Covered Entity Details

DSH110161DD Northside Hospital, Inc. (Active) - information as of 4/29/2025 11:53:53 PM

Main Details

Name

Northside Hospital, Inc.

Subdivision Name

G.I. LAB MIDTOWN - Surgery Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110161DD

Medicare Provider Number

110161

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/6/2023

Participating Start Date

6/1/2023

Participating Approval Date

4/14/2023

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Northside Hospital, Inc.
Scott Wade, VP Finance
(404) 303-3381

Primary Contact

Northside Hospital, Inc.
Judy Gardner, Director of Pharmacy
(404) 851-6793

Addresses

Street Address

1110 West Peachtree Street NW
Suite 1200
Atlanta, GA 30309

Billing Address

Northside Hospital
1000 Johnson Ferry Road
Atlanta, GA 30342

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	00001405A	1457396079
AL		1457396079
TN		1457396079
SC		1457396079
NC		1457396079
FL		1457396079

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
DSH110161A	Child	DSH	Northside Hospital, Inc.	Northside / East Cobb Imaging	4800 Olde Towne Parkway	Marietta	GA	Active
DSH110161AA	Child	DSH	Northside Hospital, Inc.	GCS-Cobb/Austell	1668 Mulkey Road	Austell	GA	Active
DSH110161AB	Child	DSH	Northside Hospital, Inc.	GCS-Camp Creek	3886 Princeton Lakes Way SW	Atlanta	GA	Active
DSH110161AC	Child	DSH	Northside Hospital, Inc.	GCS-Canton	1521 Hickory Flat Hwy	Canton	GA	Active
DSH110161AD	Child	DSH	Northside Hospital, Inc.	GCS-Cumming	1505 Northside Boulevard	Cumming	GA	Active
DSH110161AE	Child	DSH	Northside Hospital, Inc.	GCS-Douglasville	4586 Timber Ridge Drive	Douglasville	GA	Active
DSH110161AF	Child	DSH	Northside Hospital, Inc.	GCS-Midtown	550 Peachtree Street, NE	Atlanta	GA	Active
DSH110161AG	Child	DSH	Northside Hospital, Inc.	GCS-Fayetteville	132 Old Norton Road	Fayetteville	GA	Active
DSH110161AH	Child	DSH	Northside Hospital, Inc.	GCS-Gwinnett	698 Duluth Highway	Lawrenceville	GA	Active
DSH110161AJ	Child	DSH	Northside Hospital, Inc.	GCS-Hillandale	5700 Hillandale Dr.	Lithonia	GA	Active
DSH110161AK	Child	DSH	Northside Hospital, Inc.	GCS-Johns Creek	6300 Hospital Parkway	Johns Creek	GA	Active
DSH110161AL	Child	DSH	Northside Hospital, Inc.	GCS-Marietta	790 Church Street	Marietta	GA	Active
DSH110161AM	Child	DSH	Northside Hospital, Inc.	GCS-Paulding/Hiram	159 Enterprise Path	Hiram	GA	Active
DSH110161AN	Child	DSH	Northside Hospital, Inc.	GCS-Rockdale	1501 Milstead Road	Conyers	GA	Active
DSH110161AP	Child	DSH	Northside Hospital, Inc.	GCS-Decatur	2712 Lawrenceville Highway	Decatur	GA	Active
DSH110161AQ	Child	DSH	Northside Hospital, Inc.	GCS-Stockbridge	1045 Southcrest Drive	Stockbridge	GA	Active
DSH110161AR	Child	DSH	Northside Hospital, Inc.	GCS-Northside RET	1100 Johnson Ferry Road	Sandy Springs	GA	Terminated
DSH110161AS	Child	DSH	Northside Hospital, Inc.	GCS-Annex	1835 Savoy Drive	Atlanta	GA	Terminated
DSH110161AT	Child	DSH	Northside Hospital, Inc.	GCS-Center Point Infusion	1100 Johnson Ferry Road	Sandy Springs	GA	Active
DSH110161AU	Child	DSH	Northside Hospital, Inc.	Northside/Marietta Imaging	780 Canton Road NE	Marietta	GA	Active
