Covered Entity Details

DSH110078P EMORY UNIVERSITY HOSPITAL MIDTOWN (Terminated) - information as of 4/29/2025 11:58:24 PM

Main Details

Name

EMORY UNIVERSITY HOSPITAL MIDTOWN

Subdivision Name

Emory Heart and Vascular Imaging at Eastside

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110078P

Medicare Provider Number

110078

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/8/2014

Participating Start Date

7/1/2014

Participating Approval Date

6/11/2014

Last Recertification Date

8/30/2022

Termination Date
Termination Reason

1/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Emory
Greg E. Anderson, CFO
(404) 686-2823

Primary Contact

Emory Healthcare
Sydney Kchao, Corporate Director of Pharmacy, Business Operations and Finance
(404) 686-2147

Addresses

Street Address

1608 Tree Lane
Tree Lane Professional Center
101
Snellville, GA 30078

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	000000503A	1144203563

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
DSH110078A	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at Clifton Road Campus	1365 Clifton Rd NE, Bldg C, Plaza Level	Atlanta	GA	Active
DSH110078AA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Infusion Center Non-Oncology at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078AB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Nephrology	1365-A Clifton Road NE	Atlanta	GA	Terminated
DSH110078AC	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Pulmonary Infusion	1365-A Clifton Road NE	Atlanta	GA	Terminated
DSH110078AD	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Transplant Center Hepatitis C Clinic and Transplant Infusion	1365 Clifton Rd NE, Bldg B, 6th Floor	Atlanta	GA	Active
DSH110078AE	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute BMT Clinic at Clifton Road Campus	1365 Clifton Rd NE, Bldg C, Plaza Level	Atlanta	GA	Active
DSH110078AF	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology Clinic at Clifton Road Campus	1365 Clifton Rd NE, Bldg C	Atlanta	GA	Terminated
DSH110078AG	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology and Medical Oncology Clinic at Clifton Campus	1365 Clifton Rd NE, 2nd floor, Bldg C	Atlanta	GA	Active
DSH110078AH	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at EUHM Campus	550 Peachtree St NE	Atlanta	GA	Terminated
DSH110078AJ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at ESJH Campus	5665 Peachtree Dunwoody Road	Atlanta	GA	Active
DSH110078AK	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at EJCH Campus	6335 Hospital Parkway	Johns Creek	GA	Active
DSH110078AL	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology and Medical Oncology Clinic-Buford	3276 Buford Drive	Buford	GA	Active
DSH110078AM	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at Buford	3276 Buford Drive	Buford	GA	Active
DSH110078AN	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Ancillary services-Imaging	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AP	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Observation	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AQ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Respiratory	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AR	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Heart Failure Center-Arrhythmia	550 Peachtree St. NE	Atlanta	GA	Terminated
DSH110078AS	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (MRI)-Medical Office Tower	550 Peachtree St NE	Atlanta	GA	Terminated
DSH110078AT	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Campus (B2) - Non-Oncology	1365 Clifton Rd NE	Atlanta	GA	Active
DSH110078AU	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Rheumatology Clinic at Clifton Campus	1365 Clifton Rd	Atlanta	GA	Active
DSH110078AV	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	WCI Oncology Clinic and Integrative Oncology and Survivorship Clinic at Clifton Campus - Oncology	1365 Clifton Rd NE	Atlanta	GA	Active
DSH110078AW	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	PHARMACOTHERAPY CLINIC AT CLIFTON - PHARMACOTHERAPY CLINIC AT CLIFTON	1365A CLIFTON RD NE	ATLANTA	GA	Active
DSH110078AX	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEURODIAGNOSTICS - EP12 4TH FL NEURODIAGNOSTICS	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078AY	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEUROLOGY - EP12 4TH FL NEUROLOGY	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078AZ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 5TH FL NEUROLOGY - EP12 5TH FL NEUROLOGY	12 Executive Park Dr NE	Atlanta	GA	Active
DSH110078B	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078BA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEUROSURGERY - EP12 4TH FL NEUROSURGERY	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078BB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL REHAB MED - EP12 4TH FL REHAB MED	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078BC	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 5TH FL PAIN MED - EP12 5TH FL PAIN MED	12 Executive Park Dr NE	Atlanta	GA	Active
DSH110078BD	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 CARDIOLOGY - CLIFTON A2 CARDIOLOGY	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BE	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CHANTILLY CARDIOLOGY - CHANTILLY CARDIOLOGY	1605 CHANTILLY DR NE	ATLANTA	GA	Active
