Covered Entity Details

DSH110087V Northside Hospital Gwinnett (Terminated) - information as of 5/11/2025 11:24:57 PM

Main Details

Name

Northside Hospital Gwinnett

Subdivision Name

GWINNETT MEDICAL CENER - DULUTH / PACU GMCD

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110087V

Medicare Provider Number

110087

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/17/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/27/2017

Last Recertification Date

9/4/2020

Termination Date
Termination Reason

10/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Northside Hospital, Inc.
Scott Wade, VP Finance
(404) 303-3381

Primary Contact

Northside Hospital Gwinnett
Michael James Naughton, Director of Pharmacy
(678) 312-4541

Addresses

Street Address

3620 HOWELL FERRY RD
DULUTH, GA 30096-3178

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	1064A	1790715381
AL		1790715381
TN		1790715381
NC		1790715381
SC		1790715381
FL		1790715381

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
DSH110087A	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENTER-DULUTH	3620 HOWELL FERRY ROAD	DULUTH	GA	Terminated
DSH110087AA	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Speech Therapy GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AB	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Occupational Therapy GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AC	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Rehab Services GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AD	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Resp Therapy GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AE	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Cardiac Cath GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AF	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Dialysis GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AG	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Nuclear Medicine GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AH	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Nuclear Medicine Cardiac Imaging GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AJ	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / CT Scan GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AK	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Ultrasound Cardiac Imaging GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AL	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Ultrasound GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AM	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / MRI GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AN	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Interventional Rad GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AP	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Radiology GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AQ	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / Screening Mammogram	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087AR	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Anethesia GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AS	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / OP Treatment Center GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AT	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Surgery GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087AU	Child	DSH	Northside Hospital Gwinnett	Center for Cancer Care - Duluth / Radiology Ctr for Cancer Care Duluth	3855 Pleasant Hill Road	Duluth	GA	Terminated
DSH110087AV	Child	DSH	Northside Hospital Gwinnett	Center for Cancer Care - Snellville / Radiology Ctr for Cancer Care Snellville	1700 Tree Lane	Snellville	GA	Terminated
DSH110087AW	Child	DSH	Northside Hospital Gwinnett	CNTR FOR CANCER CARE-LAWRENCEVILLE / Radiology Ctr for Cancer Care Lawrenceville	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087AX	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / EKG	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087AY	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / Ultrasound	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087AZ	Child	DSH	Northside Hospital Gwinnett	DIABETES & NUTRITION EDUCATION CENTER	3215 MCCLURE BRIDGE RD	DULUTH	GA	Terminated
DSH110087B	Child	DSH	Northside Hospital Gwinnett	Center for Surgical Weight Management	3215 McClure Bridge Road	Duluth	GA	Terminated
DSH110087BA	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Procedural Nursing Unit GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087BB	Child	DSH	Northside Hospital Gwinnett	DIABETES & NUTRITION EDUCATION CENTER	100 MEDICAL CENTER BOULEVARD	LAWRENCEVILLE	GA	Terminated
