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DSH110161AS Northside Hospital, Inc. (Terminated)
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Main Details
Name
Northside Hospital, Inc.
Subdivision Name
GCS-Annex
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110161AS
Medicare Provider Number
110161
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/9/2014
Participating Start Date
4/1/2014
Participating Approval Date
2/11/2014
Last Recertification Date
8/30/2016
Termination Date
Termination Reason
10/1/2017
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
1835 Savoy Drive
Suite 104
Atlanta, GA 30341
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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