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DSH110161AX Northside Hospital, Inc. (Terminated)
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Main Details
Name
Northside Hospital, Inc.
Subdivision Name
Northside Outpatient Services - 993
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110161AX
Medicare Provider Number
110161
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/15/2014
Participating Start Date
7/1/2014
Participating Approval Date
5/29/2014
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
993 A-C 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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