DSH110161AV	Child	DSH	Northside Hospital, Inc.	Northside Stockbridge Imaging	239 Village Center Parkway	Stockbridge	GA	Active
DSH110161AW	Child	DSH	Northside Hospital, Inc.	Hammond Mental Health - Outpatient	6105 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161AX	Child	DSH	Northside Hospital, Inc.	Northside Outpatient Services - 993	993 A-C Johnson Ferry Road	Atlanta	GA	Terminated
DSH110161AY	Child	DSH	Northside Hospital, Inc.	GI Lab Roswell	1340 Upper Hembree Road	Roswell	GA	Active
DSH110161AZ	Child	DSH	Northside Hospital, Inc.	Northside Decatur Imaging	2545 Lawrenceville Highway	Decatur	GA	Active
DSH110161B	Child	DSH	Northside Hospital, Inc.	Northside / Medlock Medical Imaging	11459 Johns Creek Parkway	Johns Creek	GA	Active
DSH110161BA	Child	DSH	Northside Hospital, Inc.	Northside Eagles Landing Imaging	913 Eagles Landing Parkway	Stockbridge	GA	Active
DSH110161BB	Child	DSH	Northside Hospital, Inc.	Northside Lawrenceville Imaging	555 Old Norcross Road	Lawrenceville	GA	Active
DSH110161BC	Child	DSH	Northside Hospital, Inc.	Northside Fayetteville Imaging	1260 Highway 54 West	Fayetteville	GA	Active
DSH110161BD	Child	DSH	Northside Hospital, Inc.	Northside Decatur Urology Outpatient Surgery Center	2685 Milscott Drive	Decatur	GA	Active
DSH110161BE	Child	DSH	Northside Hospital, Inc.	Northside Douglasville Imaging	4586 Timber Ridge Drive	Douglasville	GA	Active
DSH110161BF	Child	DSH	Northside Hospital, Inc.	Alpharetta Pain Clinic	11975 Morris Road	Alpharetta	GA	Terminated
DSH110161BG	Child	DSH	Northside Hospital, Inc.	Northside Lake Hearn Imaging	1100 Lake Hearn Drive	Atlanta	GA	Active
DSH110161BH	Child	DSH	Northside Hospital, Inc.	Northside Roswell Imaging	11660 Alpharetta Highway	Roswell	GA	Active
DSH110161BJ	Child	DSH	Northside Hospital, Inc.	Northside Conyers Imaging	2287 Salem Road SE	Conyers	GA	Active
DSH110161BK	Child	DSH	Northside Hospital, Inc.	Northside Dekalb Imaging	2859 North Decatur Road	Decatur	GA	Active
DSH110161BL	Child	DSH	Northside Hospital, Inc.	Northside Medical Center Imaging	6095 Professional Parkway	Douglasville	GA	Terminated
DSH110161BM	Child	DSH	Northside Hospital, Inc.	Northside Galleria Imaging	3200 Cobb Galleria Parkway	Atlanta	GA	Terminated
DSH110161BN	Child	DSH	Northside Hospital, Inc.	Northside Gwinnett Imaging	600 Professional Drive	Lawrenceville	GA	Active
DSH110161BP	Child	DSH	Northside Hospital, Inc.	Northside Midtown Imaging	1110 West Peachtree Street NW	Atlanta	GA	Active
DSH110161BQ	Child	DSH	Northside Hospital, Inc.	Northside Hembree Imaging	1400 Hembree Road	Roswell	GA	Active
DSH110161BR	Child	DSH	Northside Hospital, Inc.	Northside Johnson Ferry Imaging	993 Johnson Ferry Road NE Bldg. F	Atlanta	GA	Active
DSH110161BS	Child	DSH	Northside Hospital, Inc.	Northside Village Center Imaging	204 Village Center Parkway	Stockbridge	GA	Active
DSH110161BT	Child	DSH	Northside Hospital, Inc.	Northside Southcrest Imaging	1035 Southcrest Drive	Stockbridge	GA	Terminated
DSH110161BU	Child	DSH	Northside Hospital, Inc.	Northside West Paces Imaging	3200 Downwood Circle NW	Atlanta	GA	Active
