Covered Entity Details

DSH110122K SOUTH GEORGIA MEDICAL CENTER (Active) - information as of 4/23/2025 10:51:13 PM

Main Details

Name

SOUTH GEORGIA MEDICAL CENTER

Subdivision Name

SGMC SMITH NORTHVIEW - SNH Wound and Burn Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110122K

Medicare Provider Number

110122

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2023

Participating Start Date

10/1/2023

Participating Approval Date

7/20/2023

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

SGMC
Ronald E Dean, CEO
(229) 259-4102

Primary Contact

SGMC
Scott Bruce Smith, Director of Pharmacy
(229) 259-4870

Addresses

Street Address

4280 N VALDOSTA RD
VALDOSTA, GA 31602-6814

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	000001724A,000001724G	1306896253,1528049046,1144096553
FL	0102075-00,110961700	1306896253,1528049046,1144096553

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
DSH110122A	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	THE SURGERY CENTER	2417 NORTH PATTERSON STREET	VALDOSTA	GA	Active
DSH110122B	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Health Care South	250 Griffin Avenue	Valdosta	GA	Terminated
DSH110122C	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Imaging Center	2409 North Patterson Street	Valdosta	GA	Active
DSH110122D	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Diabetes Management Center	3018 North Patterson Street	Valdosta	GA	Terminated
DSH110122E	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Wound Care	2330 North Ashley Street	Valdosta	GA	Terminated
DSH110122F	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	Smith Northview Hospital	4280 North Valdosta Road	Valdosta	GA	Terminated
DSH110122G	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SmithNorthview Hospital	4280 North Valdosta Road	Valdosta	GA	Active
DSH110122H	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH OR	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122J	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH CT Scan	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122K	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Wound and Burn Care	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122L	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH MRI	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122M	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Endoscopy	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122N	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Infusion	4280 N VALDOSTA RD	VALDOSTA	GA	Active
DSH110122P	Child	DSH	SOUTH GEORGIA MEDICAL CENTER	SGMC SMITH NORTHVIEW - SNH Anesthesia	4280 N VALDOSTA RD	VALDOSTA	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 5:21 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000001724G	8/22/2024 5:21 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/22/2024 5:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 5:21 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110961700	8/22/2024 5:21 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	8/22/2024 5:21 PM
Details	Last Recertification Date	Update	Recertification		8/22/2024 5:21:34 PM	8/22/2024 5:21 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144096553	1/18/2024 1:15 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	1/18/2024 1:15 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144096553	1/18/2024 1:15 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/18/2024 1:15 PM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Dean, Ronald E CEO SGMC 2292594102	7/20/2023 11:23 AM
Details	340B ID	Update	New Registration		DSH110122K	7/20/2023 11:23 AM
Details	Entity Subname	Update	New Registration	SGMC SMITH NORTHVIEW	SGMC SMITH NORTHVIEW - SNH Wound and Burn Care	7/20/2023 11:23 AM
Dates	Participating Approval Date	Update	New Registration		7/20/2023 11:23:12 AM	7/20/2023 11:23 AM
Details	State	Update	New Registration	Pending	Approved	7/20/2023 11:23 AM
Dates	Signed By Date	Update	New Registration		7/14/2023 4:12:56 PM	7/20/2023 11:23 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	7/20/2023 11:23 AM
Addresses	Main Address	Insert	New Registration		4280 N VALDOSTA RD VALDOSTA, GA 31602-6814	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000001724A	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0102075-00	7/11/2023 10:38 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	7/11/2023 10:38 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1306896253	7/11/2023 10:38 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/11/2023 10:38 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528049046	7/11/2023 10:38 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/11/2023 10:38 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1306896253	7/11/2023 10:38 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/11/2023 10:38 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528049046	7/11/2023 10:38 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/11/2023 10:38 AM
Contacts	Primary Contact	Insert	New Registration		Smith, Scott Bruce Director of Pharmacy SGMC 2292594870	7/11/2023 10:38 AM
Contacts	Authorizing Official	Insert	New Registration		Dean, Ronald E CEO SGMC 2292594102	7/11/2023 10:38 AM
Details	Assistance Received From Date	Insert	New Registration			7/11/2023 10:38 AM
Details	Assistance Received To Date	Insert	New Registration			7/11/2023 10:38 AM
Details	Last Recertification Date	Insert	New Registration			7/11/2023 10:38 AM
Details	Grant Number	Insert	New Registration			7/11/2023 10:38 AM
Details	340B ID	Insert	New Registration			7/11/2023 10:38 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2023 10:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2023 10:38 AM
Details	Medicare Provider Number	Insert	New Registration		110122	7/11/2023 10:38 AM
Details	Entity Name	Insert	New Registration		SOUTH GEORGIA MEDICAL CENTER	7/11/2023 10:38 AM
Details	NOFO Number	Insert	New Registration			7/11/2023 10:38 AM
Details	Program Code	Insert	New Registration		DSH	7/11/2023 10:38 AM
Details	Entity Subname	Insert	New Registration		SGMC SMITH NORTHVIEW	7/11/2023 10:38 AM
Dates	Participating Approval Date	Insert	New Registration			7/11/2023 10:38 AM
Details	State	Insert	New Registration		Pending	7/11/2023 10:38 AM
Dates	Registration Date	Insert	New Registration		7/11/2023 10:38:34 AM	7/11/2023 10:38 AM
Dates	Signed By Date	Insert	New Registration			7/11/2023 10:38 AM
Dates	Start Date	Insert	New Registration			7/11/2023 10:38 AM
Terminations	Termination Comments	Insert	New Registration			7/11/2023 10:38 AM
Terminations	Termination Date	Insert	New Registration			7/11/2023 10:38 AM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2023 10:38 AM
Terminations	Termination Reason	Insert	New Registration			7/11/2023 10:38 AM