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DSH110087K Northside Hospital Gwinnett (Terminated)
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Main Details
Name
Northside Hospital Gwinnett
Subdivision Name
Gwinnett Breast Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110087K
Medicare Provider Number
110087
Outpatient Facility Provider Number
110087
Additional Details
Current Program Status
Terminated
Registration Date
4/14/2014
Participating Start Date
7/1/2014
Participating Approval Date
5/9/2014
Last Recertification Date
8/14/2023
Termination Date
Termination Reason
4/1/2024
DSH percentage below statutory minimum
Contacts
Authorizing Official
Northside Hospital, Inc.
Scott Wade, VP Finance
(404) 303-3381
Primary Contact
Northside Hospital Gwinnett
Michael James Naughton, Director of Pharmacy
(678) 312-4541
Addresses
Street Address
631 Professional Drive
Suite 250
Lawrenceville, GA 30046-3370
Billing Address
Gwinnett Hospital System, Inc
PO Box 1190
Lawrenceville, GA 30046-1190
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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