DSH110161BV	Child	DSH	Northside Hospital, Inc.	Northside Riverdale Imaging	34 Upper Riverdale Road SE	Riverdale	GA	Active
DSH110161BW	Child	DSH	Northside Hospital, Inc.	Northside Marble Mill Imaging	121 Marble Mill Road	Marietta	GA	Active
DSH110161BX	Child	DSH	Northside Hospital, Inc.	Respiratory Care and Diagnostic Services	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161BY	Child	DSH	Northside Hospital, Inc.	Tower Rehab	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161BZ	Child	DSH	Northside Hospital, Inc.	Tower OP Surgery	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161CA	Child	DSH	Northside Hospital, Inc.	Tower Imaging	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161CB	Child	DSH	Northside Hospital, Inc.	Tower Pain Center	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161CC	Child	DSH	Northside Hospital, Inc.	Spine Center	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Terminated
DSH110161CD	Child	DSH	Northside Hospital, Inc.	Infusion Center	5670 Peachtree Dunwoody Rd.	Atlanta	GA	Active
DSH110161CE	Child	DSH	Northside Hospital, Inc.	Meridian Radiology	5445 Meridian Mark Road	Atlanta	GA	Active
DSH110161CF	Child	DSH	Northside Hospital, Inc.	Outpatient Radiology	980 Johnson Ferry Road	Atlanta	GA	Active
DSH110161CG	Child	DSH	Northside Hospital, Inc.	Alpharetta Radiology	3400 Old Milton Parkway, Bldg. C	Alpharetta	GA	Active
DSH110161CH	Child	DSH	Northside Hospital, Inc.	Alpharetta OP Surgery	3400 Old Milton Parkway, Bldg. A	Alpharetta	GA	Active
DSH110161CJ	Child	DSH	Northside Hospital, Inc.	Alpharetta GI Lab	3400 Old Milton Parkway, Bldg. A	Alpharetta	GA	Active
DSH110161CK	Child	DSH	Northside Hospital, Inc.	Rehab - Alpharetta Outpatient	3400 Old Milton Parkway, Bldg. C	Alpharetta	GA	Terminated
DSH110161CL	Child	DSH	Northside Hospital, Inc.	Cardiac Rehab	993 Johnson Ferry Road, Bldg. C	Atlanta	GA	Active
DSH110161CM	Child	DSH	Northside Hospital, Inc.	GCS-Decatur-Radiology	2712 Lawrenceville Highway	Decatur	GA	Active
DSH110161CN	Child	DSH	Northside Hospital, Inc.	Alpharetta Perinatal Medicine	11975 Morris Road	Alpharetta	GA	Active
DSH110161CP	Child	DSH	Northside Hospital, Inc.	Meridian OP Surgery	5445 Meridian Mark Road	Atlanta	GA	Active
DSH110161CQ	Child	DSH	Northside Hospital, Inc.	Meridian Urodiagnostic Lab	5445 Meridian Mark Road	Atlanta	GA	Active
DSH110161CR	Child	DSH	Northside Hospital, Inc.	Peachtree Dunwoody Outpatient Surgery Center	5505 Peachtree Dunwoody Road	Atlanta	GA	Active
DSH110161CS	Child	DSH	Northside Hospital, Inc.	RAD-ALPHARETTA WOMEN'S IMAGING	3400 Old Milton Parkway, Bldg. C	Alpharetta	GA	Active
DSH110161CT	Child	DSH	Northside Hospital, Inc.	NORTHSIDE HAPEVILLE IMAGING	800 Virginia Avenue	Atlanta	GA	Active
DSH110161CU	Child	DSH	Northside Hospital, Inc.	ACC - CANTON - Radiology - Therapeutic	460 Northside Cherokee Blvd	Canton	GA	Active
DSH110161CV	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - PRESTON RIDGE	3330 Preston Ridge Road	Alpharetta	GA	Active
DSH110161CW	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - MIDTOWN	1110 W Peachtree St NW	Atlanta	GA	Active