DSH110087BC	Child	DSH	Northside Hospital Gwinnett	631 IMAGING CENTER / Bone Density 631 GPC	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087BD	Child	DSH	Northside Hospital Gwinnett	JOHNS CREEK ORTHOPEDIC SURGERY CENT / OP Surgery JCASC	10670 MEDLOCK BRIDGE ROAD	DULUTH	GA	Terminated
DSH110087BE	Child	DSH	Northside Hospital Gwinnett	CENTER FOR SCREENING MAMMOGRAPHY	3855 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BF	Child	DSH	Northside Hospital Gwinnett	ACADEMIC INTERNAL MEDICINE PARTNERS	665 DULUTH HWY	LAWRENCEVILLE	GA	Terminated
DSH110087BG	Child	DSH	Northside Hospital Gwinnett	GMC SPECIALTY CENTER AT HAMILTON MILL	2108 TERON TRCE 100A	DACULA	GA	Terminated
DSH110087BH	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Womens Imaging GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BJ	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Radiology GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BK	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Interventional Rad GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BL	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / MRI GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BM	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Ultrasound GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BN	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Ultrasound Cardiac Imaging GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BP	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / CT Scan GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BQ	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Nuclear Medicine Cardiac Imaging GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BR	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Nuclear Medicine GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BS	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / Resp Therapy GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BT	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / EKG GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BU	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / DOC OR	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BV	Child	DSH	Northside Hospital Gwinnett	OUTPATIENT CENTER AT GMC-DULUTH / PACU GOC	3805 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087BW	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Labor and Delivery GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087BX	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Anesthesia GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087BY	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Radiology GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087BZ	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Screening Mammo GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087C	Child	DSH	Northside Hospital Gwinnett	Center for Cancer Care - Lawrenceville	631 Professional Drive	Lawrenceville	GA	Terminated
DSH110087CA	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Ultrasound GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087CB	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Ultrasound Cardiac Imaging GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087CC	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / Resp Therapy GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087CD	Child	DSH	Northside Hospital Gwinnett	GWINNETT WOMEN'S PAVILION / EKG GWP	550 MEDICAL CENTER BLVD	LAWRENCEVILLE	GA	Terminated
DSH110087CE	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	575 OP IMAGING CENTER / CT Scan 575	575 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CF	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	575 OP IMAGING CENTER / Ultrasound 575	575 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CG	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	575 OP IMAGING CENTER / Nuclear Med 575	575 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CH	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	575 OP IMAGING CENTER / EKG 575	575 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CJ	Child	DSH	Northside Hospital Gwinnett	631 IMAGING CENTER / Pet Scan/CT 631 MOB	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CK	Child	DSH	Northside Hospital Gwinnett	631 IMAGING CENTER / MRI 631 MOB	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CL	Child	DSH	Northside Hospital Gwinnett	631 IMAGING CENTER / Screening/Diagnostic Mammo 631 MOB	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CM	Child	DSH	Northside Hospital Gwinnett	631 IMAGING CENTER / Ultrasound 631 GPC	631 PROFESSIONAL DRIVE	LAWRENCEVILLE	GA	Terminated
DSH110087CN	Child	DSH	Northside Hospital Gwinnett	JOHNS CREEK ORTHOPEDIC SURGERY CENT / Anesthesia JCOSC	10670 MEDLOCK BRIDGE ROAD	DULUTH	GA	Terminated
