Covered Entity Details

DSH110122D SOUTH GEORGIA MEDICAL CENTER (Terminated) - information as of 4/23/2025 11:58:32 PM

Main Details

Name

SOUTH GEORGIA MEDICAL CENTER

Subdivision Name

Diabetes Management Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110122D

Medicare Provider Number

110122

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/5/2013

Last Recertification Date

9/4/2015

Termination Date
Termination Reason

10/1/2015
Other

Contacts

Authorizing Official

SGMC
Ronald E Dean, CEO
(229) 259-4102

Primary Contact

Cindy Vickery, Director of Pharmacy
(229) 259-4870

Addresses

Street Address

3018 North Patterson Street
Valdosta, GA 31602

Billing Address

South Georgia Medical Center
PO BOX 0070
Valdosta, GA 31603

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?
No

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
DSH110122A	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	THE SURGERY CENTER	2417 NORTH PATTERSON STREET	VALDOSTA	GA	Active
DSH110122B	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Health Care South	250 Griffin Avenue	Valdosta	GA	Terminated
DSH110122C	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Imaging Center	2409 North Patterson Street	Valdosta	GA	Active
DSH110122D	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Diabetes Management Center	3018 North Patterson Street	Valdosta	GA	Terminated
DSH110122E	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Wound Care	2330 North Ashley Street	Valdosta	GA	Terminated
DSH110122F	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Smith Northview Hospital	4280 North Valdosta Road	Valdosta	GA	Terminated
DSH110122G	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SmithNorthview Hospital	4280 North Valdosta Road	Valdosta	GA	Active
DSH110122H	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH OR	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122J	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH CT Scan	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122K	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Wound and Burn Care	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122L	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH MRI	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122M	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Endoscopy	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122N	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Infusion	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122P	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Anesthesia	4280 N VALDOSTA RD	VALDOSTA	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Forbes, Bill CEO South Georgia Medical Ct. 2292594175	Dean, Ronald E CEO SGMC 2292594102	12/20/2019 10:29 AM
Contacts	Authorizing Official	Update	AO Change Request	Berry, C. Ross CEO South Georgia Medical Center 2292594102	Forbes, Bill CEO South Georgia Medical Ct. 2292594175	8/20/2018 2:57 PM
Contacts	Authorizing Official	Update	Profile Change Request	Berry, Ross C. CEO South Georgia Medical Center 2292594102	Berry, C. Ross CEO South Georgia Medical Center 2292594102	10/26/2017 10:05 AM
Contacts	Authorizing Official	Update		Berry, Ross C. CEO 2292594102	Berry, Ross C. CEO South Georgia Medical Center 2292594102	10/23/2017 3:16 PM
Contacts	Authorizing Official	Update		Sauls, Randy Chief Executive Officer 2293331020	Berry, Ross C. CEO 2292594102	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Sauls, Randy Chief Executive Officer 2293331020	6/14/2017 11:21 AM
Contacts	Signed By	Insert			Sauls, Randy Chief Executive Officer 2293331020	6/14/2017 11:21 AM
Contacts	Primary Contact	Insert			Vickery, Cindy Director of Pharmacy 2292594870	6/14/2017 11:21 AM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 7:23 AM
Dates	Last Date That 340B Drugs Purchased	Update			1/1/2014 12:00:00 AM	9/4/2015 7:23 AM
Details	State	Update		Active	Terminated	9/4/2015 7:23 AM
Terminations	Termination Comments	Update			I have been unable to electronically capture medication utilization in my 340B accumalators as we are continuing to purchase from our WAC acount.	9/4/2015 7:23 AM
Terminations	Termination Date	Update			10/1/2015 12:00:00 AM	9/4/2015 7:23 AM
Terminations	Termination Effective Date	Update			9/3/2015 12:00:00 AM	9/4/2015 7:23 AM
Terminations	Termination Reason	Update			Other	9/4/2015 7:23 AM
Addresses	Main Address	Insert			3018 North Patterson Street Valdosta, GA 31602	9/4/2015 7:23 AM
Details	Last Recertification Date	Update			8/22/2014 12:00:00 AM	8/22/2014 8:09 AM
Addresses	Billing Address	Insert			South Georgia Medical Center PO BOX 0070 Valdosta, GA 31603	12/5/2013 2:51 PM
Dates	Participating Approval Date	Update			12/5/2013 12:00:00 AM	12/5/2013 2:51 PM
Details	State	Update		Pending	Active	12/5/2013 2:51 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	12/5/2013 2:51 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH110122D	12/3/2013 4:44 PM
Details	Entity Name	Update		South Georgia Medical Center	SOUTH GEORGIA MEDICAL CENTER	12/3/2013 4:44 PM
Details	Last Recertification Date	Insert				10/11/2013 2:16 PM
Details	Grant Number	Insert				10/11/2013 2:16 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/11/2013 2:16 PM
Details	Is Authorizing Official EHB Data	Insert				10/11/2013 2:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/11/2013 2:16 PM
Details	Medicare Provider Number	Insert			110122	10/11/2013 2:16 PM
Details	Entity Name	Insert			South Georgia Medical Center	10/11/2013 2:16 PM
Details	Program Code	Insert			DSH	10/11/2013 2:16 PM
Details	Entity Subname	Insert			Diabetes Management Center	10/11/2013 2:16 PM
Dates	Participating Approval Date	Insert				10/11/2013 2:16 PM
Details	State	Insert			Pending	10/11/2013 2:16 PM
Dates	Registration Date	Insert			10/11/2013 12:00:00 AM	10/11/2013 2:16 PM
Dates	Signed By Date	Insert			10/11/2013 12:00:00 AM	10/11/2013 2:16 PM
Dates	Start Date	Insert				10/11/2013 2:16 PM
Terminations	Termination Comments	Insert				10/11/2013 2:16 PM
Terminations	Termination Date	Insert				10/11/2013 2:16 PM
Terminations	Termination Effective Date	Insert				10/11/2013 2:16 PM
Terminations	Termination Reason	Insert				10/11/2013 2:16 PM