DSH110161CX	Child	DSH	Northside Hospital, Inc.	CENTER FOR PERINATAL MEDICINE - MIDTOWN - Perinatal Medicine	1110 West Peachtree Street NW	Atlanta	GA	Active
DSH110161CY	Child	DSH	Northside Hospital, Inc.	GCS-Oconee - Medical Oncology	1000 Cowles Clinic Way	Greensboro	GA	Active
DSH110161CZ	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - LAKE OCONEE - Radiation Oncology	1000 Cowles Clinic Way	Greensboro	GA	Active
DSH110161DA	Child	DSH	Northside Hospital, Inc.	MIDTOWN OUTPATIENT SURGERY CENTER - Surgery Center	1110 West Peachtree Street NW	Atlanta	GA	Active
DSH110161DB	Child	DSH	Northside Hospital, Inc.	GCS-Blue Ridge - Medical Oncology	101 Riverstone Vista	Blue Ridge	GA	Active
DSH110161DC	Child	DSH	Northside Hospital, Inc.	GCS-Macon - Medical Oncology	308 Coliseum Drive	Macon	GA	Active
DSH110161DD	Child	DSH	Northside Hospital, Inc.	G.I. LAB MIDTOWN - Surgery Center	1110 West Peachtree Street NW	Atlanta	GA	Active
DSH110161DE	Child	DSH	Northside Hospital, Inc.	GCS-Blairsville - Medical Oncology	308 Deep South Farm Road	Blairsville	GA	Active
DSH110161DF	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - HAWKINSVILLE - Radiation Oncology	214 Perry Highway	Hawkinsville	GA	Active
DSH110161DG	Child	DSH	Northside Hospital, Inc.	GCS-Griffin - Medical Oncology	747 South 8th Street	Griffin	GA	Active
DSH110161DH	Child	DSH	Northside Hospital, Inc.	GCS-Hawkinsville - Medical Oncology	214 Perry Highway	Hawkinsville	GA	Active
DSH110161DJ	Child	DSH	Northside Hospital, Inc.	Radiation Oncology Macon - Radiation Oncology	308 Coliseum Drive	Macon	GA	Active
DSH110161DK	Child	DSH	Northside Hospital, Inc.	CENTER FOR CANCER CARE HAMILTON MILL - Infusion Center	2098 TERON TRCE	DACULA	GA	Active
DSH110161DL	Child	DSH	Northside Hospital, Inc.	OP INFUSION BRASELTON - Infusion Center	1255 Friendship Road	Braselton	GA	Active
DSH110161DM	Child	DSH	Northside Hospital, Inc.	OP INFUSION GAINESVILLE - Infusion Center	1485 Jesse Jewell Parkway NE	Gainesville	GA	Active
DSH110161DN	Child	DSH	Northside Hospital, Inc.	GCS - Athens - Infusion Center	125 King Avenue 2nd Floor	Athens	GA	Active
DSH110161DP	Child	DSH	Northside Hospital, Inc.	Center for Cancer Care - Snellville - Infusion Center	1700 Tree Lane	Snellville	GA	Active
DSH110161DQ	Child	DSH	Northside Hospital, Inc.	Center for Cancer Care - Duluth - Infusion Center	3855 Pleasant Hill Road	Duluth	GA	Active
DSH110161DR	Child	DSH	Northside Hospital, Inc.	GCS - SMYRNA - Infusion Center	4298 Atlanta Rd SE	Smyrna	GA	Active
DSH110161DS	Child	DSH	Northside Hospital, Inc.	GCS - JASPER - Infusion Center	134 Mountainside Village Parkway	Jasper	GA	Active
DSH110161DT	Child	DSH	Northside Hospital, Inc.	Center for Cancer Care - Lawrenceville - Infusion Center	631 Professional Drive	Lawrenceville	GA	Active
DSH110161DU	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - SOUTH ATLANTA - Radiation Oncology	791 Oak St	Atlanta	GA	Active
DSH110161DV	Child	DSH	Northside Hospital, Inc.	RAD-MRI & IMAGING OF HABERSHAM - Radiology	638 Historic Highway 441 North	Demorest	GA	Active