DSH110087CP	Child	DSH	Northside Hospital Gwinnett	JOHNS CREEK ORTHOPEDIC SURGERY CENTER / Radiology JCOSC	10670 MEDLOCK BRIDGE ROAD	DULUTH	GA	Terminated
DSH110087CQ	Child	DSH	Northside Hospital Gwinnett	JOHNS CREEK ORTHOPEDIC SURGERY CENTER / EKG JCOSC	10670 MEDLOCK BRIDGE ROAD	DULUTH	GA	Terminated
DSH110087CR	Child	DSH	Northside Hospital Gwinnett	JOHNS CREEK ORTHOPEDIC SURGERY CENTER / PACU JCOSC	10670 MEDLOCK BRIDGE ROAD	DULUTH	GA	Terminated
DSH110087CS	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	GWINNETT CARDIAC IMAGING / EKG 755 Imaging Ctr	755 WALTHER RD	LAWRENCEVILLE	GA	Terminated
DSH110087CT	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / MRI	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087CU	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / CT Scan	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087CV	Child	DSH	Northside Hospital Gwinnett	GMC IMAGING CENTER- HAMILTON MILL / Bone Density	2078 TERON TRACE	DACULA	GA	Terminated
DSH110087CW	Child	DSH	Northside Hospital Gwinnett	CENTER FOR CANCER CARE HAMILTONMILL - Infusion Center	2098 TERON TRCE	DACULA	GA	Terminated
DSH110087CX	Child	DSH	Northside Hospital Gwinnett	NGDC Gainesville - Infusion Clinic	1485 Jesse Jewell Parkway NE	Gainesville	GA	Terminated
DSH110087CY	Child	DSH	Northside Hospital Gwinnett	NGDC Braselton - Infusion Clinic	1255 Friendship Road	Braselton	GA	Terminated
DSH110087CZ	Child	DSH	Northside Hospital Gwinnett	GCS Athens - Infusion Clinic	125 King Avenue 2nd Floor	Athens	GA	Terminated
DSH110087D	Child	DSH	Northside Hospital Gwinnett	Pain Management Center	575 Professional Drive	Lawrenceville	GA	Terminated
DSH110087DA	Child	DSH	Northside Hospital Gwinnett	Northside Hospital Infusion Center Gwinnett - Infusion Services	575 Professional Drive	Lawrenceville	GA	Terminated
DSH110087DB	Child	DSH	Northside Hospital Gwinnett	OP Surgery GDS - Surgery Center	2200 Medical Center Blvd	Lawrenceville	GA	Terminated
DSH110087E	Child	DSH	Northside Hospital Gwinnett	Center for Cancer Care - Snellville	1700 Tree Lane	Snellville	GA	Terminated
DSH110087F	Child	DSH	Northside Hospital Gwinnett	Center for Cancer Care - Duluth	3855 Pleasant Hill Road	Duluth	GA	Terminated
DSH110087G	Child	DSH	Northside Hospital Gwinnett	Johns Creek Orthopedic Surgery Center	10670 Medlock Bridge Road	Duluth	GA	Terminated
DSH110087H	Child	DSH	Northside Hospital Gwinnett	Gwinnett SportsRehab - Lawrenceville	500 Medical Center Blvd	LAWRENCEVILLE	GA	Terminated
DSH110087J	Child	DSH	Northside Hospital Gwinnett	Gwinnett SportsRehab-Duluth	3215 MCCLURE BRIDGE RD	Duluth	GA	Terminated
DSH110087K	Child	DSH	Northside Hospital Gwinnett	Gwinnett Breast Center	631 Professional Drive	Lawrenceville	GA	Terminated
DSH110087L	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	575 OP Imaging Center/ Diagnostic 575	575 Professional Drive	LAWRENCEVILLE	GA	Terminated
DSH110087M	Child	DSH	Northside Hospital Gwinnett	631 Imaging Center/ Diagnostic Radiology 631	631 Professional Drive	LAWRENCEVILLE	GA	Terminated
DSH110087N	Child	DSH	Northside Hospital Gwinnett	GMC Imaging Center - Hamilton Mill/ Radiology Hamilton Mill	2078 Teron Trace	Dacula	GA	Terminated
DSH110087P	Child	DSH	Northside Hospital Gwinnett	Wound Treatment Center	665 Duluth Hwy	Lawrenceville	GA	Terminated
DSH110087Q	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	Gwinnett Cardiac Imaging/Nuclear Medicine	755 Walther Rd	Lawrenceville	GA	Terminated
DSH110087R	Child	DSH	GWINNETT HOSPITAL SYSTEM, INC	Gwinnett Cardiac Imaging/Ultrasound	755 WALTHER RD	LAWRENCEVILLE	GA	Terminated
DSH110087S	Child	DSH	Northside Hospital Gwinnett	CONCUSSION INSTITUTE	3855 PLEASANT HILL ROAD	DULUTH	GA	Terminated
DSH110087T	Child	DSH	Northside Hospital Gwinnett	STRICKLAND FAMILY MEDICINE CENTER	665 DULUTH HWY	LAWRENCEVILLE	GA	Terminated
DSH110087U	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Emergency Services GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087V	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / PACU GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087W	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / GI Lab GMCD	3805 PLEASANT HILL RD	DULUTH	GA	Terminated
DSH110087X	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Short Stay Unit GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087Y	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / Neurology GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated
DSH110087Z	Child	DSH	Northside Hospital Gwinnett	GWINNETT MEDICAL CENER - DULUTH / EKG GMCD	3620 HOWELL FERRY RD	DULUTH	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/30/2021 12:00:00 AM	7/1/2021 8:38 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/1/2021 8:38 AM
