Covered Entity Details

DSH340113T CAROLINAS MEDICAL CENTER (Terminated) - information as of 5/9/2025 10:46:59 PM

Main Details

Name

CAROLINAS MEDICAL CENTER

Subdivision Name

CHS CMC Behavioral Health Child and Adolescent OP

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340113T

Medicare Provider Number

340113

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

8/31/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/19/2012

Last Recertification Date

8/31/2016

Termination Date
Termination Reason

10/1/2017
Site closure

Contacts

Authorizing Official

Atrium Health/Charlotte-Mecklenburg Hospital Authority
Ken Haynes, President and Executive Vice President
(704) 355-6305

Primary Contact

Atrium Health
Fern Paul-Aviles, Assistant Vice President, Pharmacy
(704) 649-9691

Addresses

Street Address

300 Billingsley Road
Charlotte, NC 28211

Billing Address

Accounts Payable
PO Box 37972
Charlotte, NC 28237

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
NC	3400113,0608109
SC	336688
TN	0340113,1507276
VA	009814159
WV	0175950000
GA	000104101A,422942719A
FL	092547100,913957500
CT	003043387
IL	561398929002
IN	100036400B
ME	179230002
OH	0303077
PA	1007534530003
		1659475754,1295789907

Shipping Addresses

Shipping Address 1

CMC-Randolph
501 Billingsley Road
Charlotte, NC 28211

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
DSH340113A	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Biddle Point	1801 ROZZELLES FERRY ROAD	CHARLOTTE	NC	Active
DSH340113AA	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Kidney	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AB	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Heart	1025 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113AC	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Liver	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AD	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Pancreas	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AF	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant & Liver Care	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AG	Child	DSH	CAROLINAS MEDICAL CENTER	Radiation Oncology	1310 E. Morehead St	Charlotte	NC	Active
DSH340113AH	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Heart Success and Transition Clinic	1237 Harding Place	Charlotte	NC	Active
DSH340113AJ	Child	DSH	CAROLINAS MEDICAL CENTER	Nuclear Medicine	1000 Blythe Blvd	Charlotte	NC	Terminated
DSH340113AK	Child	DSH	CAROLINAS MEDICAL CENTER	CMC NorthPark After-Hours Pediatric Clinic	251 Eastway Drive	Charlotte	NC	Terminated
DSH340113AL	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Sleep Disorder Lab	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AM	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Orthopedics	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AN	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - General Surgery	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AP	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Obstetrics & Gynecology	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AQ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Pediatrics	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	100 Medical Park Drive	Concord	NC	Active
DSH340113AS	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Internal Medicine	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AT	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health NorthPark - Obstetrics & Gynecology	251 Eastway Drive	Charlotte	NC	Active
DSH340113AU	Child	DSH	CAROLINAS MEDICAL CENTER	Southeast Pain Care Center	3030 Randolph Road	Charlotte	NC	Terminated
DSH340113AV	Child	DSH	CAROLINAS MEDICAL CENTER	Carolinas Wound Care Center	1601 Abbey Place	Charlotte	NC	Terminated
DSH340113AW	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	945 North Fifth Street	Albemarle	NC	Active
DSH340113AX	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Emergency Department	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AY	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Kidney Dialysis Unit	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AZ	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Same Day Procedures	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113B	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health NorthPark - Family Medicine	251 EASTWAY DRIVE	CHARLOTTE	NC	Active
DSH340113BA	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Endoscopy	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113BB	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Internal Medicine Specialty	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113BC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic	1021 Morehead Medical Dr	Charlotte	NC	Active
DSH340113BD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Rare/Complex Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Breast Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute GYN Clinic	1021 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113BG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer GU Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BH	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Gynecological Oncology Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BJ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Surgical Oncology	1021 Morehead Medical Drive	Charlotte	NC	ToBeTerminated
DSH340113BK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	4525 Cameron Valley Parkway	Charlotte	NC	Active
