Covered Entity Details

DSH370037BS SSM ST ANTHONY HOSPITAL (Active) - information as of 4/23/2025 10:53:41 PM

Main Details

Name

SSM ST ANTHONY HOSPITAL

Subdivision Name

SAPO Healthplex Mustang Pediatrics - Pediatrics

Type

Disproportionate Share Hospital

Rural

340B ID

DSH370037BS

Medicare Provider Number

370037

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2024

Participating Start Date

7/1/2024

Participating Approval Date

6/13/2024

Last Recertification Date

8/31/2024

Contacts

Authorizing Official

- SSM ST ANTHONY HOSPITAL
Shasta Manuel, VP of Finance CFO
(405) 272-7282

Primary Contact

SSM Health
Michelle Nicole Schmitt, Director of Business Operations
(608) 294-6203

Addresses

Street Address

201 S Sara Road
Suite 200
Mustang, OK 73064

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
OK	100699540A	1366545311

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
DSH370037A	Child	DSH	SSM ST ANTHONY HOSPITAL	BONE AND JOINT REPLACE CTR OP OBS	1111 N DEWEY AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AA	Child	DSH	SSM ST ANTHONY HOSPITAL	SSM ST ANTHONY SOUTH DAY TREATMENT CLINIC	2129 SW 59TH STREET	OKLAHOMA CITY	OK	Active
DSH370037AB	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians Healthplex North	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037AC	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Healthplex North ED	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037AD	Child	DSH	SSM ST ANTHONY HOSPITAL	ST ANTHONY PHYSICIANS RHEUMATOLOGY	13401 N WESTERN AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AF	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians Endocrinology	13401 N WESTERN AVE, STE 407	OKLAHOMA CITY	OK	Terminated
DSH370037AG	Child	DSH	SSM ST ANTHONY HOSPITAL	Midtown Surgery Center	1110 N Lee Ave	Oklahoma City	OK	Active
DSH370037AH	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians Neurology Associates	535 NW 9th St	Oklahoma City	OK	Active
DSH370037AJ	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians Pulmonary Clinic	608 NW 9th St	Oklahoma City	OK	Active
DSH370037AK	Child	DSH	SSM ST ANTHONY HOSPITAL	Cancer Specialists of Oklahoma	3525 NW 56th St	Oklahoma City	OK	Active
DSH370037AL	Child	DSH	SSM ST ANTHONY HOSPITAL	BONE AND JOINT HOSPITAL ANESTHESIA - BONE AND JOINT HOSPITAL ANESTHESIA	1111 N DEWEY AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AM	Child	DSH	SSM ST ANTHONY HOSPITAL	Edmond Outpatient Behavioral Health Services	416 W 15th St Building 700	Edmond	OK	Active
DSH370037AN	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Hospital Physical Therapy	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AP	Child	DSH	SSM ST ANTHONY HOSPITAL	SSM St. Anthony South Adolescent Treatment Clinic	2129 SW 59th Street	Oklahoma City	OK	Active
DSH370037AQ	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Hospital Radiology	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AR	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Surgery	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AS	Child	DSH	SSM ST ANTHONY HOSPITAL	BONE AND JOINT PHARMACY - BONE AND JOINT PHARMACY	1111 N DEWEY	OKLAHOMA CITY	OK	Terminated
DSH370037AT	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Acute Care	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AU	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Hospital Healthplex West ED - Emergency Department	3333 Territory Ln	El Reno	OK	Active
DSH370037AV	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Healthplex East Specialists (Neuro Oncology)	3400 S Douglas Blvd	Oklahoma City	OK	Active
DSH370037AW	Child	DSH	SSM ST ANTHONY HOSPITAL	SAS-Partial Hospital / SAP BHS STAGES - SAS-Partial Hospital / SAP BHS STAGES	2129 SW 59th St	OKLAHOMA CITY	OK	Terminated
DSH370037AX	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO MED ONC	1011 N Dewey Ave	OKLAHOMA CITY	OK	Active
DSH370037AY	Child	DSH	SSM ST ANTHONY HOSPITAL	Ortho Sports Med MT / SAPO ORTH SPTS MED MT - Ortho Sports Med MT / SAPO ORTH SPTS MED MT	1110 N Lee Avenue	OKLAHOMA CITY	OK	Terminated
DSH370037AZ	Child	DSH	SSM ST ANTHONY HOSPITAL	Nuclear Med-Heart/Va / SAH HEART & VASC NM - Nuclear Med-Heart/Va / SAH HEART & VASC NM	608 NW 9th	OKLAHOMA CITY	OK	Active
DSH370037B	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians North	6201 N. Santa Fe	Oklahoma City	OK	Active
DSH370037BA	Child	DSH	SSM ST ANTHONY HOSPITAL	BHS Adult / SAH BHS ADULT - BHS Adult / SAH BHS ADULT	2129 S.W. 59th	OKLAHOMA CITY	OK	ToBeTerminated
DSH370037BB	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO ENDO ASSOC-Medical / SAPO ENDO ASSOC - SAPO ENDO ASSOC-Medical / SAPO ENDO ASSOC	1111 N. Lee	Oklahoma City	OK	Terminated
