Covered Entity Details

DSH010024B JACKSON HOSPITAL AND CLINIC, INC. (Terminated) - information as of 5/4/2025 10:21:20 PM

Main Details

Name

JACKSON HOSPITAL AND CLINIC, INC.

Subdivision Name

JACKSON HOSPITAL SLEEP DISORDERS CLINIC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH010024B

Medicare Provider Number

010024

Outpatient Facility Provider Number

010024

Additional Details

Current Program Status

Terminated

Registration Date

7/15/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/12/2014

Last Recertification Date

8/20/2015

Termination Date
Termination Reason

10/1/2015
DSH percentage below statutory minimum

Contacts

Authorizing Official

Jackson Hospital
Joe Riley, CEO
(334) 293-8809

Primary Contact

LARRY SHERBETT, AVP-FINANCE
(334) 293-8820

Addresses

Street Address

1722 PINE STREET SUITE 900
MONTGOMERY, AL 36106

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
AL	hos0024h
MS	00220512
GA	000105135A
FL	092605700
		1043262488

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
DSH010024A	Child	DSH	JACKSON HOSPITAL AND CLINIC, INC.	JACKSON IMAGING CENTER, LLC	1825 PARK PLACE	MONTGOMERY	AL	Terminated
DSH010024AA	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic JFM Pine Level - Family Medicine	2175 us hwy 31 N	Deatsville	AL	Active
DSH010024AB	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Infectious Disease - Infectious Disease	1722 pine street	Montgomery	AL	Active
DSH010024AC	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Mora Surgical - General surgical	554 McQueen Smith Road North	Prattville	AL	Active
DSH010024AD	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Pike Rd Urgent Care - Urgent Care	9521 vaughn Road	Pike Road	AL	Active
DSH010024AE	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic - Prim Care - Internal Medicine	1722 Pine Street	Montgomery	AL	Active
DSH010024AF	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Hospital Family Medicine Residency Program - Family Medicine	2024 Chestnut Street	Montgomery	AL	Active
DSH010024B	Child	DSH	JACKSON HOSPITAL AND CLINIC, INC.	JACKSON HOSPITAL SLEEP DISORDERS CLINIC	1722 PINE STREET SUITE 900	MONTGOMERY	AL	Terminated
DSH010024C	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSPITAL WOUND CARE CENTER	1801 PINE STREET SUITE 101	MONTGOMERY	AL	Active
DSH010024D	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC DALRAIDA - Family Medicine	4035 ATLANTA HWY	MONTGOMERY	AL	Active
DSH010024E	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON OBSTETRICS & GYNECOLOGY - OBSTETRICS & GYNECOLOGY	1758 Park Place	Montgomery	AL	Active
DSH010024F	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Endocrinology - Endocrinology	1801 Pine Street	Montgomery	AL	Active
DSH010024G	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic- General Surgery - General Surgery	1722 Pine St.	Montgomery	AL	Active
DSH010024H	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MED MIDTOWN - Family Medicine	4150 CARMICHAEL RD	MONTGOMERY	AL	Active
DSH010024J	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Urology East - Urology	226 MITYLENE PARK DR	Montgomery	AL	Terminated
DSH010024K	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MEDICINE PRATTVILLE - Family Medicine	701 MCQUEEN SMITH RD S	PRATTVILLE	AL	Active
DSH010024L	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Urology - Urology	1722 Pine Street	Montgomery	AL	Active
DSH010024M	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Internal Medicine - Internal Medicine	1801 Pine Street	Montgomery	AL	Active
DSH010024N	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC GASTROENTEROLOGY - Gastroenterology	1722 PINE ST	MONTGOMERY	AL	Active
DSH010024P	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Family Medicine - Family Medicine	1801 Pine Street	Montgomery	AL	Active
DSH010024Q	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSP & CLINIC PK RD - Family Medicine	11123 CHANTILLY PKWY CT	PIKE ROAD	AL	Terminated
DSH010024R	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Dr. Seirafi - General Surgery	7201 Copperfield Drive	Montgomery	AL	Terminated
DSH010024S	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Neurology - Neurology	1722 Pine St	Montgomery	AL	Active
DSH010024T	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC VASCULAR SURGERY - Vascular Surgery	1758 PARK PLACE	MONTGOMERY	AL	Active
DSH010024U	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Cardiology - Cardiology	1758 Park Place	Montgomery	AL	Active
DSH010024V	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC MULTI SPECIALTY PRAT - Specialty Medicine Services	1840 E MAIN ST	PRATTVILLE	AL	Active
DSH010024W	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON SLEEP DISORDERS CENTER - Sleep Studies	1722 PINE ST	MONTGOMERY	AL	Active
DSH010024X	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC PRATTVILLE PRIMARY C - Primary Care	204 MEDICAL CENTER DR	PRATTVILLE	AL	Active
DSH010024Y	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	OP Infusion Clinic - Infusion Services	1725 Pine Street	Montgomery	AL	Active
DSH010024Z	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC RHEUMATOLOGY - Rheumatology	1722 PINE STREET	MONTGOMERY	AL	Active

