Covered Entity Details

PED443303-02 East Tennessee Children’s Hospital (Active) - information as of 4/29/2025 11:59:18 PM

Main Details

Name

East Tennessee Children’s Hospital

Subdivision Name

Pediatric Neurology - Neurology

Type

Children's Hospital

Rural

340B ID

PED443303-02

Medicare Provider Number

443303

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/11/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/6/2024

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

East Tennessee Childrens Hospital
Caryn Hawthorne, Chief Financial Officer
(865) 541-8154

Primary Contact

East Tennessee Children's Hospital Assoc, Inc
Derek Phillips, Outpatient Pharmacy Manager
(865) 541-8980

Addresses

Street Address

2100 Clinch Avenue
Suite 210
Knoxville, TN 37916

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TN	0443303	1528635455,1760476659,1659139434

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED443303-01	Child	PED	East Tennessee Children’s Hospital	Sevierville Pediatric Pulmonology - Pulmonology	502 Winfield Dunn Pkwy	Sevierville	TN	Active
PED443303-02	Child	PED	East Tennessee Children’s Hospital	Pediatric Neurology - Neurology	2100 Clinch Avenue	Knoxville	TN	Active
PED443303-03	Child	PED	East Tennessee Children’s Hospital	Rehabilitation Services - Main Campus - Physical Therapy	2100 Clinch Avenue	Knoxville	TN	Active
PED443303-04	Child	PED	East Tennessee Children’s Hospital	Pediatric Gastroenterology - Gastroenterology	2100 Clinch Ave	Knoxville	TN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/23/2024 10:41:10 AM	8/23/2024 10:41 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1659139434	4/19/2024 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/19/2024 5:17 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Hawthorne, Caryn Chief Financial Officer East Tennessee Childrens Hospital 8655418154	2/6/2024 12:56 PM
Details	340B ID	Update	New Registration		PED443303-02	2/6/2024 12:56 PM
Details	Entity Subname	Update	New Registration	Pediatric Neurology	Pediatric Neurology - Neurology	2/6/2024 12:56 PM
Dates	Participating Approval Date	Update	New Registration		2/6/2024 12:56:09 PM	2/6/2024 12:56 PM
Details	State	Update	New Registration	Pending	Approved	2/6/2024 12:56 PM
Dates	Signed By Date	Update	New Registration		1/11/2024 5:32:49 PM	2/6/2024 12:56 PM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	2/6/2024 12:56 PM
Addresses	Main Address	Insert	New Registration		2100 Clinch Avenue Suite 210 Knoxville, TN 37916	1/11/2024 4:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/11/2024 4:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0443303	1/11/2024 4:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	1/11/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1528635455	1/11/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	1/11/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760476659	1/11/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	1/11/2024 4:02 PM
Contacts	Authorizing Official	Insert	New Registration		Hawthorne, Caryn Chief Financial Officer East Tennessee Childrens Hospital 8655418154	1/11/2024 4:02 PM
Contacts	Primary Contact	Insert	New Registration		Phillips, Derek Outpatient Pharmacy Manager East Tennessee Children's Hospital Assoc, Inc 8655418980	1/11/2024 4:02 PM
Details	Assistance Received From Date	Insert	New Registration			1/11/2024 4:02 PM
Details	Assistance Received To Date	Insert	New Registration			1/11/2024 4:02 PM
Details	Last Recertification Date	Insert	New Registration			1/11/2024 4:02 PM
Details	Grant Number	Insert	New Registration			1/11/2024 4:02 PM
Details	340B ID	Insert	New Registration			1/11/2024 4:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/11/2024 4:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/11/2024 4:02 PM
Details	Medicare Provider Number	Insert	New Registration		443303	1/11/2024 4:02 PM
Details	Entity Name	Insert	New Registration		East Tennessee Children’s Hospital	1/11/2024 4:02 PM
Details	NOFO Number	Insert	New Registration			1/11/2024 4:02 PM
Details	Program Code	Insert	New Registration		PED	1/11/2024 4:02 PM
Details	Entity Subname	Insert	New Registration		Pediatric Neurology	1/11/2024 4:02 PM
Dates	Participating Approval Date	Insert	New Registration			1/11/2024 4:02 PM
Details	State	Insert	New Registration		Pending	1/11/2024 4:02 PM
Dates	Registration Date	Insert	New Registration		1/11/2024 4:02:48 PM	1/11/2024 4:02 PM
Dates	Signed By Date	Insert	New Registration			1/11/2024 4:02 PM
Dates	Start Date	Insert	New Registration			1/11/2024 4:02 PM
Terminations	Termination Comments	Insert	New Registration			1/11/2024 4:02 PM
Terminations	Termination Date	Insert	New Registration			1/11/2024 4:02 PM
Terminations	Termination Effective Date	Insert	New Registration			1/11/2024 4:02 PM
Terminations	Termination Reason	Insert	New Registration			1/11/2024 4:02 PM