Covered Entity Details

DSH110143J COBB HOSPITAL, INC. (Active) - information as of 6/5/2025 2:40:45 PM

Main Details

Name

COBB HOSPITAL, INC.

Subdivision Name

NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Austell

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110143J

Medicare Provider Number

110143

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/9/2019

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Wellstar Cobb Hospital
Felix Soto Izaguirre, Chief Financial Officer
(470) 732-5039

Primary Contact

Wellstar Health System
Sarah Oliver, 340B Program Director
(470) 956-4931

Addresses

Street Address

1700 HOSPITAL SOUTH DR
STE 300
AUSTELL, GA 30106-8116

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	000000426A,521899833A	1467420448,1821275629

Shipping Addresses

Shipping Address 1

COBB HOSPITAL, INC.
3950 AUSTELL ROAD
Austell, GA 30106

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
DSH110143A	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR CHEMO INFUSION OF AUSTELL	1700 HOSPITAL SOUTH DRIVE	AUSTELL	GA	Active
DSH110143B	Child	DSH	COBB HOSPITAL, INC.	Kennestone Cancer Center / Wellstar Cobb Infusion Therapy Tower	340 Kennestone Hospital Blvd Suite 100	Marietta	GA	Active
DSH110143C	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB OUTPATIENT / Stat Cancer Clinic	1700 Hospital South Drive	AUSTELL	GA	Active
DSH110143D	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB / Cardiac Diagnostics	1700 HOSPITAL SOUTH DRIVE	AUSTELL	GA	Active
DSH110143E	Child	DSH	WELLSTAR COBB HOSPITAL	WELLSTAR COBB OUTPATIENT / Wound Clinic	1605 MULKEY ROAD	AUSTELL	GA	Terminated
DSH110143F	Child	DSH	WELLSTAR COBB HOSPITAL	WellStar Cobb Outpatient / Burn Clinic	1605 Milkey Road Suite A	Austell	GA	Terminated
DSH110143G	Child	DSH	WELLSTAR COBB HOSPITAL	WellStar Cobb Outpatient / Wellness Counseling Services	1625 HOSPITAL NORTH DRIVE	AUSTELL	GA	Terminated
DSH110143H	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Roswell	4500 Hospital Blvd	ROSWELL	GA	Active
DSH110143J	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Austell	1700 HOSPITAL SOUTH DR	AUSTELL	GA	Active
DSH110143K	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Douglasville	6002 PROFESSIONAL PKWY	DOUGLASVILLE	GA	Active
DSH110143L	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Cartersville	100 MARKET PLACE BLVD	CARTERSVILLE	GA	Active
DSH110143M	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Paulding	144 BILL CARRUTH PKWY	HIRAM	GA	Active
DSH110143N	Child	DSH	WELLSTAR COBB HOSPITAL	WELLSTAR COBB HOSPITAL ASC VININGS - GENERAL SURGERY	4441 ATLANTA ROAD SE	SMYRNA	GA	Terminated
DSH110143P	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB HOSPITAL HEART FAILUR - Wellstar Cobb Heart Failure Clinic	1791 MULKEY RD	AUSTELL	GA	Active
DSH110143Q	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GA ONCOLOGY CENTERS - Northwest Georgia Oncology Cherokee	1120 WELLSTAR WAY	HOLLY SPRINGS	GA	Active
DSH110143R	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GA ONCOLOGY CTRS AT VHP - NORTHWEST GA ONCOLOGY CTRS AT VHP	4441 ATLANTA RD SE	SMYRNA	GA	Active
DSH110143S	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB RADIATION ONCOLOGY - Radiation Therapy	1800 HOSPITAL SOUTH DR	AUSTELL	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Oliver, Sarah 340B Program Manager WellStar Health System 4709564931	Oliver, Sarah 340B Program Director Wellstar Health System 4709564931	10/15/2024 7:29 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 9:42:25 AM	8/22/2024 4:43:01 PM	8/22/2024 4:43 PM
Details	Entity Name	Update	Change Request	WELLSTAR COBB HOSPITAL	COBB HOSPITAL, INC.	6/12/2024 12:07 PM