DSH370037BC	Child	DSH	SSM ST ANTHONY HOSPITAL	Healthplx Mustang CT / HPM CT / HPM RADIOLOGY - Healthplx Mustang CT / HPM CT / HPM RADIOLOGY	201 S Sara Rd	MUSTANG	OK	Active
DSH370037BD	Child	DSH	SSM ST ANTHONY HOSPITAL	Healthplex North MRI / HPN MRI - Healthplex North MRI / HPN MRI	13401 N Western Ave	OKLAHOMA CITY	OK	Active
DSH370037BE	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO MWC PAIN / SAPO MWC PAIN - SAPO MWC PAIN / SAPO MWC PAIN	1800 S. Douglas Blvd	Midwest City	OK	Terminated
DSH370037BF	Child	DSH	SSM ST ANTHONY HOSPITAL	HP North IV Therapy / HPN IV THERAPY - HP North IV Therapy / HPN IV THERAPY	13401 N Western Ave	OKLAHOMA CITY	OK	Active
DSH370037BG	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO CARDVASC DISEA / SAPO CARDVASC DISEASE - SAPO CARDVASC DISEA / SAPO CARDVASC DISEASE	608 NW 9th St	Oklahoma City	OK	Terminated
DSH370037BH	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO ORTH SPTS MED MUS / SAPO ORTH SPTS MED MUS - SAPO ORTH SPTS MED MUS / SAPO ORTH SPTS MED MUS	201 S Sara Rd	MUSTANG	OK	Active
DSH370037BJ	Child	DSH	SSM ST ANTHONY HOSPITAL	Cancer Care Pet CT / SAPO CSOO PET\CT - Cancer Care Pet CT / SAPO CSOO PET\CT	3525 NW 56th Street	Oklahoma City	OK	Terminated
DSH370037BK	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Hospital / Anesthesia - Bone and Joint Hospital / Anesthesia	1110 North Lee Avenue	Oklahoma City	OK	Terminated
DSH370037BL	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians' Office / Family Medicine - St. Anthony Physicians' Office / Family Medicine	6201 N. Santa Fe, Suite 2020	Oklahoma City	OK	Terminated
DSH370037BM	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Neurovascular Surgery - Neurovascular Surgery	800 NW 9th St	Oklahoma City	OK	Active
DSH370037BN	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Endocrinology - Endocrinology	6205 N Santa Fe Ave	Oklahoma City	OK	Active
DSH370037BP	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Neurosurgical Oncology - Neurosurgical Oncology	800 NW 9th St	Oklahoma City	OK	Active
DSH370037BQ	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Gastrology MOB 235 - Gastrology	535 NW 9th St	Oklahoma City	OK	Active
DSH370037BR	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Healthplex Mustang Pain Care - Pain	201 S Sara Road	Mustang	OK	Active
DSH370037BS	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Healthplex Mustang Pediatrics - Pediatrics	201 S Sara Road	Mustang	OK	Active
DSH370037BT	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Cardiology Healthplex Mustang - Cardiology	201 S Sara Road	Mustang	OK	Active
DSH370037BU	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Healthplex South Pediatrics - Pediatrics	13500 S Tulsa Dr	Oklahoma City	OK	Active
DSH370037BV	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Sleep Healthplex North - Sleep Medicine	6205 N Santa Fe Ave	Oklahoma City	OK	Active
DSH370037BW	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Pulmonary Healthplex North - Pulmonology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BX	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Pain Healthplex North - Pain	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BY	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Neurology Healthplex North - Neurology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BZ	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Healthplex North Primary Care - Primary Care	13401 N Western Ave	Oklahoma City	OK	Terminated
DSH370037CA	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Cardiology Healthplex North - Cardiology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037D	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians Choctaw	15679 NE 23rd Street	Choctaw	OK	Active
DSH370037E	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Healthplex East Internal Medicine	3400 S. Douglas Blvd.	Oklahoma City	OK	Active
DSH370037F	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Family Medicine Center	1110 N. Lee Ave., Suite 300	OKLAHOMA CITY	OK	Active
DSH370037G	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians Heart and Vascular Clinic	608 N.W. 9th	Oklahoma CIty	OK	Terminated
DSH370037H	Child	DSH	SSM ST ANTHONY HOSPITAL	SSM Health Neurology	800 NW 9th St	Oklahoma City	OK	Active
DSH370037J	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Hematology Oncology Radiation	1011 N. Dewey Ave	Oklahoma City	OK	Active
DSH370037K	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians Heart and Vascular Clinic	608 N.W. 9th St.	Oklahoma City	OK	Active
DSH370037L	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Vascular Associates	608 N.W. 9th St.	Oklahoma City	OK	Terminated