DSH340113BL	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	4525 Cameron Valley Parkway	Charlotte	NC	Active
DSH340113BM	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	10660 Park Road	Charlotte	NC	Active
DSH340113BN	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113BP	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113BQ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113BR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center (0001 344200)	1100 South Tryon St	Charlotte	NC	Terminated
DSH340113BS	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology (0001 344400)	1100 South Tryon St	Charlotte	NC	Terminated
DSH340113BT	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center (0001 342800)	10826 Mallard Creek Road	Charlotte	NC	Terminated
DSH340113BU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology (0001 343700)	10826 Mallard Creek Road	Charlotte	NC	Terminated
DSH340113BV	Child	DSH	CAROLINAS MEDICAL CENTER	HPB (Hepato-Pancreatico-Biliary) Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BW	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Primary Care	501 Billingsley Rd.	Charlotte	NC	Terminated
DSH340113BX	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health SouthPark Emergency Department	6965 Fairview Rd.	Charlotte	NC	Active
DSH340113BY	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic Concord	100 Medical Park Drive	Concord	NC	Active
DSH340113BZ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic Albemarle	945 North Fifth Street	Albemarle	NC	Active
DSH340113C	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Emergency Department	501 BILLINGSLEY ROAD	CHARLOTTE	NC	Active
DSH340113CA	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Hematology and Lymphoma Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Sickle Cell Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CC	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Heart Failure (CHF) Clinic	1025 Medical Center Drive	Charlotte	NC	Terminated
DSH340113CD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center (0001 331300)	1401 Matthews Township Pkwy	Matthews	NC	Terminated
DSH340113CE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic (0001 331400)	1401 Matthews Township Pkwy	Matthews	NC	Terminated
DSH340113CF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	15830 Ballantyne Medical Place	Charlotte	NC	Active
DSH340113CG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic	15830 BALLANTYNE MEDICAL PLACE	CHARLOTTE	NC	Active
DSH340113CH	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Gastroenterology & Hepatology	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CJ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Survivorship / Survivorship (338600)	711 E. Morehead St	Charlotte	NC	Terminated
DSH340113CK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Palliative Care	1021 Morehead Medical Dr	Charlotte	NC	Active
DSH340113CL	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute / ALS Center, and Neuromuscular, Movement, and Headache Programs	1010 Edgehill Rd	Charlotte	NC	Active
DSH340113CM	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute / Infusion Service	1225 Harding Place	Charlotte	NC	Active
DSH340113CN	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Medication Management Clinic	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113CP	Child	DSH	CAROLINAS MEDICAL CENTER	ADULT INTEGRATED CONTINUUM - Eagle Program	501 Billingsley Road	Charlotte	NC	Active
DSH340113CQ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute - Epilepsy Clinic	1225 Harding Place	Charlotte	NC	Active
DSH340113CR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113CS	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CT	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113CU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Surgical Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113CV	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center	16455 Statesville Rd	Huntersville	NC	Active
DSH340113CW	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology	16455 Statesville Rd	Huntersville	NC	Active
DSH340113CX	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Endocrine Oncology	10660 Park Road	Charlotte	NC	ToBeTerminated
DSH340113CY	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Cutaneous/Plastics	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CZ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health General & Complex Abdominal Surgery - CMC Trauma Clinic	1025 Morehead Medical Drive	Charlotte	NC	ToBeTerminated
DSH340113D	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park Infectious Diseases Clinic	1350 SOUTH KINGS DRIVE	CHARLOTTE	NC	Terminated
DSH340113DA	Child	DSH	CAROLINAS MEDICAL CENTER	Pediatric Outpatient Infusion Center CLIV	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113DB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Union	1550 Faulk Street	Monroe	NC	Active
DSH340113DC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Union	1550 Faulk Street	Monroe	NC	Active
DSH340113DD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Lincoln	447 McAlister Road	Lincolnton	NC	Active
DSH340113DE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Lincoln	447 McAlister Road	Lincolnton	NC	Active
DSH340113DF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Cleveland	201 East Grover St	Shelby	NC	Active
DSH340113DG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Cleveland	201 East Grover St	Shelby	NC	Active
