Covered Entity Details

DSH340014DQ Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center (Terminated) - information as of 5/30/2025 8:16:59 PM

Main Details

Name

Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center

Subdivision Name

NOVANT HEALTH UROLOGY - Novant Health Urology - Kimel Park

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340014DQ

Medicare Provider Number

340014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/11/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/31/2019

Last Recertification Date

Termination Date
Termination Reason

7/7/2020
DSH percentage below statutory minimum

Contacts

Authorizing Official

Novant Health
Geoffrey Gardner, SVP Finance
(336) 718-2078

Primary Contact

Novant Health
Elizabeth Anne Corazzo, Manager Pharmacy 340B
(336) 277-0301

Addresses

Street Address

140 KIMEL PARK DR
Suite 100
WINSTON SALEM, NC 27103-6160

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
NC	1235629890
		1235629890

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
DSH340014A	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Salem Family Medicine	105 VEST MILL CIRCLE	WINSTON-SALEM	NC	Terminated
DSH340014AA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Family Medicine	291 Broad Street	Kernersville	NC	Terminated
DSH340014AB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Northwest Family Medicine	7607-B Highway 68N	Oak Ridge	NC	Terminated
DSH340014AC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Lexington Primary Care	110 West Medical Park Drive	Lexington	NC	Terminated
DSH340014AE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Davie Medical Associates	485 Valley Road	Mocksville	NC	Terminated
DSH340014AF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Hillsdale Medical Associates	121 Medical Drive	Advance	NC	Terminated
DSH340014AG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Surry Medical Associates	865 Westlake Drive	Mount Airy	NC	Terminated
DSH340014AH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Pilot Mountain Medical Care	207 Medical Street	Pilot Mountain	NC	Terminated
DSH340014AJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health West Forsyth Internal Medicine and Pediatrics	105 Stadium Oaks Drive	Clemmons	NC	Terminated
DSH340014AK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Yadkin Medical Associates	305 East Lee Avenue	Yadkinville	NC	Terminated
DSH340014AL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health New Garden Medical Associates	1941 New Garden Road	Greensboro	NC	Terminated
DSH340014AM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Wound Care and Hyperbaric Medicine	250 Charlois Boulevard	Winston-Salem	NC	Terminated
DSH340014AN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Hawthorne Outpatient Surgery	1999 South Hawthorne Road	Winston-Salem	NC	Terminated
DSH340014AP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Orthopedic Outpatient Surgery	180 Kimel Park Drive	Winston-Salem	NC	Terminated
DSH340014AQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Maplewood Family Medicine	100 Robinhood Medical Plaza	Winston-Salem	NC	Terminated
DSH340014AR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health North Point Medical Associates	1995 Bethabara Road	Winston-Salem	NC	Terminated
DSH340014AS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Premier Medical Associates	3333 Brookview Hills Boulevard	Winston-Salem	NC	Terminated
DSH340014AT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Thomasville Medical Associates	309 Pineywood Road	Thomasville	NC	Terminated
DSH340014AU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Rheumatology and Arthritis	1551 Westbrook Plaza Dr	Winston-Salem	NC	Terminated
DSH340014AV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Triad Endocrine	500 Pineview Drive	Kernersville	NC	Terminated
DSH340014AX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Urology Partners - Baldwin	2010 Baldwin Lane	Winston-Salem	NC	Terminated
DSH340014AY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Urology Partners - Kernersville	1730 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014AZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Winston Salem Health Care (Dermatology)	175 Kimel Park Drive	Winston Salem	NC	Terminated
DSH340014B	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Mountainview Medical	212 MOORE ROAD	KING	NC	Terminated
DSH340014BB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Family Medicine	400 Jonestown Road	Winston-Salem	NC	Terminated
DSH340014BC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Cardiology Kernersville	1710 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Cardiology Winston-Salem	186 Kimel Park Drive	Winston-Salem	NC	Terminated
DSH340014BE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Speech therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Operating Room	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Recovery Room (PACU)	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Anesthesia	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Nuclear Medicine	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology Ultrasound	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology CT Scanners	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Laboratory	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Anatomic Pathology	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Cardio-Pulmonary Services	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Physical Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Occupational Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Neurodiagnostics	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Rehab Clinics	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Medical Surgical	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BW	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Bariatric Solutions	760 Highland Oaks Dr	Winston-Salem	NC	Terminated
