Covered Entity Details

DSH110074E PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC (Terminated) - information as of 5/9/2025 10:49:10 PM

Main Details

Name

PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC

Subdivision Name

Piedmont Athens - AMSP XRAY/CT Imaging

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110074E

Medicare Provider Number

110074

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/10/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/10/2019

Last Recertification Date

8/26/2024

Termination Date
Termination Reason

1/1/2025
Change of covered entity type

Contacts

Authorizing Official

Piedmont Athens Regional
Justin Roberts, CFO
(706) 475-3463

Primary Contact

Piedmont Athens Regional
Don Wesley Tyson, Director of Pharmacy
(706) 475-4438

Addresses

Street Address

3320 Old Jefferson Road
STE A
Athens, GA 30607

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	000000074A	1437186111

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
DSH110074A	Child	DSH	ATHENS REGIONAL MEDICAL CENTER, INC	Home Infusion	1510 PRINCE AVENUE	ATHENS	GA	Terminated
DSH110074B	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	PIEDMONT ATHENS REGIONAL MEDICAL CENTER INC / Out Patient Surgery Center	1295 PRINCE AVENUE	ATHENS	GA	Terminated
DSH110074C	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - OHC MRI Imaging	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074D	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - OHC CT Imaging	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074E	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - AMSP XRAY/CT Imaging	3320 Old Jefferson Road	Athens	GA	Terminated
DSH110074F	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - CT Urology	2142 West Broad Street	Athens	GA	Terminated
DSH110074G	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - OHC US Imaging	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074H	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - OHC Mammo Imaging	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074J	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens - OHC XRAY Imaging	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074K	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Community Care Clinic - Piedmont Athens Regional Community Care Clinic	1270 Prince Ave.	Athens	GA	Terminated
DSH110074L	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Sleep Center - Sleep Lab	145 Pine Needle Road	Athens	GA	Terminated
DSH110074M	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Ambulatory Health - Coumadin Clinic	242 King Avenue	Athens	GA	Terminated
DSH110074N	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR Hawthorne Athens OP DS	120 Hawthorne Park	Athens	GA	Terminated
DSH110074P	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR Hawthorne Watkinsville OP DS	1351 Stone Bridge Parkway	Watkinsville	GA	Terminated
DSH110074Q	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	PIedmont Athens Regional Rehabilitation - PAR OT OHC	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074R	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Rehabilitation - PAR ST OHC	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074S	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR OHC OP DS	1305 Jennings Mill Road	Watkinsville	GA	Terminated
DSH110074T	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR Royston OP DS	930 Franklin Springs Street	Royston	GA	Terminated
DSH110074U	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR Neurology OP DS	1086 1/2	Athens	GA	Terminated
DSH110074V	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR Main Campus OP DS	242 King Avenue	Athens	GA	Terminated
DSH110074W	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Lab Outreach - PAR West Broad OP DS	2142 West Broad Street	Athens	GA	Terminated
DSH110074X	Child	DSH	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	Piedmont Athens Regional Rheumatology - PAR Rheumatology	1270 Prince Avenue	Athens	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/21/2024 11:31 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	10/21/2024 11:31 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/21/2024 11:31 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/21/2024 11:31 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	10/21/2024 11:31 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 8:00:15 AM	8/26/2024 12:05:51 PM	8/26/2024 12:05 PM
