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DSH110161BF Northside Hospital, Inc. (Terminated)
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Main Details
Name
Northside Hospital, Inc.
Subdivision Name
Alpharetta Pain Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110161BF
Medicare Provider Number
110161
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/14/2016
Participating Start Date
7/1/2016
Participating Approval Date
4/29/2016
Last Recertification Date
8/28/2018
Termination Date
Termination Reason
7/1/2019
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
11975 Morris Road
Suite 125
Alpharetta, GA 30005
Billing Address
Northside Hospital
1000 Johnson Ferry Road
Atlanta, GA 30342
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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