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DSH110161Q Northside Hospital, Inc. (Terminated)
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Main Details
Name
Northside Hospital, Inc.
Subdivision Name
Northside Hospital Outpatient Services
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110161Q
Medicare Provider Number
110161
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/8/2013
Participating Start Date
4/1/2013
Participating Approval Date
3/11/2013
Last Recertification Date
8/30/2016
Termination Date
Termination Reason
7/1/2017
Site closure
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
980 Johnson Ferry Road
Atlanta, GA 30342
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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