Covered Entity Details

DSH110044A PHOEBE SUMTER MEDICAL CENTER (Active) - information as of 5/13/2025 1:27:39 AM

Main Details

Name

PHOEBE SUMTER MEDICAL CENTER

Subdivision Name

Oncology Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110044A

Medicare Provider Number

110044

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

8/28/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/14/2012

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Phoebe Sumter Medical Center, Inc
Michelle H Doggett, VP Controller, PSMC
(229) 931-1288

Primary Contact

Phoebe Sumter Medical Center, Inc.
Darryl Lane Hawkins, Manager, Pharmacy
(229) 931-1209

Addresses

Street Address

120 Hwy 280 W
Americus, GA 31719

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	000000019A	1609001312

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
DSH110044A	Child	DSH	PHOEBE SUMTER MEDICAL CENTER	Oncology Clinic	120 Hwy 280 W	Americus	GA	Active
DSH110044B	Child	DSH	PHOEBE SUMTER MEDICAL CENTER	Ellaville Rural Health Clinic	339 S BROAD STREET	ELLAVILLE	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	120 Hwy 280 W Suite A Americus, GA 31719	120 Hwy 280 W Americus, GA 31719	4/14/2025 7:51 AM
Details	Entity Subname	Update	Change Request	Phoebe Sumter Medical Center Oncology Cl	Oncology Clinic	4/14/2025 7:51 AM
Details	Last Recertification Date	Update	Recertification	8/22/2023 11:54:23 AM	8/28/2024 9:27:29 AM	8/28/2024 9:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Hawkins, Darryl Lane Director of Pharmacy Phoebe Sumter Medical Center 2299311209	Hawkins, Darryl Lane Manager, Pharmacy Phoebe Sumter Medical Center, Inc. 2299311209	8/20/2024 12:33 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:31:13 PM	8/22/2023 11:54:23 AM	8/22/2023 11:54 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 3:46:34 PM	8/30/2022 1:31:13 PM	8/30/2022 1:31 PM
Contacts	Authorizing Official	Update	Profile Change Request	Doggett, Michelle H Director of Finance Phoebe Sumter Medical Center, Inc 2299311288	Doggett, Michelle H VP Controller, PSMC Phoebe Sumter Medical Center, Inc 2299311288	12/6/2021 3:41 PM
Contacts	Authorizing Official	Update	AO Change Request	Lunneborg, Brandi Lee Chief Executive Officer Phoebe Sumter Medical Center 2299311191	Doggett, Michelle H Director of Finance Phoebe Sumter Medical Center, Inc 2299311288	11/16/2021 10:19 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 11:45:08 AM	9/10/2021 3:46:34 PM	9/10/2021 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1609001312 ( )		9/8/2020 11:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1609001312	9/8/2020 11:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 11:45 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 11:17:31 AM	9/8/2020 11:45:08 AM	9/8/2020 11:45 AM
Contacts	Authorizing Official	Update	AO Change Request	LUNNEBORG, BRANDI CEO Phoebe Sumter Medical Center 2299311280	Lunneborg, Brandi Lee Chief Executive Officer Phoebe Sumter Medical Center 2299311191	1/17/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 8:03:42 AM	9/3/2019 11:17:31 AM	9/3/2019 11:17 AM
Details	Last Recertification Date	Update	Recertification	12/5/2017 2:08:39 PM	8/20/2018 8:03:42 AM	8/20/2018 8:03 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	12/5/2017 2:08:39 PM	12/5/2017 2:08 PM
Contacts	Authorizing Official	Update		LUNNEBORG, BRANDI CEO 2299311280	LUNNEBORG, BRANDI CEO Phoebe Sumter Medical Center 2299311280	11/15/2017 9:49 AM
Contacts	Primary Contact	Update		Hawkins, Darryl Director of Pharmacy 2299311209	Hawkins, Darryl Lane Director of Pharmacy Phoebe Sumter Medical Center 2299311209	10/5/2017 11:53 AM
Addresses	Main Address	Insert			120 Hwy 280 W Suite A Americus, GA 31719	8/30/2016 3:25 PM
Contacts	Signed By	Insert			Petersen, Keith CEO 2299311280	8/30/2016 3:25 PM
Contacts	Authorizing Official	Update		Harding, John CEO 2299311280	LUNNEBORG, BRANDI CEO 2299311280	8/30/2016 3:25 PM
Contacts	Primary Contact	Insert			Hawkins, Darryl Director of Pharmacy 2299311209	8/30/2016 3:25 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 3:25 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 4:43 PM
Contacts	Authorizing Official	Update		Hair, Laurie CFO 2299311280	Harding, John CEO 2299311280	8/26/2014 10:48 AM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 10:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/24/2013 2:41 PM
Medicaid Billing	Medicaid: Number	Insert			000000019A	9/24/2013 2:41 PM
Medicaid Billing	Medicaid: State	Insert			GA	9/24/2013 2:41 PM
Medicaid Billing	NPI: Number	Insert			1609001312	9/24/2013 2:41 PM
Contacts	Authorizing Official	Insert			Hair, Laurie CFO 2299311280	9/24/2013 2:41 PM
Details	Last Recertification Date	Update		9/6/2013 10:00:56 AM	9/6/2013 12:00:00 AM	9/24/2013 2:41 PM
Details	Last Recertification Date	Update			9/6/2013 10:00:56 AM	9/6/2013 10:00 AM
Details	Entity Subname	Update			Phoebe Sumter Medical Center Oncology Cl	11/7/2012 2:50 PM
Details	340B ID	Update		IS-AP-DSH110044A	DSH110044A	9/14/2012 5:56 PM
Dates	Participating Approval Date	Update			9/14/2012 12:00:00 AM	9/14/2012 5:56 PM
Details	State	Update		Pending	Active	9/14/2012 5:56 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/14/2012 5:56 PM
Details	340B ID	Update		AP083112C	IS-AP-DSH110044A	9/13/2012 8:17 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	AP083112C	8/31/2012 5:07 PM
Details	Last Recertification Date	Insert				8/28/2012 3:12 PM
Details	Grant Number	Insert				8/28/2012 3:12 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	8/28/2012 3:12 PM
Details	Is Authorizing Official EHB Data	Insert				8/28/2012 3:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/28/2012 3:12 PM
Details	Medicare Provider Number	Insert			110044	8/28/2012 3:12 PM
Details	Entity Name	Insert			PHOEBE SUMTER MEDICAL CENTER	8/28/2012 3:12 PM
Details	Program Code	Insert			DSH	8/28/2012 3:12 PM
Details	Entity Subname	Insert				8/28/2012 3:12 PM
Dates	Participating Approval Date	Insert				8/28/2012 3:12 PM
Details	State	Insert			Pending	8/28/2012 3:12 PM
Dates	Registration Date	Insert			8/28/2012 12:00:00 AM	8/28/2012 3:12 PM
Dates	Signed By Date	Insert			8/28/2012 12:00:00 AM	8/28/2012 3:12 PM
Dates	Start Date	Insert				8/28/2012 3:12 PM
Terminations	Termination Comments	Insert				8/28/2012 3:12 PM
Terminations	Termination Date	Insert				8/28/2012 3:12 PM
Terminations	Termination Effective Date	Insert				8/28/2012 3:12 PM
Terminations	Termination Reason	Insert				8/28/2012 3:12 PM