| Details | State | Update | | To Be Terminated | Terminated | 10/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 8/27/2021 12:00:00 AM | 8/30/2021 10:49 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 8/30/2021 10:49 AM |
| Terminations | Termination Comments | Update | Recertification | | Infusion Center and Oncology Hematology Oncology Practice is now located inside the hospital with no plans to move-JR | 8/30/2021 10:49 AM |
| Terminations | Termination Date | Update | Recertification | | 10/1/2021 12:00:00 AM | 8/30/2021 10:49 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 8/27/2021 12:00:00 AM | 8/30/2021 10:49 AM |
| Terminations | Termination Reason | Update | Recertification | | Outpatient facility moved within the 4 walls of the parent hospital | 8/30/2021 10:49 AM |
| Addresses | Main Address | Update | Change Request |
100 Willowbrook Way SE
Calhoun, GA 30701 |
1035 Red Bud Rd
Suite 100
Calhoun, GA 30701 | 5/12/2021 10:41 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1760402424 ( ) | | 9/8/2020 4:07 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760402424 | 9/8/2020 4:07 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | GA | 9/8/2020 4:07 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1669867487 | 9/8/2020 4:07 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | GA | 9/8/2020 4:07 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2019 2:01:12 PM | 9/8/2020 4:07:40 PM | 9/8/2020 4:07 PM |
| Contacts | Authorizing Official | Update | Change Request | Reeves, Cory David
CFO
Adventist Health System Georgia inc DBA Gordon Hospital
7068794710 | Guyton, Alan
Regional CFO
Adventist Health System Georgia DBA Gordon Hospital
7068794710 | 4/24/2020 9:01 AM |
| Contacts | Primary Contact | Update | Change Request | Bayne, Christina
Interim 340B Regional Mgr
Southeast Region
8286508298 | Roselli, Jessica
340B Coordinator
AdventHealth Hendersonville
8286812168 | 1/6/2020 10:38 AM |
| Addresses | Billing Address | Update | Recertification | Gordon Hospital
c/o Adventist Health System
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | AdventHealth Gordon
c/o AdventHealth
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | 9/2/2019 2:01 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2018 1:59:28 PM | 9/2/2019 2:01:12 PM | 9/2/2019 2:01 PM |
| Details | Entity Subname | Update | Recertification | AdventHealth Infusion Center Calhoun | AdventHealth Infusion Center Calhoun and AdventHealth Medical Group Hematology Oncology at Calhoun | 9/2/2019 2:01 PM |
| Details | Entity Subname | Update | Change Request | Gordon Hospital Medical Oncology | AdventHealth Infusion Center Calhoun | 4/2/2019 12:39 PM |
| Details | Entity Name | Update | Change Request | GORDON HOSPITAL | AdventHealth Gordon | 4/2/2019 12:38 PM |
| Contacts | Primary Contact | Update | Change Request | Molnar, Diane
340B Regional Manager
Southeast Region
8286812168 | Bayne, Christina
Interim 340B Regional Mgr
Southeast Region
8286508298 | 12/20/2018 5:20 PM |
| Details | Last Recertification Date | Update | Recertification | 11/8/2017 12:27:28 PM | 8/24/2018 1:59:28 PM | 8/24/2018 1:59 PM |
| Addresses | Main Address | Update | Recertification |
100 Willowbrook Way
Calhoun, GA 30701 |
100 Willowbrook Way SE
Calhoun, GA 30701 | 11/8/2017 12:27 PM |
| Addresses | Billing Address | Update | Recertification | Gordon Hospital
P.O. Box 12938
Calhoun, GA 30703 | Gordon Hospital
c/o Adventist Health System
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | 11/8/2017 12:27 PM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 11/8/2017 12:27:28 PM | 11/8/2017 12:27 PM |
| Contacts | Authorizing Official | Update | | Reeves, Cory
