Covered Entity Details

DSH110107T Atrium Health Navicent The Medical Center (Active) - information as of 5/10/2025 11:09:04 PM

Main Details

Name

Atrium Health Navicent The Medical Center

Subdivision Name

Beverly Knight Olson Children's Hospital Outpatient Services - Pediatric Surgical Services

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110107T

Medicare Provider Number

110107

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/17/2023

Participating Start Date

4/1/2023

Participating Approval Date

1/19/2023

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Atrium Health Navicent
Kimberly Shrewsbury, SVP and CFO
(205) 965-7895

Primary Contact

North Carolina Baptist Hospital
Bibi W Wishart, Program Director, 340B
(336) 713-3426

Addresses

Street Address

700 Spring Street
Macon, GA 31201

Billing Address

Medical Center of Central Georgia
777 Hemlock St
MSC #113
Macon, GA 31201-2102

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	000001207A,003115096A	1043270564,1639296395

Shipping Addresses

Shipping Address 1

Medical Center of Central Georgia Pharmacy
777 Hemlock St
Dock H1
Macon, GA 31201

Shipping Address 2

Beverly Knight Olson Children's Hospital Outpatient Services
700 Spring Street
Macon, GA 31201

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
DSH110107A	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Surgery Macon	1014 Forsyth Street	Macon	GA	Active
DSH110107B	Child	DSH	Atrium Health Navicent The Medical Center	Endoscopy ASC (ENDO CAS)	1014 Forsyth Street	Macon	GA	Active
DSH110107C	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent WT Anderson Infusion Center, a facility of Atrium Health Navicent The Medical Center	800 1st Street	Macon	GA	Active
DSH110107D	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Outpatient Rehab Services	770 Hemlock Street	Macon	GA	Terminated
DSH110107E	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Wound Care	818 Forsyth Street	Macon	GA	Active
DSH110107F	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Emergency Medical	675 New Street	Macon	GA	Terminated
DSH110107G	Child	DSH	MEDICAL CENTER OF CENTRAL GEORGIA	Baldwin County EMS (EMS Baldwin)	560 W. Martin Luther King Jr Dr	Milledgeville	GA	Terminated
DSH110107H	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Breast Care Center	800 1st Street	Macon	GA	Active
DSH110107J	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care North	3400 Riverside Drive	Macon	GA	Active
DSH110107K	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care Northwest	5925 Zebulon Road	Macon	GA	Active
DSH110107L	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Urgent Care East	1339 Gray Highway	Macon	GA	Active
DSH110107M	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Primary Care West Macon	3780 Eisenhower Parkway	Macon	GA	Active
DSH110107N	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Imaging & Laboratory	1650 Hardeman Avenue	Macon	GA	Active
DSH110107P	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Children's Care Downtown Macon	1014 Forsyth Street	Macon	GA	Active
DSH110107Q	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent Children's Care Pediatric Hematology Oncology	770 Pine Street	Macon	GA	Active
DSH110107R	Child	DSH	Atrium Health Navicent The Medical Center	Atrium Health Navicent WT Anderson Community Health Center	764 Pine Street	Macon	GA	Active
DSH110107S	Child	DSH	Atrium Health Navicent The Medical Center	Womens Ambulatory OB GYN Health	764 Pine Street	Macon	GA	Active
DSH110107T	Child	DSH	Atrium Health Navicent The Medical Center	Beverly Knight Olson Children's Hospital Outpatient Services - Pediatric Surgical Services	700 Spring Street	Macon	GA	Active
DSH110107U	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Pre-surgery holding (Just for Today)	840 Pine Street	Macon	GA	Active
DSH110107V	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Operating Room	840 Pine Street	Macon	GA	Active
DSH110107W	Child	DSH	Atrium Health Navicent The Medical Center	Operating Room - Pre-surgical and post-surgical clinic	840 Pine Street	Macon	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	Wishart, Bibi W Program Director, 340B North Carolina Baptist Hospital 3367133426	4/16/2025 2:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	003115100A (GA)		9/3/2024 4:17 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 11:17:48 AM	9/3/2024 4:17:19 PM	9/3/2024 4:17 PM
Contacts	Authorizing Official	Update	AO Change Request	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	Shrewsbury, Kimberly SVP and CFO Atrium Health Navicent 2059657895	8/29/2024 6:50 AM
Contacts	Authorizing Official	Update	Profile Change Request	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	8/13/2024 2:16 PM
Contacts	Signed By	Update	Profile Change Request	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	8/13/2024 2:16 PM