DSH340014BX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH ONCOLOGY SPECIALISTS	1010 BETHESDA COURT	WINSTON-SALEM	NC	Terminated
DSH340014BY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center ICU	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Mammography	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014C	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Winston-Salem Health Care	250 CHARLOIS BLVD.	WINSTON SALEM	NC	Terminated
DSH340014CA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CLINICAL DECISION	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014CB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Clinical Laboratory	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014CC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Osteoporosis Clinic - Kernersville	1710 Kernersville Medical Blvd	Kernersville	NC	Terminated
DSH340014CD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Convenient Care Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CE	Child	DSH	FORSYTH MEMORIAL HOSPITAL INC	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Psychiatry	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CF	Child	DSH	FORSYTH MEMORIAL HOSPITAL INC	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Chemo Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Laboratory	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Internal Medicine	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Coumadin Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Pfafftown Family Medicine	4611 Yadkinville Road	Pfafftown	NC	Terminated
DSH340014CL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH VILLAGE POINT FAMILY Medicine	7130 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Emergency Room Observation and Procedure	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Emergency Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Physical Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Respiratory	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Clinical Laboratory	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Cat Scan	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Ultrasound	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Radiology	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Recovery Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CW	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Operating Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Anesthesia	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CARDIOLOGY MT AIRY	694 RIVERSIDE DR	MOUNT AIRY	NC	Terminated
DSH340014CZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CARDIOLOGY CLEMMONS	7114 VILLAGE MEDICAL CIR	CLEMMONS	NC	Terminated
DSH340014DA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL INC / NH Cardiology WSHC	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014DB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Outpatient Infusion	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NH SURRY MEDICAL ASSOCIATES (ROCKFORD)	2133 ROCKFORD STREET	MT AIRY	NC	Terminated
DSH340014DD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH PSYCHIATRIC MEDICINE	309 PINEYWOOD ROAD	THOMASVILLE	NC	Terminated
DSH340014DE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH RHEUMATOLOGY & ARTHRITIS - WESTBROOK	1551 WESTBROOK PLAZA DR	WINSTON SALEM	NC	Terminated
DSH340014DF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Wound Care Hyperbaric Medicine - Hawthorne	1901 S Hawthorne Rd	Winston Salem	NC	Terminated
DSH340014DG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center / KMC PAV - KMC Pre-Anesthesia Visit	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Cent / CMC PAV - CMC Pre-Anesthesia Visit	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Center/ CMC Occupational Therapy	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center / KMC Mobile PET - KMC Mobile PET	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Intermediate Unit (IMU)	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Center / CMC Clinical Nursing (2A&2B) Observation	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Novant Health Clemmons Medical Center Speech Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL IN - DBA Novant Health Psychiatry-Forsyth	175 KIMEL PARK DR	WINSTON SALEM	NC	Terminated
DSH340014DQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH UROLOGY - Novant Health Urology - Kimel Park	140 KIMEL PARK DR	WINSTON SALEM	NC	Terminated
DSH340014DR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Osteoporosis Clinic - Winston Salem - Osteoporosis clinic	3333 Silas Creek Parkway	Winston-Salem	NC	Terminated
DSH340014DS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Novant Health Clemmons Medical Center Cardiac Non-Invasive Lab	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH TRIAD ENDOCRINE - Endocrinology	1941 NEW GARDEN RD	GREENSBORO	NC	Terminated
DSH340014DU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL INC - Novant Health Rheumatology & Arthritis - Kernersville	291 BROAD ST	KERNERSVILLE	NC	Terminated
DSH340014DV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH FORSYTH ENDOCRINE CON - Novant Health Forsyth Endocrine - Thomasville	903 RANDOLPH ST	THOMASVILLE	NC	Terminated
DSH340014E	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	1710 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014F	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	1213 Lexington Avenue	Thomasville	NC	Terminated
DSH340014G	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	865 WEST LAKE DRIVE	MOUNT AIRY	NC	Terminated
DSH340014H	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	276 OLD MOCKSVILLE ROAD	STATESVILLE	NC	Terminated