DSH370037M	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Pulmonary Specialty Clinic	6205 N. Santa Fe	Oklahoma CIty	OK	Terminated
DSH370037N	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Family Medicine South	13500 S. Tulsa Dr	Oklahoma City	OK	Active
DSH370037P	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Family Medicine East	3400 S. Douglas	OKLAHOMA CITY	OK	Active
DSH370037Q	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Hospital Healthplex South ED	13500 S. Tulsa Drive	Oklahoma City	OK	Active
DSH370037R	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Healthplex East ED	3400 S. Douglas	Oklahoma City	OK	Active
DSH370037S	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Midtown Pediatrics	608 N.W. 9th	Oklahoma City	OK	Active
DSh370037T	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Behaviorial Medicine	1031 N. Lee Ave	Oklahoma City	OK	Active
DSH370037U	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Shawnee Physicians Shawnee Family Medicine	3214 Kethley Road	Shawnee	OK	Terminated
DSH370037V	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Shawnee Physicians	3315 Kethley Road	Shawnee	OK	Terminated
DSH370037W	Child	DSH	SSM ST ANTHONY HOSPITAL	Saints Pediatric Associates	608 N.W. 9th Street	OKLAHOMA CITY	OK	Terminated
DSH370037X	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Healthplex Mustang ED	201 S Sara Road	Mustang	OK	Active
DSH370037Y	Child	DSH	SSM ST ANTHONY HOSPITAL	SSM HEALTH CARE OF OKLAHOMA, INC./ST ANTHONY PHYSICIANS MUSTANG	201 S Sara Road	Mustang	OK	Active
DSH370037Z	Child	DSH	SSM ST ANTHONY HOSPITAL	ST ANTHONY PHYSICIANS GASTROENTEROLOGY IBD	535 NW 9th St	Oklahoma City	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/31/2024 1:41:47 PM	8/31/2024 1:41 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	6/13/2024 2:12 PM
Details	340B ID	Update	New Registration		DSH370037BS	6/13/2024 2:12 PM
Details	Entity Name	Update	New Registration	ST ANTHONY HOSPITAL	SSM ST ANTHONY HOSPITAL	6/13/2024 2:12 PM
Details	Entity Subname	Update	New Registration	SAPO Healthplex Mustang Pediatrics	SAPO Healthplex Mustang Pediatrics - Pediatrics	6/13/2024 2:12 PM
Dates	Participating Approval Date	Update	New Registration		6/13/2024 2:12:44 PM	6/13/2024 2:12 PM
Details	State	Update	New Registration	Pending	Approved	6/13/2024 2:12 PM
Dates	Signed By Date	Update	New Registration		6/10/2024 3:37:26 PM	6/13/2024 2:12 PM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	6/13/2024 2:12 PM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	5/7/2024 9:40 AM
Addresses	Main Address	Insert	New Registration		201 S Sara Road Suite 200 Mustang, OK 73064	4/10/2024 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2024 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100699540A	4/10/2024 3:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/10/2024 3:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366545311	4/10/2024 3:41 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/10/2024 3:41 PM
Contacts	Authorizing Official	Insert	New Registration		Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	4/10/2024 3:41 PM
Contacts	Primary Contact	Insert	New Registration		Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	4/10/2024 3:41 PM
Details	Assistance Received From Date	Insert	New Registration			4/10/2024 3:41 PM
Details	Assistance Received To Date	Insert	New Registration			4/10/2024 3:41 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2024 3:41 PM
Details	Grant Number	Insert	New Registration			4/10/2024 3:41 PM
Details	340B ID	Insert	New Registration			4/10/2024 3:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2024 3:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2024 3:41 PM
Details	Medicare Provider Number	Insert	New Registration		370037	4/10/2024 3:41 PM
Details	Entity Name	Insert	New Registration		ST ANTHONY HOSPITAL	4/10/2024 3:41 PM
Details	NOFO Number	Insert	New Registration			4/10/2024 3:41 PM
Details	Program Code	Insert	New Registration		DSH	4/10/2024 3:41 PM
Details	Entity Subname	Insert	New Registration		SAPO Healthplex Mustang Pediatrics	4/10/2024 3:41 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2024 3:41 PM
Details	State	Insert	New Registration		Pending	4/10/2024 3:41 PM
Dates	Registration Date	Insert	New Registration		4/10/2024 3:41:26 PM	4/10/2024 3:41 PM
Dates	Signed By Date	Insert	New Registration			4/10/2024 3:41 PM
Dates	Start Date	Insert	New Registration			4/10/2024 3:41 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2024 3:41 PM
Terminations	Termination Date	Insert	New Registration			4/10/2024 3:41 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2024 3:41 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2024 3:41 PM