Details	Entity Name	Update	Change Request	MEDICAL CENTER OF CENTRAL GEORGIA	Atrium Health Navicent The Medical Center	1/25/2024 11:28 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	107701900 (FL)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1156A (SC)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300036425 (IN)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4154975-00 (MD)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	7100071000 (KY)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000182376 (CO)		9/7/2023 11:17 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q046883 (TN)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (ME)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (CA)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (IA)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (IL)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (MI)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (NC)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (VA)		9/7/2023 11:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1043270564 (WA)		9/7/2023 11:17 AM
Details	Last Recertification Date	Update	Recertification		9/7/2023 11:17:48 AM	9/7/2023 11:17 AM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	1/19/2023 10:23 AM
Details	340B ID	Update	New Registration		DSH110107T	1/19/2023 10:23 AM
Details	Entity Name	Update	New Registration	AHN THE MEDICAL CENTER	MEDICAL CENTER OF CENTRAL GEORGIA	1/19/2023 10:23 AM
Details	Entity Subname	Update	New Registration	Beverly Knight Olson Children's Hospital Outpatient Services	Beverly Knight Olson Children's Hospital Outpatient Services - Pediatric Surgical Services	1/19/2023 10:23 AM
Dates	Participating Approval Date	Update	New Registration		1/19/2023 10:23:35 AM	1/19/2023 10:23 AM
Details	State	Update	New Registration	Pending	Approved	1/19/2023 10:23 AM
Dates	Signed By Date	Update	New Registration		1/17/2023 11:42:02 AM	1/19/2023 10:23 AM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	1/19/2023 10:23 AM
Addresses	Main Address	Insert	New Registration		700 Spring Street Macon, GA 31201	1/17/2023 10:16 AM
Addresses	Billing Address	Insert	New Registration		Medical Center of Central Georgia 777 Hemlock St MSC #113 Macon, GA 31201-2102	1/17/2023 10:16 AM
Addresses	Shipping Address	Insert	New Registration		Medical Center of Central Georgia Pharmacy 777 Hemlock St Dock H1 Macon, GA 31201	1/17/2023 10:16 AM
Addresses	Shipping Address	Insert	New Registration		Beverly Knight Olson Children's Hospital Outpatient Services 700 Spring Street Macon, GA 31201	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000001207A	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003115096A	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003115100A	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		107701900	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1156A	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300036425	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4154975-00	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7100071000	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000182376	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q046883	1/17/2023 10:16 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		ME	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		IA	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		WA	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270564	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	1/17/2023 10:16 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639296395	1/17/2023 10:16 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	1/17/2023 10:16 AM
Contacts	Primary Contact	Insert	New Registration		Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	1/17/2023 10:16 AM
Contacts	Authorizing Official	Insert	New Registration		Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	1/17/2023 10:16 AM
Details	Assistance Received From Date	Insert	New Registration			1/17/2023 10:16 AM
Details	Assistance Received To Date	Insert	New Registration			1/17/2023 10:16 AM
Details	Last Recertification Date	Insert	New Registration			1/17/2023 10:16 AM
Details	Grant Number	Insert	New Registration			1/17/2023 10:16 AM
Details	340B ID	Insert	New Registration			1/17/2023 10:16 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/17/2023 10:16 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/17/2023 10:16 AM
Details	Medicare Provider Number	Insert	New Registration		110107	1/17/2023 10:16 AM
Details	Entity Name	Insert	New Registration		AHN THE MEDICAL CENTER	1/17/2023 10:16 AM
Details	NOFO Number	Insert	New Registration			1/17/2023 10:16 AM
Details	Program Code	Insert	New Registration		DSH	1/17/2023 10:16 AM
Details	Entity Subname	Insert	New Registration		Beverly Knight Olson Children's Hospital Outpatient Services	1/17/2023 10:16 AM
Dates	Participating Approval Date	Insert	New Registration			1/17/2023 10:16 AM
Details	State	Insert	New Registration		Pending	1/17/2023 10:16 AM
Dates	Registration Date	Insert	New Registration		1/17/2023 10:16:22 AM	1/17/2023 10:16 AM
Dates	Signed By Date	Insert	New Registration			1/17/2023 10:16 AM
Dates	Start Date	Insert	New Registration			1/17/2023 10:16 AM
Terminations	Termination Comments	Insert	New Registration			1/17/2023 10:16 AM
Terminations	Termination Date	Insert	New Registration			1/17/2023 10:16 AM
Terminations	Termination Effective Date	Insert	New Registration			1/17/2023 10:16 AM
Terminations	Termination Reason	Insert	New Registration			1/17/2023 10:16 AM