Terminations	Termination Date	Update	Termination Request		10/1/2021 12:00:00 AM	7/1/2021 8:38 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	7/1/2021 8:38 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	7/1/2021 8:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790715381	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 10:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1790715381	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 10:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1790715381	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 10:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1790715381	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 10:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1790715381	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/4/2020 10:44 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	9/4/2020 10:44 PM
Contacts	Primary Contact	Update	Recertification	Naughton, Michael James Director of Pharmacy Gwinnett Hospital System, Inc 6783124541	Naughton, Michael James Director of Pharmacy Northside Hospital Gwinnett 6783124541	9/4/2020 10:44 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 2:37:45 PM	9/4/2020 10:44:19 PM	9/4/2020 10:44 PM
Details	Entity Name	Update	Change Request	GWINNETT HOSPITAL SYSTEM, INC	Northside Hospital Gwinnett	1/14/2020 3:11 PM
Contacts	Authorizing Official	Update	AO Change Request	MCBRIDE III, THOMAS Y. Executive VP & CFO Gwinnett Hospital System, Inc. 6783124308	Wade, Scott VP Finance Northside Hospital, Inc. 4043033381	1/6/2020 10:30 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 1:40:24 PM	8/20/2019 2:37:45 PM	8/20/2019 2:37 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 3:58:11 PM	9/10/2018 1:40:24 PM	9/10/2018 1:40 PM
Details	Last Recertification Date	Update	Recertification		12/5/2017 3:58:11 PM	12/5/2017 3:58 PM
Details	Entity Name	Update	Change Request	GWINNETT HOSPITAL SYSTEM INC	GWINNETT HOSPITAL SYSTEM, INC	10/26/2017 2:47 PM
Contacts	Authorizing Official	Update		MCBRIDE III, THOMAS Y. Executive VP & CFO 6783124308	MCBRIDE III, THOMAS Y. Executive VP & CFO Gwinnett Hospital System, Inc. 6783124308	10/17/2017 10:38 AM
Contacts	Signed By	Update		MCBRIDE III, THOMAS Y. Executive VP & CFO 6783124308	MCBRIDE III, THOMAS Y. Executive VP & CFO Gwinnett Hospital System, Inc. 6783124308	10/17/2017 10:38 AM
Contacts	Primary Contact	Update		Naughton, Michael Director of Pharmacy 6783124541	Naughton, Michael James Director of Pharmacy Gwinnett Hospital System, Inc 6783124541	10/6/2017 4:01 PM
Contacts	Authorizing Official	Insert			MCBRIDE III, THOMAS Y. Executive VP & CFO 6783124308	8/9/2017 1:04 PM
Contacts	Signed By	Insert			MCBRIDE III, THOMAS Y. Executive VP & CFO 6783124308	8/9/2017 1:04 PM
Addresses	Main Address	Insert			3620 HOWELL FERRY RD DULUTH, GA 30096-3178	2/28/2017 10:14 AM
Contacts	Primary Contact	Insert			Naughton, Michael Director of Pharmacy 6783124541	2/28/2017 10:14 AM
Dates	Participating Approval Date	Update			2/27/2017 12:00:00 AM	2/27/2017 6:01 PM
Details	State	Update		Pending	Active	2/27/2017 6:01 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/27/2017 6:01 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75268	DSH110087V	1/23/2017 4:22 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75268	1/17/2017 2:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 2:56 PM
Medicaid Billing	Medicaid: Number	Insert			1064A	1/17/2017 2:56 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/17/2017 2:56 PM
Medicaid Billing	NPI: Number	Insert			1790715381	1/17/2017 2:56 PM
Details	Last Recertification Date	Insert				1/17/2017 2:56 PM
Details	Grant Number	Insert				1/17/2017 2:56 PM
Details	340B ID	Insert				1/17/2017 2:56 PM
Details	Is Authorizing Official EHB Data	Insert				1/17/2017 2:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/17/2017 2:56 PM
Details	Medicare Provider Number	Insert			110087	1/17/2017 2:56 PM
Details	Entity Name	Insert			GWINNETT HOSPITAL SYSTEM INC	1/17/2017 2:56 PM
Details	Program Code	Insert			DSH	1/17/2017 2:56 PM
Details	Entity Subname	Insert			GWINNETT MEDICAL CENER - DULUTH / PACU GMCD	1/17/2017 2:56 PM
Dates	Participating Approval Date	Insert				1/17/2017 2:56 PM
Details	State	Insert			Pending	1/17/2017 2:56 PM
Dates	Registration Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 2:56 PM
Dates	Signed By Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 2:56 PM
Dates	Start Date	Insert				1/17/2017 2:56 PM
Terminations	Termination Comments	Insert				1/17/2017 2:56 PM
Terminations	Termination Date	Insert				1/17/2017 2:56 PM
Terminations	Termination Effective Date	Insert				1/17/2017 2:56 PM
Terminations	Termination Reason	Insert				1/17/2017 2:56 PM