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DSH110007F PHOEBE PUTNEY MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
PHOEBE PUTNEY MEMORIAL HOSPITAL
Subdivision Name
OUTPATIENT CLINIC AT DOUGHERTY COUNTY JAIL
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH110007F
Medicare Provider Number
110007
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
9/15/2010
Participating Start Date
10/1/2010
Participating Approval Date
9/20/2010
Last Recertification Date
11/13/2017
Termination Date
Termination Reason
10/1/2018
Business decision by the Covered Entity
Contacts
Authorizing Official
Phoebe Putney Memorial Hospital
Brian Church, CFO & CAO
(229) 312-4066
Primary Contact
Phoebe Putney Memorial Hospital
Randy Carver, MANAGER, PHARMACY
(229) 312-0115
Addresses
Street Address
1302 EVELYN AVENUE
ALBANY, GA 31701
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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