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DSH110161BL Northside Hospital, Inc. (Terminated)
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Main Details
Name
Northside Hospital, Inc.
Subdivision Name
Northside Medical Center Imaging
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110161BL
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
8/26/2019
Termination Date
Termination Reason
7/1/2020
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
6095 Professional Parkway
Suite 101B
Douglasville, GA 30134
Billing Address
Northside Hospital
1000 Johnson Ferry Road
Atlanta, GA 30342
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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