DSH340113DH	Child	DSH	CAROLINAS MEDICAL CENTER	Radiation Oncology - Radiation Therapy and Brachytherapy	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DJ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Community Care Primary Care - Archdale Family Medicine	5929 South Blvd	Charlotte	NC	Active
DSH340113DK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Surgical Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DL	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DM	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center	1100 Healing Way	Indian Trail	NC	Active
DSH340113DN	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DP	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC AYA Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DQ	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - US	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - Thoracic Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DS	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - NM	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DT	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - PET	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC Cancer Rehab Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DV	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - Thoracic Cardiology Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DW	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - CT	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DX	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC Sexual Health	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DY	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Kenilworth - Kenilworth Infusion Center	1225 Harding Place	Charlotte	NC	Active
DSH340113DZ	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - MR	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113E	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Infusion Center	1601 Abbey Place	Charlotte	NC	Active
DSH340113EA	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - XR	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113EB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - GI Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113EC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Infusion Center - Non-Oncology Infusion service line	100 Medical Park Drive	Concord	NC	Active
DSH340113F	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Children's Specialty Center	1001 Blythe Blvd	CHARLOTTE	NC	Active
DSH340113G	Child	DSH	CAROLINAS MEDICAL CENTER	Carolinas Diabetes Center	1025 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113H	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health General & Complex Abdominal Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113J	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Orthopedic Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113K	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Dental Clinic	1000 Blythe Blvd	Charlotte	NC	Active
DSH340113L	Child	DSH	CAROLINAS MEDICAL CENTER	CMC Elizabeth Family Medicine	2001 Vail Avenue	Charlotte	NC	Active
DSH340113M	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute/MS Center, Sleep Center, and Sub-specialty Services	1225 Harding Place	Charlotte	NC	Active
DSH340113N	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health One Day Surgery	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113Q	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Pain Management	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113R	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Children's Cancer & Blood Disorders	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113S	Child	DSH	CAROLINAS MEDICAL CENTER	Adult Integrated Continuum	501 Billingsley Road	Charlotte	NC	Active
DSH340113T	Child	DSH	CAROLINAS MEDICAL CENTER	CHS CMC Behavioral Health Child and Adolescent OP	300 Billingsley Road	Charlotte	NC	Terminated
DSH340113U	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Outpatient Medication Services Clinic	501 Billingsley Road	Charlotte	NC	Active
DSH340113V	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Observation Unit	501 Billingsley Road	Charlotte	NC	Active
DSH340113W	Child	DSH	CAROLINAS MEDICAL CENTER	Teen Health Connection	3541 Randolph Road	Charlotte	NC	Active
DSH340113X	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Fertility Center Morehead Medical Plaza	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113Y	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Blumenthal Infusion Center	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113Z	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center	1025 Morehead Medical Drive	Charlotte	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Recertification	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	Haynes, Ken President and Executive Vice President Atrium Health/Charlotte-Mecklenburg Hospital Authority 7043556305	8/30/2021 10:51 AM
Contacts	Authorizing Official	Update	AO Change Request	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	6/3/2020 8:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	Paul-Aviles, Fern Assistant Vice President, Pharmacy Atrium Health 7046499691	9/12/2019 2:13 PM
Contacts	Authorizing Official	Update		Leighty, Scott Senior Vice President 7045122414	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	10/12/2017 9:08 AM
Contacts	Primary Contact	Update		Paul-Aviles, Fern Pharmacy Director 7046499691	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	9/22/2017 2:54 PM