DSH110078BF	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 CARDIOLOGY - ESJH 5671 CARDIOLOGY	5671 PEACHTREE DUNWOODY RD, FLOOR 3, STE 300	ATLANTA	GA	Active
DSH110078BG	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 CT SURG - CLIFTON A2 CT SURG	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BH	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 HEART FAILURE - CLIFTON A2 HEART FAILURE	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BJ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 VASC SURG - CLIFTON A2 VASC SURG	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BK	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 DIABETES EDU - CLIFTON A3 DIABETES EDU	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BL	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 DIABETES MGMT - CLIFTON A3 DIABETES MGMT	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BM	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 DIABETES EDU - ESJH 5671 DIABETES EDU	5671 PEACHTREE DUNWOODY RD, FLOOR 2, STE 210	ATLANTA	GA	Active
DSH110078BN	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 ENDOCRINOLOGY - CLIFTON A3 ENDOCRINOLOGY	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BP	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 NEPH - CLIFTON A3 NEPH	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BQ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 PULMONARY - CLIFTON A3 PULMONARY	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BR	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CHANTILLY PULMONARY - CHANTILLY PULMONARY	1605 CHANTILLY DR, 3RD FLOOR, SUITE 392	ATLANTA	GA	Active
DSH110078BS	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5673 PULMONARY - ESJH 5673 PULMONARY	5673 PEACHTREE DUNWOODY RD, FLOOR 5, STE 525	ATLANTA	GA	Active
DSH110078BT	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON B1 GASTRO - CLIFTON B1 GASTRO	1365 CLIFTON RD NE, BLDG B FLOOR 1	ATLANTA	GA	Active
DSH110078BU	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5673 7TH FL GASTRO - ESJH 5673 7TH FL GASTRO	5673 Peachtree Dunwoody Rd	Atlanta	GA	Active
DSH110078BV	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON B1 HEPATOLOGY - CLIFTON B1 HEPATOLOGY	1365 CLIFTON RD NE, BLDG B FLOOR 1	ATLANTA	GA	Active
DSH110078BW	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON C2 SURG ONC - CLIFTON C2 SURG ONC	1365 CLIFTON RD NE, BLDG C FLOOR 2	ATLANTA	GA	Active
DSH110078BX	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	SJH Oncology Surg Srvc - ESJH 5665 COLORECTAL, ESJH 5665 SURG ONC, ESJH 5665 WOUND CARE	5665 PEACHTREE DUNWOODY RD NE	Atlanta	GA	Active
DSH110078BY	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	LOCUST GROVE CARDIOLOGY - LOCUST GROVE CARDIOLOGY	4899 BILL GARDNER PKWY	LOCUST GROVE	GA	Active
DSH110078BZ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 ENDOCRINOLOGY - ESJH 5671 ENDOCRINOLOGY	5671 PEACHTREE DUNWOODY RD, FLOOR 2, STE 210	ATLANTA	GA	Active
DSH110078C	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Road Campus (A3)	1365A Clifton Road NE, 3rd Floor, Bldg A	Atlanta	GA	Active
DSH110078CA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EJC Plaza 2nd Floor Cardiology - EJCH PLAZA 2ND FL CARDIOLOGY EUHM, EJCH PLAZA 2ND FL CARDIOVASCULAR IMAGING	6335 Hospital Pkwy	Johns Creek	GA	Active
DSH110078CB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON C2 P&R SURG - CLIFTON C2 P&R SURG	1365 CLIFTON RD NE, BLDG C FLOOR 2	ATLANTA	GA	Active
DSH110078D	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Endocrinology	1365 Clifton Road, N.E.	Atlanta	GA	Terminated
DSH110078E	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Campus (B1)	1365B Clifton Road NE, Bldg B	Atlanta	GA	Active
DSH110078F	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at EJCH Campus	6335 Hospital Parkway	Johns Creek	GA	Active
DSH110078G	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at ESJH Campus	5665 Peachtree Dunwoody Rd	Atlanta	GA	Active
DSH110078H	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging-Peachtree City	101 World Drive	Peachtree City	GA	Active
DSH110078J	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Southern Heart Cardiac Technicals at Locust Grove	4899 Bill Gardner Parkway	Locust Grove	GA	Active
DSH110078K	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging at Stockbridge	1050 Eagles Landing Parkway	Stockbridge	GA	Active
DSH110078L	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging at Riverdale	6507 Professional Place	Riverdale	GA	Active
DSH110078M	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078N	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Decatur	2801 N Decatur Rd	Decatur	GA	Terminated
DSH110078P	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Eastside	1608 Tree Lane	Snellville	GA	Terminated
DSH110078Q	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Hillandale	5461 Hillandale Dr	Lithonia	GA	Terminated
DSH110078R	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Rockdale	1400 Wellbrook Circle NE	Conyers	GA	Terminated
DSH110078S	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Villa Rica	401 Permian Way	Villa Rica	GA	Terminated
DSH110078T	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Smyrna	1060 Windy Hill Road	Smyrna	GA	Active
DSH110078U	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory University Hospital Midtown Imaging at Buford	3276 Buford Drive, Suite 202	Buford	GA	Active