Contacts	Authorizing Official	Update	Change Request	Smith, Jason Grady COO Piedmont Athens Regional Medical Center 7064751860	Roberts, Justin CFO Piedmont Athens Regional 7064753463	12/4/2023 2:26 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 4:03:23 PM	8/15/2023 8:00:15 AM	8/15/2023 8:00 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 1:34:54 PM	9/8/2022 4:03:23 PM	9/8/2022 4:03 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003129999A (GA)		12/14/2021 2:43 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003255255A (GA)		12/14/2021 2:43 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1639421704 (GA)		12/14/2021 2:43 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1134712763 (GA)		12/14/2021 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/22/2021 4:27 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003255255A	9/22/2021 4:27 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	9/22/2021 4:27 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134712763	9/22/2021 4:27 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	9/22/2021 4:27 PM
Details	Last Recertification Date	Update	Recertification	8/31/2020 8:42:04 AM	8/24/2021 1:34:54 PM	8/24/2021 1:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/20/2021 3:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003129999A	5/20/2021 3:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	5/20/2021 3:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639421704	5/20/2021 3:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	5/20/2021 3:25 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	8/31/2020 8:42 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 11:34:32 AM	8/31/2020 8:42:04 AM	8/31/2020 8:42 AM
Addresses	Main Address	Update	Change Request	3320 Old Jefferson Road Building 200 Athens, GA 30607	3320 Old Jefferson Road STE A Athens, GA 30607	10/2/2019 9:04 AM
Addresses	Main Address	Update	Change Request	3320 Old Jefferson Road Building 200 C Athens, GA 30607	3320 Old Jefferson Road Building 200 Athens, GA 30607	9/30/2019 11:07 AM
Details	Last Recertification Date	Update	Recertification		8/19/2019 11:34:32 AM	8/19/2019 11:34 AM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Authorizing Official	Update	Change Request	peck, charles a President and CEO Piedmont Athens Regional Medical Center 6505156301	Smith, Jason Grady COO Piedmont Athens Regional Medical Center 7064751860	3/28/2019 2:52 PM
Contacts	Signed By	Insert	New Registration		peck, charles a President and CEO Piedmont Athens Regional Medical Center 6505156301	1/10/2019 2:31 PM
Details	340B ID	Update	New Registration		DSH110074E	1/10/2019 2:31 PM
Details	Entity Name	Update	New Registration	ATHENS REGIONAL MEDICAL CENTER	PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC	1/10/2019 2:31 PM
Details	Entity Subname	Update	New Registration	Piedmont Athens	Piedmont Athens - AMSP XRAY/CT Imaging	1/10/2019 2:31 PM
Dates	Participating Approval Date	Update	New Registration		1/10/2019 2:31:17 PM	1/10/2019 2:31 PM
Details	State	Update	New Registration	Pending	Approved	1/10/2019 2:31 PM
Dates	Signed By Date	Update	New Registration		1/10/2019 12:17:39 PM	1/10/2019 2:31 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/10/2019 2:31 PM
Addresses	Main Address	Insert	New Registration		3320 Old Jefferson Road Building 200 C Athens, GA 30607	1/10/2019 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000074A	1/10/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/10/2019 11:24 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1437186111	1/10/2019 11:24 AM
Contacts	Primary Contact	Insert	New Registration		Tyson, Don Wesley Director of Pharmacy Piedmont Athens Regional 7064754438	1/10/2019 11:24 AM
Contacts	Authorizing Official	Insert	New Registration		peck, charles a President and CEO Piedmont Athens Regional Medical Center 6505156301	1/10/2019 11:24 AM
Details	Last Recertification Date	Insert	New Registration			1/10/2019 11:24 AM
Details	Grant Number	Insert	New Registration			1/10/2019 11:24 AM
Details	340B ID	Insert	New Registration			1/10/2019 11:24 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2019 11:24 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2019 11:24 AM
Details	Medicare Provider Number	Insert	New Registration		110074	1/10/2019 11:24 AM
Details	Entity Name	Insert	New Registration		ATHENS REGIONAL MEDICAL CENTER	1/10/2019 11:24 AM
Details	Program Code	Insert	New Registration		DSH	1/10/2019 11:24 AM
Details	Entity Subname	Insert	New Registration		Piedmont Athens	1/10/2019 11:24 AM
Dates	Participating Approval Date	Insert	New Registration			1/10/2019 11:24 AM
Details	State	Insert	New Registration		Pending	1/10/2019 11:24 AM
Dates	Registration Date	Insert	New Registration		1/10/2019 11:24:42 AM	1/10/2019 11:24 AM
Dates	Signed By Date	Insert	New Registration			1/10/2019 11:24 AM
Dates	Start Date	Insert	New Registration			1/10/2019 11:24 AM
Terminations	Termination Comments	Insert	New Registration			1/10/2019 11:24 AM
Terminations	Termination Date	Insert	New Registration			1/10/2019 11:24 AM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2019 11:24 AM
Terminations	Termination Reason	Insert	New Registration			1/10/2019 11:24 AM