Addresses	Shipping Address	Insert	Group Change Request		COBB HOSPITAL, INC. 3950 AUSTELL ROAD Austell, GA 30106	6/10/2024 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		000000426A	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		521899833A	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467420448	12/8/2023 3:18 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1821275629	12/8/2023 3:18 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 2:52:44 PM	8/21/2023 9:42:25 AM	8/21/2023 9:42 AM
Contacts	Primary Contact	Update	PC Change Request	Doshi, Snehal SVP Ancillary and Support Svcs WellStar Health System 4706440322	Oliver, Sarah 340B Program Manager WellStar Health System 4709564931	6/22/2023 8:04 AM
Contacts	Authorizing Official	Update	AO Change Request	King, Heath Austin CFO Wellstar Cobb Hospital 4707325039	Soto Izaguirre, Felix Chief Financial Officer Wellstar Cobb Hospital 4707325039	1/31/2023 2:24 PM
Contacts	Primary Contact	Update	Profile Change Request	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	Doshi, Snehal SVP Ancillary and Support Svcs WellStar Health System 4706440322	1/12/2023 1:00 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 3:41:04 PM	8/29/2022 2:52:44 PM	8/29/2022 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 11:13:33 AM	8/25/2021 3:41:04 PM	8/25/2021 3:41 PM
Details	Last Recertification Date	Update	Recertification		8/27/2020 11:13:33 AM	8/27/2020 11:13 AM
Contacts	Primary Contact	Update	Change Request	Emamifar, Amir Director of Pharmacy WellStar Cobb Hospital 4707324151	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	4/23/2020 4:57 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		King, Heath Austin CFO Wellstar Cobb Hospital 4707325039	10/9/2019 11:09 AM
Details	340B ID	Update	New Registration		DSH110143J	10/9/2019 11:09 AM
Details	Entity Name	Update	New Registration	COBB HOSPITAL AND MEDICAL CENTER	WELLSTAR COBB HOSPITAL	10/9/2019 11:09 AM
Details	Entity Subname	Update	New Registration	NORTHWEST GEORGIA ONCOLOGY CENTERS	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Austell	10/9/2019 11:09 AM
Dates	Participating Approval Date	Update	New Registration		10/9/2019 11:09:03 AM	10/9/2019 11:09 AM
Details	State	Update	New Registration	Pending	Approved	10/9/2019 11:09 AM
Dates	Signed By Date	Update	New Registration		10/9/2019 9:36:59 AM	10/9/2019 11:09 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/9/2019 11:09 AM
Addresses	Main Address	Insert	New Registration		1700 HOSPITAL SOUTH DR STE 300 AUSTELL, GA 30106-8116	10/9/2019 9:36 AM
Contacts	Primary Contact	Insert	New Registration		Emamifar, Amir Director of Pharmacy WellStar Cobb Hospital 4707324151	10/9/2019 9:36 AM
Contacts	Authorizing Official	Insert	New Registration		King, Heath Austin CFO Wellstar Cobb Hospital 4707325039	10/9/2019 9:36 AM
Details	Last Recertification Date	Insert	New Registration			10/9/2019 9:36 AM
Details	Grant Number	Insert	New Registration			10/9/2019 9:36 AM
Details	340B ID	Insert	New Registration			10/9/2019 9:36 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2019 9:36 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2019 9:36 AM
Details	Medicare Provider Number	Insert	New Registration		110143	10/9/2019 9:36 AM
Details	Entity Name	Insert	New Registration		COBB HOSPITAL AND MEDICAL CENTER	10/9/2019 9:36 AM
Details	Program Code	Insert	New Registration		DSH	10/9/2019 9:36 AM
Details	Entity Subname	Insert	New Registration		NORTHWEST GEORGIA ONCOLOGY CENTERS	10/9/2019 9:36 AM
Dates	Participating Approval Date	Insert	New Registration			10/9/2019 9:36 AM
Details	State	Insert	New Registration		Pending	10/9/2019 9:36 AM
Dates	Registration Date	Insert	New Registration		10/9/2019 9:36:56 AM	10/9/2019 9:36 AM
Dates	Signed By Date	Insert	New Registration			10/9/2019 9:36 AM
Dates	Start Date	Insert	New Registration			10/9/2019 9:36 AM
Terminations	Termination Comments	Insert	New Registration			10/9/2019 9:36 AM
Terminations	Termination Date	Insert	New Registration			10/9/2019 9:36 AM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2019 9:36 AM
Terminations	Termination Reason	Insert	New Registration			10/9/2019 9:36 AM