Covered Entity Details

DSH110107N Atrium Health Navicent The Medical Center (Active) - information as of 6/19/2025 11:52:27 PM

Main Details

Name

Atrium Health Navicent The Medical Center

Subdivision Name

Atrium Health Navicent Imaging & Laboratory

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110107N

Medicare Provider Number

110107

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

9/7/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/17/2012

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Atrium Health Navicent
Kimberly Shrewsbury, SVP and CFO
(205) 965-7895

Primary Contact

North Carolina Baptist Hospital
Bibi W Wishart, Program Director, 340B
(336) 713-3426

Addresses

Street Address

1650 Hardeman Avenue
Macon, GA 31201

Billing Address

Medical Center of Central Georgia
777 Hemlock Street
MSC #113
Macon, GA 31201

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	000001207A,003115096A	1043270564,1639296395

Shipping Addresses

Shipping Address 1

Medical Center of Central Georgia
777 Hemlock Street
Dock H1
Macon, GA 31201

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
DSH110107A	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Surgery Macon	1014 Forsyth Street	Macon	GA	Active
DSH110107B	Child	DSH	Atrium Health Navicent The Medical Center	Endoscopy ASC (ENDO CAS)	1014 Forsyth Street	Macon	GA	Active
DSH110107C	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent WT Anderson Infusion Center, a facility of Atrium Health Navicent The Medical Center	800 1st Street	Macon	GA	Active
DSH110107D	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Outpatient Rehab Services	770 Hemlock Street	Macon	GA	Terminated
DSH110107E	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Wound Care	818 Forsyth Street	Macon	GA	Active
DSH110107F	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Emergency Medical	675 New Street	Macon	GA	Terminated
DSH110107G	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Baldwin County EMS (EMS Baldwin)	560 W. Martin Luther King Jr Dr	Milledgeville	GA	Terminated
DSH110107H	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Breast Care Center	800 1st Street	Macon	GA	Active
DSH110107J	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care North	3400 Riverside Drive	Macon	GA	Active
DSH110107K	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care Northwest	5925 Zebulon Road	Macon	GA	Active
DSH110107L	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care East	1339 Gray Highway	Macon	GA	Active
DSH110107M	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Primary Care West Macon	3780 Eisenhower Parkway	Macon	GA	Active
DSH110107N	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Imaging & Laboratory	1650 Hardeman Avenue	Macon	GA	Active
DSH110107P	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Children's Care Downtown Macon	1014 Forsyth Street	Macon	GA	Active
DSH110107Q	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Children's Care Pediatric Hematology Oncology	770 Pine Street	Macon	GA	Active
DSH110107R	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent WT Anderson Community Health Center	764 Pine Street	Macon	GA	Active
DSH110107S	Child	DSH	Atrium Health Navicent The Medical Center	Womens Ambulatory OB GYN Health	764 Pine Street	Macon	GA	Active
DSH110107T	Child	DSH	Atrium Health Navicent The Medical Center	Beverly Knight Olson Children's Hospital Outpatient Services - Pediatric Surgical Services	700 Spring Street	Macon	GA	Active
DSH110107U	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Pre-surgery holding (Just for Today)	840 Pine Street	Macon	GA	Active
DSH110107V	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Operating Room	840 Pine Street	Macon	GA	Active
DSH110107W	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Pre-surgical and post-surgical clinic	840 Pine Street	Macon	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	Wishart, Bibi W Program Director, 340B North Carolina Baptist Hospital 3367133426	4/16/2025 2:47 PM
Addresses	Billing Address	Update	Recertification	Medical Center of Central Georgia 777 Hemlock Street MSC 113 Macon, GA 31201	Medical Center of Central Georgia 777 Hemlock Street MSC #113 Macon, GA 31201	9/3/2024 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	003115100A (GA)		9/3/2024 4:22 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 11:15:39 AM	9/3/2024 4:22:38 PM	9/3/2024 4:22 PM
Contacts	Authorizing Official	Update	AO Change Request	Saunders, Ninfa President/CEO Navicent Health, Inc. 4786336805	Shrewsbury, Kimberly SVP and CFO Atrium Health Navicent 2059657895	8/29/2024 6:50 AM
Contacts	Authorizing Official	Update	Profile Change Request	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	8/13/2024 2:16 PM
Details	Entity Name	Update	Change Request	MEDICAL CENTER OF CENTRAL GEORGIA	Atrium Health Navicent The Medical Center	1/25/2024 11:28 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4154975-00 (MD)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q046883 (TN)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1156A (SC)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000182376 (CO)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300036425 (IN)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	7100071000 (KY)		9/7/2023 11:15 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	107701900 (FL)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (CA)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (IA)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (IL)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (MI)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (NC)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (VA)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (WA)		9/7/2023 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (ME)		9/7/2023 11:15 AM
Details	Last Recertification Date	Update	Recertification	9/14/2022 1:43:14 PM	9/7/2023 11:15:39 AM	9/7/2023 11:15 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 8:05:08 AM	9/14/2022 1:43:14 PM	9/14/2022 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	910349000 (FL)		9/10/2021 8:05 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100001991 (WI)		9/10/2021 8:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2021 8:05 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		107701900	9/10/2021 8:05 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/10/2021 8:05 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (NV)		9/10/2021 8:05 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 3:43:04 PM	9/10/2021 8:05:08 AM	9/10/2021 8:05 AM
