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DSH110143F WELLSTAR COBB HOSPITAL (Terminated)
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Main Details
Name
WELLSTAR COBB HOSPITAL
Subdivision Name
WellStar Cobb Outpatient / Burn Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110143F
Medicare Provider Number
110143
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/4/2017
Participating Start Date
4/1/2017
Participating Approval Date
2/28/2017
Last Recertification Date
8/28/2018
Termination Date
Termination Reason
4/1/2019
Outpatient facility moved within the 4 walls of the parent hospital
Contacts
Authorizing Official
Wellstar Cobb Hospital
Heath Austin King, CFO
(470) 732-5039
Primary Contact
WellStar Cobb Hospital
Amir Emamifar, Director of Pharmacy
(470) 732-4151
Addresses
Street Address
1605 Milkey Road Suite A
Austell, GA 30103
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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