| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Vice President, Clinical Services
John D. Archbold Memorial Hospital
2292282771 | Newman, Chris
Vice President, Clinical and Support Services
John D. Archbold Memorial Hospital
2292282771 | 8/29/2024 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2023 2:04:42 PM | 8/22/2024 4:57:17 PM | 8/22/2024 4:57 PM |
| Addresses | Billing Address | Update | Recertification | John D. Archbold Memorial Hospital
920 Cairo Road
Thomasville, GA 31792 | MITCHELL COUNTY HOSPITAL
920 Cairo Road
Thomasville, GA 31792 | 8/24/2023 2:04 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 5:25:44 PM | 8/24/2023 2:04:42 PM | 8/24/2023 2:04 PM |
| Details | Entity Subname | Update | Recertification | Outpatient Rehab | ARCHBOLD THERAPY CAMILLA | 8/24/2023 2:04 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 1:54:54 PM | 9/7/2022 5:25:44 PM | 9/7/2022 5:25 PM |
| Addresses | Shipping Address | Update | Change Request | Mitchell County Hospital
90 E. Stephens Street
Camilla, GA 37130-1836 | Mitchell County Hospital
90 E. Stephens Street
Camilla, GA 31730-1836 | 4/18/2022 7:35 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 000001339A (GA) | | 4/18/2022 7:35 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 020989100 (FL) | | 4/18/2022 7:35 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1700830247 (GA) | | 4/18/2022 7:35 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1700830247 (FL) | | 4/18/2022 7:35 AM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2020 5:39:08 PM | 8/27/2021 1:54:54 PM | 8/27/2021 1:54 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Vice President, Ancillary Services
John D. Archbold Memorial Hospital
2292282771 | Newman, Chris
Vice President, Clinical Services
John D. Archbold Memorial Hospital
2292282771 | 2/17/2021 8:31 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1700830247 | 8/19/2020 5:39 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | GA | 8/19/2020 5:39 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1700830247 | 8/19/2020 5:39 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | FL | 8/19/2020 5:39 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1700830247 ( ) | | 8/19/2020 5:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2019 12:29:00 PM | 8/19/2020 5:39:08 PM | 8/19/2020 5:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 10:26:04 AM | 8/28/2019 12:29:00 PM | 8/28/2019 12:29 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/20/2019 10:00 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 000001339A | 3/20/2019 10:00 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | GA | 3/20/2019 10:00 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/20/2019 10:00 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 020989100 | 3/20/2019 10:00 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 3/20/2019 10:00 AM |
| Details | Last Recertification Date | Update | Recertification | 11/14/2017 11:31:33 AM | 8/22/2018 10:26:04 AM | 8/22/2018 10:26 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Hembree, Greg S.
CFO
John D. Archboold Memorial Hospital
2292282853 | Hembree, Greg S.
CFO
John D. Archbold Memorial Hospital
2292282853 | 4/26/2018 6:19 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Newman, Chris
Pharmacy Director
John D. Archbold Memorial Hospital
2292282752 | Newman, Chris
Vice President, Ancillary Services
John D. Archbold Memorial Hospital
2292282771 | 3/29/2018 9:50 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2016 12:00:00 AM | 11/14/2017 11:31:33 AM | 11/14/2017 11:31 AM |
| Contacts | Authorizing Official | Update | | Hembree, Greg S.
CFO
2292282853 | Hembree, Greg S.
CFO
John D. Archboold Memorial Hospital
2292282853 | 10/22/2017 1:10 PM |
| Contacts | Primary Contact | Update | | Newman, Chris
Pharmacy Director
2292282752 | Newman, Chris
Pharmacy Director
John D. Archbold Memorial Hospital
2292282752 | 9/29/2017 9:39 AM |
| Contacts | Authorizing Official | Insert | | | Hembree, Greg S.
CFO
2292282853 | 1/22/2017 3:05 PM |
| Contacts | Primary Contact | Insert | | | Newman, Chris
Pharmacy Director
2292282752 | 1/22/2017 3:05 PM |
| Contacts | Signed By | Insert | | | HIGHTOWER, CHARLES D.
CFO
2292282853 | 1/22/2017 3:05 PM |
| Addresses | Main Address | Insert | | |
99 E Broad Street
Camilla, GA 31730-1836 | 1/22/2017 2:58 PM |
| Addresses | Billing Address | Insert | | | John D. Archbold Memorial Hospital
920 Cairo Road
Thomasville, GA 31792 | 1/22/2017 2:58 PM |
| Addresses | Shipping Address | Insert | | | Mitchell County Hospital
90 E. Stephens Street
Camilla, GA 37130-1836 | 1/22/2017 2:58 PM |
| Details | Last Recertification Date | Update | | 8/17/2015 12:00:00 AM | 8/18/2016 12:00:00 AM | 8/18/2016 3:35 PM |
| Details | Last Recertification Date | Update | | | 8/17/2015 12:00:00 AM | 8/17/2015 10:51 AM |
| Dates | Participating Approval Date | Update | | | 12/11/2014 12:00:00 AM | 12/11/2014 6:45 AM |
| Details | State | Update | | Pending | Active | 12/11/2014 6:45 AM |
| Dates | Start Date | Update | | | 1/1/2015 12:00:00 AM | 12/11/2014 6:45 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_47440 | CAH111331-03 | 12/4/2014 2:36 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_47440 | 10/15/2014 7:35 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1700830247 | 10/15/2014 7:35 AM |
| Details | Last Recertification Date | Insert | | | | 10/15/2014 7:35 AM |
| Details | Grant Number | Insert | | | | 10/15/2014 7:35 AM |
| Details | 340B ID | Insert | | | | 10/15/2014 7:35 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/15/2014 7:35 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/15/2014 7:35 AM |
| Details | Medicare Provider Number | Insert | | | 111331 | 10/15/2014 7:35 AM |
| Details | Entity Name | Insert | | | MITCHELL COUNTY HOSPITAL | 10/15/2014 7:35 AM |
| Details | Program Code | Insert | | | CAH | 10/15/2014 7:35 AM |
| Details | Entity Subname | Insert | | | Outpatient Rehab | 10/15/2014 7:35 AM |
| Dates | Participating Approval Date | Insert | | | | 10/15/2014 7:35 AM |
| Details | State | Insert | | | Pending | 10/15/2014 7:35 AM |
| Dates | Registration Date | Insert | | | 10/15/2014 12:00:00 AM | 10/15/2014 7:35 AM |
| Dates | Signed By Date | Insert | | | 10/15/2014 12:00:00 AM | 10/15/2014 7:35 AM |
| Dates | Start Date | Insert | | | | 10/15/2014 7:35 AM |
| Terminations | Termination Comments | Insert | | | | 10/15/2014 7:35 AM |
| Terminations | Termination Date | Insert | | | | 10/15/2014 7:35 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/15/2014 7:35 AM |
| Terminations | Termination Reason | Insert | | | | 10/15/2014 7:35 AM |