CFO
7068794710 | Reeves, Cory David
CFO
Adventist Health System Georgia inc DBA Gordon Hospital
7068794710 | 10/3/2017 9:43 AM |
| Contacts | Signed By | Update | | Reeves, Cory
CFO
7068794710 | Reeves, Cory David
CFO
Adventist Health System Georgia inc DBA Gordon Hospital
7068794710 | 10/3/2017 9:43 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Molnar, Diane
340B Regional Manager
Park Ridge Health
8286812168 | Molnar, Diane
340B Regional Manager
Southeast Region
8286812168 | 9/22/2017 10:04 AM |
| Contacts | Primary Contact | Update | | Molnar, Diane
340B Regional Manager
8286812168 | Molnar, Diane
340B Regional Manager
Park Ridge Health
8286812168 | 9/18/2017 3:08 PM |
| Contacts | Primary Contact | Insert | | | Molnar, Diane
340B Regional Manager
8286812168 | 8/10/2017 5:14 PM |
| Contacts | Authorizing Official | Insert | | | Reeves, Cory
CFO
7068794710 | 7/13/2017 10:06 AM |
| Contacts | Signed By | Insert | | | Reeves, Cory
CFO
7068794710 | 7/13/2017 10:06 AM |
| Addresses | Main Address | Insert | | |
100 Willowbrook Way
Calhoun, GA 30701 | 8/10/2016 8:09 PM |
| Details | Last Recertification Date | Update | | 8/13/2015 12:00:00 AM | 8/10/2016 12:00:00 AM | 8/10/2016 8:09 PM |
| Details | Last Recertification Date | Update | | | 8/13/2015 12:00:00 AM | 8/13/2015 3:42 PM |
| Addresses | Billing Address | Insert | | | Gordon Hospital
P.O. Box 12938
Calhoun, GA 30703 | 6/22/2015 7:40 AM |
| Details | Entity Subname | Update | | Infusion Center | Gordon Hospital Medical Oncology | 4/29/2015 7:58 AM |
| Dates | Participating Approval Date | Update | | | 3/5/2015 12:00:00 AM | 3/5/2015 5:30 PM |
| Details | State | Update | | Pending | Active | 3/5/2015 5:30 PM |
| Dates | Start Date | Update | | | 4/1/2015 12:00:00 AM | 3/5/2015 5:30 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_49174 | DSH110023A | 2/24/2015 3:56 PM |
| Details | Entity Subname | Update | | Gordon Hospital Infusion Center | Infusion Center | 2/24/2015 3:56 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_49174 | 1/14/2015 11:44 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/14/2015 11:44 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 000000833A | 1/14/2015 11:44 AM |
| Medicaid Billing | Medicaid: State | Insert | | | GA | 1/14/2015 11:44 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1760402424 | 1/14/2015 11:44 AM |
| Details | Last Recertification Date | Insert | | | | 1/14/2015 11:44 AM |
| Details | Grant Number | Insert | | | | 1/14/2015 11:44 AM |
| Details | 340B ID | Insert | | | | 1/14/2015 11:44 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/14/2015 11:44 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2015 11:44 AM |
| Details | Medicare Provider Number | Insert | | | 110023 | 1/14/2015 11:44 AM |
| Details | Entity Name | Insert | | | GORDON HOSPITAL | 1/14/2015 11:44 AM |
| Details | Program Code | Insert | | | DSH | 1/14/2015 11:44 AM |
| Details | Entity Subname | Insert | | | Gordon Hospital Infusion Center | 1/14/2015 11:44 AM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2015 11:44 AM |
| Details | State | Insert | | | Pending | 1/14/2015 11:44 AM |
| Dates | Registration Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 11:44 AM |
| Dates | Signed By Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 11:44 AM |
| Dates | Start Date | Insert | | | | 1/14/2015 11:44 AM |
| Terminations | Termination Comments | Insert | | | | 1/14/2015 11:44 AM |
| Terminations | Termination Date | Insert | | | | 1/14/2015 11:44 AM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2015 11:44 AM |
| Terminations | Termination Reason | Insert | | | | 1/14/2015 11:44 AM |