM | 11/14/2017 11:31 AM |
| Contacts | Authorizing Official | Update | | Hembree, Greg S.
CFO
2292282853 | Hembree, Greg S.
CFO
John D. Archboold Memorial Hospital
2292282853 | 10/22/2017 1:10 PM |
| Contacts | Primary Contact | Update | | Newman, Chris
Pharmacy Director
2292282752 | Newman, Chris
Pharmacy Director
John D. Archbold Memorial Hospital
2292282752 | 9/29/2017 9:39 AM |
| Contacts | Authorizing Official | Insert | | | Hembree, Greg S.
CFO
2292282853 | 1/22/2017 3:05 PM |
| Contacts | Primary Contact | Insert | | | Newman, Chris
Pharmacy Director
2292282752 | 1/22/2017 3:05 PM |
| Addresses | Main Address | Insert | | |
259 US HWY 19 N
CAMILLA, GA 31730 | 1/22/2017 2:57 PM |
| Addresses | Billing Address | Insert | | | MITCHELL COUNTY HOSPITAL
900 CAIRO ROAD
THOMASVILLE, GA 31792 | 1/22/2017 2:57 PM |
| Details | Last Recertification Date | Update | | 8/17/2015 12:00:00 AM | 8/18/2016 12:00:00 AM | 8/18/2016 3:35 PM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 8/17/2015 10:51 AM |
| Details | Last Recertification Date | Update | | 9/5/2014 12:00:00 AM | 8/17/2015 12:00:00 AM | 8/17/2015 10:51 AM |
| Details | Last Recertification Date | Update | | 9/10/2013 12:00:00 AM | 9/5/2014 12:00:00 AM | 9/5/2014 7:48 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1922211515 | 9/10/2013 9:48 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 9/10/2013 12:00:00 AM | 9/10/2013 9:48 AM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/4/2012 8:18 AM |
| Details | Last Recertification Date | Insert | | | | 9/16/2010 12:55 PM |
| Details | Grant Number | Insert | | | | 9/16/2010 12:55 PM |
| Details | 340B ID | Insert | | | CAH111331-01 | 9/16/2010 12:55 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/16/2010 12:55 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/16/2010 12:55 PM |
| Details | Medicare Provider Number | Insert | | | 111331 | 9/16/2010 12:55 PM |
| Details | Entity Name | Insert | | | MITCHELL COUNTY HOSPITAL | 9/16/2010 12:55 PM |
| Details | Program Code | Insert | | | CAH | 9/16/2010 12:55 PM |
| Details | Entity Subname | Insert | | | MEDICAL GROUP OF MITCHELL COUNTY | 9/16/2010 12:55 PM |
| Dates | Participating Approval Date | Insert | | | 9/15/2010 12:00:00 AM | 9/16/2010 12:55 PM |
| Details | State | Insert | | | Active | 9/16/2010 12:55 PM |
| Dates | Registration Date | Insert | | | 9/15/2010 12:00:00 AM | 9/16/2010 12:55 PM |
| Dates | Signed By Date | Insert | | | 9/3/2010 12:00:00 AM | 9/16/2010 12:55 PM |
| Dates | Start Date | Insert | | | 9/16/2010 12:00:00 AM | 9/16/2010 12:55 PM |
| Terminations | Termination Comments | Insert | | | | 9/16/2010 12:55 PM |
| Terminations | Termination Date | Insert | | | | 9/16/2010 12:55 PM |
| Terminations | Termination Effective Date | Insert | | | | 9/16/2010 12:55 PM |
| Terminations | Termination Reason | Insert | | | | 9/16/2010 12:55 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 9/15/2010 4:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 841859123C | 9/15/2010 4:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | GA | 9/15/2010 4:15 PM |