Covered Entity Details

DSH110044B PHOEBE SUMTER MEDICAL CENTER (Active) - information as of 5/20/2025 11:40:32 PM

Main Details

Name

PHOEBE SUMTER MEDICAL CENTER

Subdivision Name

Ellaville Rural Health Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110044B

Medicare Provider Number

110044

Outpatient Facility Provider Number

113403

Additional Details

Current Program Status

Active

Registration Date

4/8/2019

Participating Start Date

7/1/2019

Participating Approval Date

4/12/2019

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Phoebe Sumter Medical Center, Inc
Michelle H Doggett, VP Controller, PSMC
(229) 931-1288

Primary Contact

Phoebe Sumter Medical Center, Inc.
Darryl Lane Hawkins, Manager, Pharmacy
(229) 931-1209

Addresses

Street Address

339 S BROAD STREET
ELLAVILLE, GA 31806-3304

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	003112355A	1376778001

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
DSH110044A	Child	DSH	PHOEBE SUMTER MEDICAL CENTER	Oncology Clinic	120 Hwy 280 W	Americus	GA	Active
DSH110044B	Child	DSH	PHOEBE SUMTER MEDICAL CENTER	Ellaville Rural Health Clinic	339 S BROAD STREET	ELLAVILLE	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Subname	Update	Change Request	PHOEBE SUMTER MEDICAL CENTR-ELLAVIL - Primary Medicine - Rural Health Clinic	Ellaville Rural Health Clinic	1/16/2025 2:02 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 11:55:02 AM	8/28/2024 9:27:41 AM	8/28/2024 9:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Hawkins, Darryl Lane Director of Pharmacy Phoebe Sumter Medical Center 2299311209	Hawkins, Darryl Lane Manager, Pharmacy Phoebe Sumter Medical Center, Inc. 2299311209	8/20/2024 12:33 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:31:30 PM	8/22/2023 11:55:02 AM	8/22/2023 11:55 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 3:43:24 PM	8/30/2022 1:31:30 PM	8/30/2022 1:31 PM
Contacts	Authorizing Official	Update	Profile Change Request	Doggett, Michelle H Director of Finance Phoebe Sumter Medical Center, Inc 2299311288	Doggett, Michelle H VP Controller, PSMC Phoebe Sumter Medical Center, Inc 2299311288	12/6/2021 3:41 PM
Contacts	Authorizing Official	Update	AO Change Request	Lunneborg, Brandi Lee Chief Executive Officer Phoebe Sumter Medical Center 2299311191	Doggett, Michelle H Director of Finance Phoebe Sumter Medical Center, Inc 2299311288	11/16/2021 10:19 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 11:44:32 AM	9/10/2021 3:43:24 PM	9/10/2021 3:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1376778001 ( )		9/8/2020 11:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1376778001	9/8/2020 11:44 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 11:44 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 11:14:13 AM	9/8/2020 11:44:32 AM	9/8/2020 11:44 AM
Contacts	Authorizing Official	Update	AO Change Request	LUNNEBORG, BRANDI CEO Phoebe Sumter Medical Center 2299311280	Lunneborg, Brandi Lee Chief Executive Officer Phoebe Sumter Medical Center 2299311191	1/17/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification		9/3/2019 11:14:13 AM	9/3/2019 11:14 AM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Addresses	Main Address	Update	Change Request	72 S BROAD STREET ELLAVILLE, GA 31806-3475	339 S BROAD STREET ELLAVILLE, GA 31806-3304	4/18/2019 10:32 AM
Contacts	Signed By	Insert	New Registration		LUNNEBORG, BRANDI CEO Phoebe Sumter Medical Center 2299311280	4/12/2019 5:07 PM
Details	340B ID	Update	New Registration		DSH110044B	4/12/2019 5:07 PM
Details	Entity Subname	Update	New Registration	PHOEBE SUMTER MEDICAL CENTR-ELLAVIL	PHOEBE SUMTER MEDICAL CENTR-ELLAVIL - Primary Medicine - Rural Health Clinic	4/12/2019 5:07 PM
Dates	Participating Approval Date	Update	New Registration		4/12/2019 5:07:57 PM	4/12/2019 5:07 PM
Details	State	Update	New Registration	Pending	Approved	4/12/2019 5:07 PM
Dates	Signed By Date	Update	New Registration		4/9/2019 3:32:19 PM	4/12/2019 5:07 PM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	4/12/2019 5:07 PM
Medicaid Billing	Medicaid: Number	Update	New Registration	000000019F	003112355A	4/8/2019 3:04 PM
Addresses	Main Address	Insert	New Registration		72 S BROAD STREET ELLAVILLE, GA 31806-3475	4/8/2019 3:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2019 3:04 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000019F	4/8/2019 3:04 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/8/2019 3:04 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376778001	4/8/2019 3:04 PM
Contacts	Authorizing Official	Insert	New Registration		LUNNEBORG, BRANDI CEO Phoebe Sumter Medical Center 2299311280	4/8/2019 3:04 PM
Contacts	Primary Contact	Insert	New Registration		Hawkins, Darryl Lane Director of Pharmacy Phoebe Sumter Medical Center 2299311209	4/8/2019 3:04 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2019 3:04 PM
Details	Grant Number	Insert	New Registration			4/8/2019 3:04 PM
Details	340B ID	Insert	New Registration			4/8/2019 3:04 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2019 3:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2019 3:04 PM
Details	Medicare Provider Number	Insert	New Registration		110044	4/8/2019 3:04 PM
Details	Entity Name	Insert	New Registration		PHOEBE SUMTER MEDICAL CENTER	4/8/2019 3:04 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2019 3:04 PM
Details	Entity Subname	Insert	New Registration		PHOEBE SUMTER MEDICAL CENTR-ELLAVIL	4/8/2019 3:04 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2019 3:04 PM
Details	State	Insert	New Registration		Pending	4/8/2019 3:04 PM
Dates	Registration Date	Insert	New Registration		4/8/2019 3:04:45 PM	4/8/2019 3:04 PM
Dates	Signed By Date	Insert	New Registration			4/8/2019 3:04 PM
Dates	Start Date	Insert	New Registration			4/8/2019 3:04 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2019 3:04 PM
Terminations	Termination Date	Insert	New Registration			4/8/2019 3:04 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2019 3:04 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2019 3:04 PM