History

Section	Field	Action	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Riley, Joe CEO 3342938809	Riley, Joe CEO Jackson Hospital 3342938809	9/27/2017 1:37 PM
Contacts	Authorizing Official	Update	SHERBETT, LARRY AVP-FINANCE 3342938820	Riley, Joe CEO 3342938809	9/11/2017 3:29 PM
Addresses	Main Address	Insert		1722 PINE STREET SUITE 900 MONTGOMERY, AL 36106	8/20/2015 3:44 PM
Contacts	Authorizing Official	Insert		SHERBETT, LARRY AVP-FINANCE 3342938820	8/20/2015 3:44 PM
Contacts	Primary Contact	Insert		SHERBETT, LARRY AVP-FINANCE 3342938820	8/20/2015 3:44 PM
Contacts	Signed By	Insert		SHERBETT, LARRY AVP-FINANCE 3342938820	8/20/2015 3:44 PM
Details	Last Recertification Date	Update		8/20/2015 12:00:00 AM	8/20/2015 3:44 PM
Dates	Last Date That 340B Drugs Purchased	Update		8/20/2015 12:00:00 AM	8/20/2015 3:44 PM
Details	State	Update	Active	Terminated	8/20/2015 3:44 PM
Terminations	Termination Comments	Update		DSH % determined to be below statutory minimum on 8/20/15	8/20/2015 3:44 PM
Terminations	Termination Date	Update		10/1/2015 12:00:00 AM	8/20/2015 3:44 PM
Terminations	Termination Effective Date	Update		8/20/2015 12:00:00 AM	8/20/2015 3:44 PM
Terminations	Termination Reason	Update		DSH percentage below statutory minimum	8/20/2015 3:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert		False	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Number	Insert		hos0024h	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: State	Insert		AL	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert		False	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Number	Insert		00220512	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: State	Insert		MS	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert		False	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Number	Insert		000105135A	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: State	Insert		GA	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert		False	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: Number	Insert		092605700	7/22/2015 9:19 AM
Medicaid Billing	Medicaid: State	Insert		FL	7/22/2015 9:19 AM
Medicaid Billing	NPI: Number	Insert		1043262488	7/22/2015 9:19 AM
Dates	Participating Approval Date	Update		9/12/2014 12:00:00 AM	9/12/2014 3:28 PM
Details	State	Update	Pending	Active	9/12/2014 3:28 PM
Dates	Start Date	Update		10/1/2014 12:00:00 AM	9/12/2014 3:28 PM
Details	340B ID	Update	OUTPATIENT_ONLINE_REG_45895	DSH010024B	8/20/2014 8:18 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45895	7/15/2014 12:09 PM
Details	Last Recertification Date	Insert			7/15/2014 12:09 PM
Details	Grant Number	Insert			7/15/2014 12:09 PM
Details	340B ID	Insert			7/15/2014 12:09 PM
Details	Is Authorizing Official EHB Data	Insert			7/15/2014 12:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert			7/15/2014 12:09 PM
Details	Medicare Provider Number	Insert		010024	7/15/2014 12:09 PM
Details	Entity Name	Insert		JACKSON HOSPITAL AND CLINIC, INC.	7/15/2014 12:09 PM
Details	Program Code	Insert		DSH	7/15/2014 12:09 PM
Details	Entity Subname	Insert		JACKSON HOSPITAL SLEEP DISORDERS CLINIC	7/15/2014 12:09 PM
Dates	Participating Approval Date	Insert			7/15/2014 12:09 PM
Details	State	Insert		Pending	7/15/2014 12:09 PM
Dates	Registration Date	Insert		7/15/2014 12:00:00 AM	7/15/2014 12:09 PM
Dates	Signed By Date	Insert		7/15/2014 12:00:00 AM	7/15/2014 12:09 PM
Dates	Start Date	Insert			7/15/2014 12:09 PM
Terminations	Termination Comments	Insert			7/15/2014 12:09 PM
Terminations	Termination Date	Insert			7/15/2014 12:09 PM
Terminations	Termination Effective Date	Insert			7/15/2014 12:09 PM
Terminations	Termination Reason	Insert			7/15/2014 12:09 PM