DSH110078V	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Imaging Stockbridge	3625 GA Hwy 138	Stockbridge	GA	Active
DSH110078W	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (CT) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078X	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (General Diagnostics) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078Y	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (PET) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078Z	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at MOT Rheumatology	550 Peachtree Street NE	Atlanta	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory University Hospital Midtown 4046862147	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory Healthcare 4046862147	5/1/2024 2:16 PM
Contacts	Primary Contact	Update	Profile Change Request	Kchao, Sydney Assistant Director of Pharmacy, Finance Emory University Hospital Midtown 4046862147	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory University Hospital Midtown 4046862147	1/10/2024 10:20 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/14/2022 12:00:00 AM	12/19/2022 7:27 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/19/2022 7:27 AM
Terminations	Termination Date	Update	Termination Request		1/1/2023 12:00:00 AM	12/19/2022 7:27 AM
Terminations	Termination Effective Date	Update	Termination Request		12/15/2022 12:00:00 AM	12/19/2022 7:27 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	12/19/2022 7:27 AM
Details	Last Recertification Date	Update	Recertification	9/5/2021 3:49:20 PM	8/30/2022 7:31:33 AM	8/30/2022 7:31 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 1:05:04 PM	9/5/2021 3:49:20 PM	9/5/2021 3:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144203563	9/8/2020 1:05 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 1:05 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1144203563 ( )		9/8/2020 1:05 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 6:13:32 PM	9/8/2020 1:05:04 PM	9/8/2020 1:05 PM
Details	Last Recertification Date	Update	Recertification	9/3/2018 8:58:46 AM	9/10/2019 6:13:32 PM	9/10/2019 6:13 PM
Contacts	Primary Contact	Update	Change Request	Norman, Christy VP Pharmacy Services Emory Healthcare Inc 4046862304	Kchao, Sydney Assistant Director of Pharmacy, Finance Emory University Hospital Midtown 4046862147	11/18/2018 3:45 PM
Addresses	Main Address	Update	Recertification	1608 Tree Leaf Lane Professional Center #101 Snellville, GA 30078	1608 Tree Lane Tree Lane Professional Center 101 Snellville, GA 30078	9/3/2018 8:58 AM
Details	Last Recertification Date	Update	Recertification	11/17/2017 5:02:28 PM	9/3/2018 8:58:46 AM	9/3/2018 8:58 AM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/17/2017 5:02:28 PM	11/17/2017 5:02 PM
Contacts	Primary Contact	Insert	Change Request		Norman, Christy VP Pharmacy Services Emory Healthcare Inc 4046862304	10/10/2017 6:40 PM
Contacts	Authorizing Official	Update		Anderson, Greg E. CFO 4046862823	Anderson, Greg E. CFO Emory 4046862823	9/24/2017 7:33 PM
Contacts	Authorizing Official	Insert			Anderson, Greg E. CFO 4046862823	7/17/2017 6:05 PM
Contacts	Signed By	Insert			HATCHER Jr., JAMES T. CFO 4046867519	5/3/2017 12:43 PM
Addresses	Main Address	Insert			1608 Tree Leaf Lane Professional Center #101 Snellville, GA 30078	5/3/2017 12:43 PM
Medicaid Billing	Medicaid: Number	Update		00000503A	000000503A	4/19/2017 9:00 AM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 7:51 AM
Details	Entity Subname	Update		EUHM Cardiac Technicals Snellville	Emory Heart and Vascular Imaging at Eastside	9/2/2016 7:51 AM
Medicaid Billing	NPI: Number	Insert			1144203563	10/5/2015 7:23 PM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 10:17 AM
Details	Last Recertification Date	Update			8/28/2014 12:00:00 AM	8/28/2014 11:47 AM
Dates	Participating Approval Date	Update			6/11/2014 12:00:00 AM	6/11/2014 5:25 PM
Details	State	Update		Pending	Active	6/11/2014 5:25 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	6/11/2014 5:25 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH110078P	4/15/2014 9:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/8/2014 5:05 PM
Medicaid Billing	Medicaid: Number	Insert			00000503A	4/8/2014 5:05 PM
Medicaid Billing	Medicaid: State	Insert			GA	4/8/2014 5:05 PM
Details	Last Recertification Date	Insert				4/8/2014 5:05 PM
Details	Grant Number	Insert				4/8/2014 5:05 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/8/2014 5:05 PM
Details	Is Authorizing Official EHB Data	Insert				4/8/2014 5:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/8/2014 5:05 PM
Details	Medicare Provider Number	Insert			110078	4/8/2014 5:05 PM
Details	Entity Name	Insert			EMORY UNIVERSITY HOSPITAL MIDTOWN	4/8/2014 5:05 PM
Details	Program Code	Insert			DSH	4/8/2014 5:05 PM
Details	Entity Subname	Insert			EUHM Cardiac Technicals Snellville	4/8/2014 5:05 PM
Dates	Participating Approval Date	Insert				4/8/2014 5:05 PM
Details	State	Insert			Pending	4/8/2014 5:05 PM
Dates	Registration Date	Insert			4/8/2014 12:00:00 AM	4/8/2014 5:05 PM
Dates	Signed By Date	Insert			4/8/2014 12:00:00 AM	4/8/2014 5:05 PM
Dates	Start Date	Insert				4/8/2014 5:05 PM
Terminations	Termination Comments	Insert				4/8/2014 5:05 PM
Terminations	Termination Date	Insert				4/8/2014 5:05 PM
Terminations	Termination Effective Date	Insert				4/8/2014 5:05 PM
Terminations	Termination Reason	Insert				4/8/2014 5:05 PM