Details	Entity Subname	Update	Recertification	Central Georgia Diagnostics	Atrium Health Navicent Imaging & Laboratory	9/10/2021 8:05 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (CA)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (IL)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (IA)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (SC)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (VA)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (WA)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (MI)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1043270564 (NC)		9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q046883	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1156A	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000182376	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300036425	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7100071000	9/11/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043270564	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	9/11/2020 3:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1740307404 ( )		9/11/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	9/11/2020 3:43 PM
Contacts	Primary Contact	Update	Recertification	Pennell, Jennafer Hill Interim Director of Pharmacy The Medical Center Navicent Health 4786331440	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	9/11/2020 3:43 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 1:44:57 PM	9/11/2020 3:43:04 PM	9/11/2020 3:43 PM
Contacts	Authorizing Official	Update	AO Change Request	Harris, Susan COO The Medical Center Navicent Health 4786331452	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	8/19/2020 6:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4154975-00	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		910349000	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100001991	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043270564	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/11/2019 1:44 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 3:29:30 PM	9/11/2019 1:44:57 PM	9/11/2019 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/11/2019 2:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003115100A	1/11/2019 2:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	1/11/2019 2:34 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740307404	1/11/2019 2:34 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639296395	1/11/2019 2:34 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	003115100A (GA)		9/10/2018 3:29 PM
Details	Last Recertification Date	Update	Recertification	11/20/2017 1:49:20 PM	9/10/2018 3:29:30 PM	9/10/2018 3:29 PM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/20/2017 1:49:20 PM	11/20/2017 1:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Hill Pennell, Jennafer Interim Director of Pharmacy The Medical Center Navicent Health 4786331440	Pennell, Jennafer Hill Interim Director of Pharmacy The Medical Center Navicent Health 4786331440	11/6/2017 5:30 PM
Contacts	Authorizing Official	Update	Change Request	Saunders, Ninfa President/CEO 4786336805	Harris, Susan COO The Medical Center Navicent Health 4786331452	10/24/2017 6:42 PM
Addresses	Billing Address	Insert	Change Request		Medical Center of Central Georgia 777 Hemlock Street MSC 113 Macon, GA 31201	10/19/2017 3:45 PM
Addresses	Shipping Address	Insert	Change Request		Medical Center of Central Georgia 777 Hemlock Street Dock H1 Macon, GA 31201	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000001207A	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003115096A	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003115100A	10/19/2017 3:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/19/2017 3:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1043270564	10/19/2017 3:45 PM
Contacts	Authorizing Official	Update		Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	Saunders, Ninfa President/CEO Navicent Health, Inc. 4786336805	10/18/2017 9:58 AM
Contacts	Primary Contact	Update		Hill Pennell, Jennafer Interim Director of Pharmacy 4786331440	Hill Pennell, Jennafer Interim Director of Pharmacy The Medical Center Navicent Health 4786331440	10/10/2017 4:30 PM
Contacts	Authorizing Official	Update		Saunders, Ninfa President/CEO 4786336805	Saunders, Ninfa President/CEO 4786336805	9/11/2017 3:29 PM
Contacts	Primary Contact	Update		Meyer von Bremen, Bernard Director of Pharmacy Services 4786331440	Hill Pennell, Jennafer Interim Director of Pharmacy 4786331440	8/1/2017 2:12 PM
Contacts	Signed By	Insert			Faulk, Don CEO 4786336805	8/24/2016 1:24 PM
Contacts	Authorizing Official	Insert			Saunders, Ninfa President/CEO 4786336805	8/24/2016 1:24 PM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 11:18 AM
Addresses	Main Address	Insert			1650 Hardeman Avenue Macon, GA 31201	8/24/2016 11:18 AM
Contacts	Primary Contact	Insert			Meyer von Bremen, Bernard Director of Pharmacy Services 4786331440	8/13/2015 8:43 AM
Details	Last Recertification Date	Update		8/20/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 8:43 AM
Details	Last Recertification Date	Update		9/10/2013 8:45:26 AM	8/20/2014 12:00:00 AM	8/20/2014 1:43 PM
Details	Last Recertification Date	Update			9/10/2013 8:45:26 AM	9/10/2013 8:45 AM
Details	340B ID	Update		IS-AP-DSH110107N	DSH110107N	9/17/2012 3:08 PM
Dates	Participating Approval Date	Update			9/17/2012 12:00:00 AM	9/17/2012 3:08 PM
Details	State	Update		Pending	Active	9/17/2012 3:08 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/17/2012 3:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-AP-DSH110107N	9/14/2012 2:04 PM
Details	Last Recertification Date	Insert				9/7/2012 1:26 PM
Details	Grant Number	Insert				9/7/2012 1:26 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	9/7/2012 1:26 PM
Details	Is Authorizing Official EHB Data	Insert				9/7/2012 1:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/7/2012 1:26 PM
Details	Medicare Provider Number	Insert			110107	9/7/2012 1:26 PM
Details	Entity Name	Insert			MEDICAL CENTER OF CENTRAL GEORGIA	9/7/2012 1:26 PM
Details	Program Code	Insert			DSH	9/7/2012 1:26 PM
Details	Entity Subname	Insert			Central Georgia Diagnostics	9/7/2012 1:26 PM
Dates	Participating Approval Date	Insert				9/7/2012 1:26 PM
Details	State	Insert			Pending	9/7/2012 1:26 PM
Dates	Registration Date	Insert			9/7/2012 12:00:00 AM	9/7/2012 1:26 PM
Dates	Signed By Date	Insert			9/7/2012 12:00:00 AM	9/7/2012 1:26 PM
Dates	Start Date	Insert				9/7/2012 1:26 PM
Terminations	Termination Comments	Insert				9/7/2012 1:26 PM
Terminations	Termination Date	Insert				9/7/2012 1:26 PM
Terminations	Termination Effective Date	Insert				9/7/2012 1:26 PM
Terminations	Termination Reason	Insert				9/7/2012 1:26 PM