Contacts	Primary Contact	Insert			Paul-Aviles, Fern Pharmacy Director 7046499691	7/25/2017 1:24 PM
Contacts	Authorizing Official	Insert			Leighty, Scott Senior Vice President 7045122414	7/25/2017 1:24 PM
Contacts	Signed By	Insert			Gombar, Greg Chief Financial Officer 7043552154	7/25/2017 1:24 PM
Addresses	Main Address	Insert			300 Billingsley Road Charlotte, NC 28211	7/25/2017 8:52 AM
Addresses	Billing Address	Insert			Accounts Payable PO Box 37972 Charlotte, NC 28237	7/25/2017 8:52 AM
Addresses	Shipping Address	Insert			CMC-Randolph 501 Billingsley Road Charlotte, NC 28211	7/25/2017 8:52 AM
Details	State	Update		To Be Terminated	Terminated	7/25/2017 8:52 AM
Dates	Last Date That 340B Drugs Purchased	Update			5/29/2017 12:00:00 AM	7/25/2017 8:51 AM
Details	State	Update		Active	To Be Terminated	7/25/2017 8:51 AM
Terminations	Termination Comments	Update			This child site removed from cost report for DSH340113 filed 5/30/17	7/25/2017 8:51 AM
Terminations	Termination Date	Update			10/1/2017 12:00:00 AM	7/25/2017 8:51 AM
Terminations	Termination Effective Date	Update			5/30/2017 12:00:00 AM	7/25/2017 8:51 AM
Terminations	Termination Reason	Update			Site closure	7/25/2017 8:51 AM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 9:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			003043387	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			CT	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			913957500	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			FL	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			422942719A	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			GA	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			561398929002	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			100036400B	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			IN	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			179230002	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			ME	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			0303077	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			OH	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			1007534530003	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			PA	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Number	Insert			1507276	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: State	Insert			TN	4/18/2016 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			336688	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			SC	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			0340113	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			TN	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			009814159	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			VA	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			0175950000	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			WV	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			000104101A	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			GA	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: Number	Insert			092547100	10/19/2015 9:29 AM
Medicaid Billing	Medicaid: State	Insert			FL	10/19/2015 9:29 AM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 2:13 PM
Details	Entity Subname	Update		CMC-Randolph Child and Adolescent OP	CHS CMC Behavioral Health Child and Adolescent OP	10/21/2014 6:54 PM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 10:48 AM
Medicaid Billing	NPI: Number	Insert			1295789907	1/21/2014 9:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/12/2013 11:02 AM
Medicaid Billing	Medicaid: Number	Insert			0608109	9/12/2013 11:02 AM
Medicaid Billing	Medicaid: State	Insert			NC	9/12/2013 11:02 AM
Medicaid Billing	NPI: Number	Insert			1659475754	9/12/2013 11:02 AM
Details	Last Recertification Date	Update			9/12/2013 12:00:00 AM	9/12/2013 11:02 AM
Details	340B ID	Update		IS-DR-DSH340113T	DSH340113T	9/19/2012 2:37 PM
Dates	Participating Approval Date	Update			9/19/2012 12:00:00 AM	9/19/2012 2:37 PM
Details	State	Update		Pending	Active	9/19/2012 2:37 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/19/2012 2:37 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DR-DSH340113T	9/17/2012 5:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/31/2012 11:31 AM
Medicaid Billing	Medicaid: Number	Insert			3400113	8/31/2012 11:31 AM
Medicaid Billing	Medicaid: State	Insert			NC	8/31/2012 11:31 AM
Details	Last Recertification Date	Insert				8/31/2012 11:31 AM
Details	Grant Number	Insert				8/31/2012 11:31 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	8/31/2012 11:31 AM
Details	Is Authorizing Official EHB Data	Insert				8/31/2012 11:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert				8/31/2012 11:31 AM
Details	Medicare Provider Number	Insert			340113	8/31/2012 11:31 AM
Details	Entity Name	Insert			CAROLINAS MEDICAL CENTER	8/31/2012 11:31 AM
Details	Program Code	Insert			DSH	8/31/2012 11:31 AM
Details	Entity Subname	Insert			CMC-Randolph Child and Adolescent OP	8/31/2012 11:31 AM
Dates	Participating Approval Date	Insert				8/31/2012 11:31 AM
Details	State	Insert			Pending	8/31/2012 11:31 AM
Dates	Registration Date	Insert			8/31/2012 12:00:00 AM	8/31/2012 11:31 AM
Dates	Signed By Date	Insert			8/31/2012 12:00:00 AM	8/31/2012 11:31 AM
Dates	Start Date	Insert				8/31/2012 11:31 AM
Terminations	Termination Comments	Insert				8/31/2012 11:31 AM
Terminations	Termination Date	Insert				8/31/2012 11:31 AM
Terminations	Termination Effective Date	Insert				8/31/2012 11:31 AM
Terminations	Termination Reason	Insert				8/31/2012 11:31 AM