DSH110161DW	Child	DSH	Northside Hospital, Inc.	RAD-IMAGING CENTER OF WARNER ROBINS - Radiology	2706 Watson Blvd	Warner Robins	GA	Active
DSH110161DX	Child	DSH	Northside Hospital, Inc.	SHOA CANCER INFUSION CTR BUFORD - Infusion Center	2800 Buford Dr	Buford	GA	Active
DSH110161DY	Child	DSH	Northside Hospital, Inc.	GCS - MILLEDGEVILLE - Infusion Center	111 Fieldstone Dr	Milledgeville	GA	Active
DSH110161DZ	Child	DSH	Northside Hospital, Inc.	RAD-NORTHSIDE BARFIELD IMAGING - Radiology	6095 Barfield Road	Sandy Springs	GA	Active
DSH110161E	Child	DSH	Northside Hospital, Inc.	Northside / North Crescent Women's Imaging	11975 Morris Road, Suite 120	Alpharetta	GA	Terminated
DSH110161F	Child	DSH	Northside Hospital, Inc.	RADIATION ONCOLOGY - ALPHARETTA	3400 Old Milton Parkway, Bldg. B	Alpharetta	GA	Active
DSH110161G	Child	DSH	Northside Hospital, Inc.	Pediatric Imaging Center at Northside / Alpharetta	3300 Old Milton Parkway	Alpharetta	GA	Active
DSH110161H	Child	DSH	Northside Hospital, Inc.	Northside / Dunwoody Outpatient Surgery Center	4553 North Shallowford Road, Ste 60C	Atlanta	GA	Terminated
DSH110161J	Child	DSH	Northside Hospital, Inc.	Northside Hospital Outpatient Center & Radiology at Meridian Mark	5445 Meridian Mark Road	Atlanta	GA	Terminated
DSH110161K	Child	DSH	Northside Hospital, Inc.	Northside Hospital Imaging at Peachtree Dunwoody	5505 Peachtree-Dunwoody Road	Atlanta	GA	Active
DSH110161L	Child	DSH	Northside Hospital, Inc.	Northside Sandy Springs Outpatient Surgery	975 Johnson Ferry Road	Atlanta	GA	Active
DSH110161N	Child	DSH	Northside Hospital, Inc.	Northside / Alpharetta Medical Campus	3400-A-C Old Milton Parkway	Alpharetta	GA	Terminated
DSH110161P	Child	DSH	Northside Hospital, Inc.	Medical Tower at Northside Hospital	5670 Peachtree-Dunwoody Rd	Atlanta	GA	Terminated
DSH110161Q	Child	DSH	Northside Hospital, Inc.	Northside Hospital Outpatient Services	980 Johnson Ferry Road	Atlanta	GA	Terminated
DSH110161S	Child	DSH	Northside Hospital, Inc.	ACC-Alpharetta	3400 Old Milton Pkwy	Alpharetta	GA	Active
DSH110161T	Child	DSH	Northside Hospital, Inc.	ACC-Conyers	1498 Klondike Road	Conyers	GA	Active
DSH110161U	Child	DSH	Northside Hospital, Inc.	ACC-Cumming	1505 Northside Boulevard	Cumming	GA	Active
DSH110161V	Child	DSH	Northside Hospital, Inc.	ACC-Decatur	2545 Lawrenceville Highway	Decatur	GA	Active
DSH110161W	Child	DSH	Northside Hospital, Inc.	ACC-Stockbridge	1050 Eagles Landing Parkway	Stockbridge	GA	Active
DSH110161X	Child	DSH	Northside Hospital, Inc.	ACC-Tower	5670 Peachtree Dunwoody Road	Atlanta	GA	Active
DSH110161Y	Child	DSH	Northside Hospital, Inc.	GCS-Alpharetta	3330 Preston Ridge Road	Alpharetta	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 11:30:24 AM	8/12/2024 10:09:00 AM	8/12/2024 10:09 AM
Details	Last Recertification Date	Update	Recertification		8/14/2023 11:30:24 AM	8/14/2023 11:30 AM
Details	State	Update	OPA Edit	Approved	Active	6/1/2023 1:42 PM
Dates	Start Date	Update	OPA Edit	7/1/2023 12:00:00 AM	6/1/2023 12:00:00 AM	6/1/2023 1:42 PM
Contacts	Signed By	Insert	New Registration		Wade, Scott VP Finance Northside Hospital, Inc. 4043033381	4/14/2023 7:49 AM
