Covered Entity Details

DSH110225C PIEDMONT MOUNTAINSIDE HOSPITAL INC. (Terminated) - information as of 6/3/2025 12:00:57 PM

Main Details

Name

PIEDMONT MOUNTAINSIDE HOSPITAL INC.

Subdivision Name

Piedmont Ellijay Outpatient Imaging Center / Radiology Diagnostics

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110225C

Medicare Provider Number

110225

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/8/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/16/2015

Last Recertification Date

8/22/2018

Termination Date
Termination Reason

1/1/2019
DSH percentage below statutory minimum

Contacts

Authorizing Official

Piedmont Healthcare Multiple Hospital Entities
John G. Miles, Vice President / CFO
(770) 400-2336

Primary Contact

Piedmont Mountainside Hospital
pam Mingo, Director of Pharmacy
(706) 301-5262 Ext: 5262

Addresses

Street Address

309 Highland Parkway, Suite 100
East Ellijay, GA 30540

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	000001493A
		1780643411

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
DSH110225A	Child	DSH	Piedmont Mountainside Hospital	Infusion Center	620 JL White Dr Suite 140	Jasper	GA	Terminated
DSH110225B	Child	DSH	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	PIEDMONT MOUNTAINSIDE HOSPITAL CARDIOVASCULAR IMAGING CENTER	15 Reinhardt College Parkway, Suite 110B	Canton	GA	Terminated
DSH110225C	Child	DSH	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	Piedmont Ellijay Outpatient Imaging Center / Radiology Diagnostics	309 Highland Parkway, Suite 100	East Ellijay	GA	Terminated
DSH110225D	Child	DSH	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	Hyperbaric Center / Wound Care	620 JL White Drive, Suite 140B	Jasper	GA	Terminated
DSH110225E	Child	DSH	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	PIEDMONT MOUNTAINSIDE HOSPITAL - ELLIJAY Free Standing ED	1360 SOUTH MAIN STREET	ELLIJAY	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/28/2018 12:00:00 AM	12/3/2018 6:54 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/3/2018 6:54 AM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	12/3/2018 6:54 AM
Terminations	Termination Effective Date	Update	Termination Request		11/30/2018 12:00:00 AM	12/3/2018 6:54 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	12/3/2018 6:54 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 8:31:52 PM	8/22/2018 8:58:19 AM	8/22/2018 8:58 AM
Contacts	Authorizing Official	Update	Profile Change Request	Miles, John G. Vice President / CFO Piedmont Newnan Hospital 7704002336	Miles, John G. Vice President / CFO Piedmont Healthcare Multiple Hospital Entities 7704002336	7/6/2018 1:37 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	1493A	000001493A	6/5/2018 11:32 AM
Contacts	Authorizing Official	Update	Change Request	Leal, Justin David COO Piedmont Mountainside Hospital 4046052424	Miles, John G. Vice President / CFO Piedmont Newnan Hospital 7704002336	12/4/2017 1:41 PM
Addresses	Main Address	Update	Recertification	309 Highland East Ellijay, GA 30540	309 Highland Parkway, Suite 100 East Ellijay, GA 30540	11/15/2017 8:31 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/15/2017 8:31:52 PM	11/15/2017 8:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/22/2017 8:37 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1493A	9/22/2017 8:37 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	9/22/2017 8:37 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1780643411	9/22/2017 8:37 AM
Details	Entity Name	Update	Change Request	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	PIEDMONT MOUNTAINSIDE HOSPITAL INC.	9/22/2017 8:37 AM
Contacts	Primary Contact	Update		Mingo, pam Director of Pharmacy 7063015262-5262	Mingo, pam Director of Pharmacy Piedmont Mountainside Hospital 7063015262-5262	9/21/2017 4:07 PM
Contacts	Authorizing Official	Update	Profile Change Request	Leal, Justin Exec Dir Operations Piedmont Mountainside Hospital 4048058320	Leal, Justin David COO Piedmont Mountainside Hospital 4046052424	9/21/2017 3:35 PM
Contacts	Authorizing Official	Update		Leal, Justin Exec Dir Operations 4048058320	Leal, Justin Exec Dir Operations Piedmont Mountainside Hospital 4048058320	9/21/2017 3:34 PM
Contacts	Signed By	Insert			Powell, Frank CFO 7063015381	8/9/2017 11:17 AM
Addresses	Main Address	Insert			309 Highland East Ellijay, GA 30540	7/21/2017 6:19 PM
Contacts	Authorizing Official	Insert			Leal, Justin Exec Dir Operations 4048058320	7/21/2017 6:19 PM
Contacts	Primary Contact	Insert			Mingo, pam Director of Pharmacy 7063015262-5262	7/21/2017 6:19 PM
Details	Last Recertification Date	Update			8/17/2016 12:00:00 AM	8/17/2016 2:32 PM
Details	Entity Subname	Update		Piedmont Mountainside Outpatient Imaging Center / Radiology Diagnostics	Piedmont Ellijay Outpatient Imaging Center / Radiology Diagnostics	8/17/2015 8:31 AM
Dates	Participating Approval Date	Update			7/16/2015 12:00:00 AM	7/16/2015 10:28 AM
Details	State	Update		Pending	Active	7/16/2015 10:28 AM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/16/2015 10:28 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_52549	DSH110225C	7/9/2015 11:38 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_52549	7/8/2015 11:50 AM
Details	Last Recertification Date	Insert				7/8/2015 11:50 AM
Details	Grant Number	Insert				7/8/2015 11:50 AM
Details	340B ID	Insert				7/8/2015 11:50 AM
Details	Is Authorizing Official EHB Data	Insert				7/8/2015 11:50 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/8/2015 11:50 AM
Details	Medicare Provider Number	Insert			110225	7/8/2015 11:50 AM
Details	Entity Name	Insert			PIEDMONT MOUNTAINSIDE HOSPITAL INC.	7/8/2015 11:50 AM
Details	Program Code	Insert			DSH	7/8/2015 11:50 AM
Details	Entity Subname	Insert			Piedmont Mountainside Outpatient Imaging Center / Radiology Diagnostics	7/8/2015 11:50 AM
Dates	Participating Approval Date	Insert				7/8/2015 11:50 AM
Details	State	Insert			Pending	7/8/2015 11:50 AM
Dates	Registration Date	Insert			7/8/2015 12:00:00 AM	7/8/2015 11:50 AM
Dates	Signed By Date	Insert			7/8/2015 12:00:00 AM	7/8/2015 11:50 AM
Dates	Start Date	Insert				7/8/2015 11:50 AM
Terminations	Termination Comments	Insert				7/8/2015 11:50 AM
Terminations	Termination Date	Insert				7/8/2015 11:50 AM
Terminations	Termination Effective Date	Insert				7/8/2015 11:50 AM
Terminations	Termination Reason	Insert				7/8/2015 11:50 AM