DSH340014J	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health KERNERSVILLE MEDICAL CENTER CARDIAC NON-INVASIVE LAB	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014K	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CENTER/KMC WOUND & HYPERBARIC	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014L	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH OUTPATIENT WOUND CARE CENTER - KERNERSVILLE	1710 KERNERSVILLE MEDICAL PKWY	KERNERSVILLE	NC	Terminated
DSH340014M	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Emergency Department	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014N	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CENTER OUTPATIENT INFUSION	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014P	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Arcadia Family Medicine	12208 N NC Highway 150	Winston-Salem	NC	Terminated
DSH340014Q	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Chair City Family Medicine	903 Randolph Street	Thomasville	NC	Terminated
DSH340014R	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Family Medicine	6301 Stadium Drive	Clemmons	NC	Terminated
DSH340014S	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Lewisville Family Medicine	1225 Lewisville-Clemmons Road	Lewisville	NC	Terminated
DSH340014T	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Neurology	2025 Frontis Plaza Boulevard	Winston-Salem	NC	Terminated
DSH340014U	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Endocrine Consultants	755 Highland Oaks Drive	Winston-Salem	NC	Terminated
DSH340014W	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Internal Medicine	1381 Westgate Center Drive	Winston-Salem	NC	Terminated
DSH340014Y	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Infectious Disease Specialists	1381 Westgate Center Drive	Winston-Salem	NC	Terminated
DSH340014Z	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Gateway Family Medicine	390 Salem Avenue	Winston-Salem	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Hansen, Elizabeth Corazzo Supervisor Pharmacy 340B Novant Health 3362770301	Corazzo, Elizabeth Anne Manager Pharmacy 340B Novant Health 3362770301	2/7/2023 4:18 PM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	7/30/2020 7:52 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	10/1/2020 12:00:00 AM	7/7/2020 12:00:00 AM	7/30/2020 7:52 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2020 12:00:00 AM	7/6/2020 7:54 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/6/2020 7:54 AM
Terminations	Termination Date	Update	Termination Request		10/1/2020 12:00:00 AM	7/6/2020 7:54 AM
Terminations	Termination Effective Date	Update	Termination Request		7/2/2020 12:00:00 AM	7/6/2020 7:54 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	7/6/2020 7:54 AM
Contacts	Authorizing Official	Update	Change Request	Terrell, Cedric A SVP Pharmacy Services Novant Health, Inc. 7043840611	Gardner, Geoffrey SVP Finance Novant Health 3367182078	1/17/2020 8:23 AM
Addresses	Main Address	Update	Change Request	140 KIMEL PARK DR WINSTON SALEM, NC 27103-6160	140 KIMEL PARK DR Suite 100 WINSTON SALEM, NC 27103-6160	10/15/2019 6:32 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Terrell, Cedric A SVP Pharmacy Services Novant Health, Inc. 7043840611	7/31/2019 3:02 PM
Details	340B ID	Update	New Registration		DSH340014DQ	7/31/2019 3:02 PM
Details	Entity Name	Update	New Registration	FORSYTH MEMORIAL HOSPITAL INC	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	7/31/2019 3:02 PM
Details	Entity Subname	Update	New Registration	NOVANT HEALTH UROLOGY	NOVANT HEALTH UROLOGY - Novant Health Urology - Kimel Park	7/31/2019 3:02 PM
Dates	Participating Approval Date	Update	New Registration		7/31/2019 3:02:21 PM	7/31/2019 3:02 PM
Details	State	Update	New Registration	Pending	Approved	7/31/2019 3:02 PM
Dates	Signed By Date	Update	New Registration		7/31/2019 12:04:53 PM	7/31/2019 3:02 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/31/2019 3:02 PM
Addresses	Main Address	Insert	New Registration		140 KIMEL PARK DR WINSTON SALEM, NC 27103-6160	7/11/2019 11:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2019 11:41 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1235629890	7/11/2019 11:41 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	7/11/2019 11:41 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235629890	7/11/2019 11:41 AM
Contacts	Authorizing Official	Insert	New Registration		Terrell, Cedric A SVP Pharmacy Services Novant Health, Inc. 7043840611	7/11/2019 11:41 AM
Contacts	Primary Contact	Insert	New Registration		Hansen, Elizabeth Corazzo Supervisor Pharmacy 340B Novant Health 3362770301	7/11/2019 11:41 AM
Details	Last Recertification Date	Insert	New Registration			7/11/2019 11:41 AM
Details	Grant Number	Insert	New Registration			7/11/2019 11:41 AM
Details	340B ID	Insert	New Registration			7/11/2019 11:41 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2019 11:41 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2019 11:41 AM
Details	Medicare Provider Number	Insert	New Registration		340014	7/11/2019 11:41 AM
Details	Entity Name	Insert	New Registration		FORSYTH MEMORIAL HOSPITAL INC	7/11/2019 11:41 AM
Details	Program Code	Insert	New Registration		DSH	7/11/2019 11:41 AM
Details	Entity Subname	Insert	New Registration		NOVANT HEALTH UROLOGY	7/11/2019 11:41 AM
Dates	Participating Approval Date	Insert	New Registration			7/11/2019 11:41 AM
Details	State	Insert	New Registration		Pending	7/11/2019 11:41 AM
Dates	Registration Date	Insert	New Registration		7/11/2019 11:41:23 AM	7/11/2019 11:41 AM
Dates	Signed By Date	Insert	New Registration			7/11/2019 11:41 AM
Dates	Start Date	Insert	New Registration			7/11/2019 11:41 AM
Terminations	Termination Comments	Insert	New Registration			7/11/2019 11:41 AM
Terminations	Termination Date	Insert	New Registration			7/11/2019 11:41 AM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2019 11:41 AM
Terminations	Termination Reason	Insert	New Registration			7/11/2019 11:41 AM