Details	340B ID	Update	New Registration		DSH110161DD	4/14/2023 7:49 AM
Details	Entity Name	Update	New Registration	NORTHSIDE HOSPITAL	Northside Hospital, Inc.	4/14/2023 7:49 AM
Details	Entity Subname	Update	New Registration	G.I. LAB MIDTOWN	G.I. LAB MIDTOWN - Surgery Center	4/14/2023 7:49 AM
Dates	Participating Approval Date	Update	New Registration		4/14/2023 7:49:35 AM	4/14/2023 7:49 AM
Details	State	Update	New Registration	Pending	Approved	4/14/2023 7:49 AM
Dates	Signed By Date	Update	New Registration		4/12/2023 9:41:20 AM	4/14/2023 7:49 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	4/14/2023 7:49 AM
Addresses	Main Address	Insert	New Registration		1110 West Peachtree Street NW Suite 1200 Atlanta, GA 30309	4/6/2023 10:04 AM
Addresses	Billing Address	Insert	New Registration		Northside Hospital 1000 Johnson Ferry Road Atlanta, GA 30342	4/6/2023 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/6/2023 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00001405A	4/6/2023 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	4/6/2023 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457396079	4/6/2023 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/6/2023 10:04 AM
Contacts	Primary Contact	Insert	New Registration		Gardner, Judy Director of Pharmacy Northside Hospital, Inc. 4048516793	4/6/2023 10:04 AM
Contacts	Authorizing Official	Insert	New Registration		Wade, Scott VP Finance Northside Hospital, Inc. 4043033381	4/6/2023 10:04 AM
Details	Assistance Received From Date	Insert	New Registration			4/6/2023 10:04 AM
Details	Assistance Received To Date	Insert	New Registration			4/6/2023 10:04 AM
Details	Last Recertification Date	Insert	New Registration			4/6/2023 10:04 AM
Details	Grant Number	Insert	New Registration			4/6/2023 10:04 AM
Details	340B ID	Insert	New Registration			4/6/2023 10:04 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/6/2023 10:04 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/6/2023 10:04 AM
Details	Medicare Provider Number	Insert	New Registration		110161	4/6/2023 10:04 AM
Details	Entity Name	Insert	New Registration		NORTHSIDE HOSPITAL	4/6/2023 10:04 AM
Details	NOFO Number	Insert	New Registration			4/6/2023 10:04 AM
Details	Program Code	Insert	New Registration		DSH	4/6/2023 10:04 AM
Details	Entity Subname	Insert	New Registration		G.I. LAB MIDTOWN	4/6/2023 10:04 AM
Dates	Participating Approval Date	Insert	New Registration			4/6/2023 10:04 AM
Details	State	Insert	New Registration		Pending	4/6/2023 10:04 AM
Dates	Registration Date	Insert	New Registration		4/6/2023 10:04:15 AM	4/6/2023 10:04 AM
Dates	Signed By Date	Insert	New Registration			4/6/2023 10:04 AM
Dates	Start Date	Insert	New Registration			4/6/2023 10:04 AM
Terminations	Termination Comments	Insert	New Registration			4/6/2023 10:04 AM
Terminations	Termination Date	Insert	New Registration			4/6/2023 10:04 AM
Terminations	Termination Effective Date	Insert	New Registration			4/6/2023 10:04 AM
Terminations	Termination Reason	Insert	New Registration			4/6/2023 10:04 AM