Covered Entity Details

DSH490045G UVA HEALTH PRINCE WILLIAM MEDICAL CENTER (Active) - information as of 5/19/2025 12:53:39 AM

Main Details

Name

UVA HEALTH PRINCE WILLIAM MEDICAL CENTER

Subdivision Name

PWMC Mobile Mammography - 3159 - Mammography

Type

Disproportionate Share Hospital

Rural

340B ID

DSH490045G

Medicare Provider Number

490045

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/8/2024

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

UVA Health System
Brian Wilmoth, Strategic Planning and Reimbursement Officer
(434) 243-9802

Primary Contact

UVA Health System
Jordan T DeAngelis, Director Pharmacy
(434) 982-1950

Addresses

Street Address

8700 Sudley Road
Manassas, VA 20110

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
MD	005495000	1417005760
NC	1417005760	1417005760
VA	4900456	1417005760

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
DSH490045A	Child	DSH	PRINCE WILLIAM HOSPITAL DBA NOVANT HEALTH PRINCE WILLIAM MEDICAL	NHUVA O/P ATC - Outpatient Addiction Treatment Center	8680 Hospital Way	Manassas	VA	Terminated
DSH490045B	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	Ancillary Sleep/Neuro - 3156	8640 Sudley Rd, Building 2	Manassas	VA	Active
DSH490045C	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	NHUVA OP Wound Care - Outpatient Wound Care	8644 Sudley Rd	Manassas	VA	Terminated
DSH490045D	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	NHUVA Diabetes Center - UVA - Diabetes Center	8640 Sudley Rd, Building 2	Manassas	VA	Terminated
DSH490045E	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	Cardiac Rehab - 5108 - Cardiac Rehab	8640 Sudley Road	Manassas	VA	Terminated
DSH490045F	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	Outpatient Behavioral HEalth - 3219 - Behavorial Health	8644 Sudley Road	Manassas	VA	Active
DSH490045G	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	PWMC Mobile Mammography - 3159 - Mammography	8700 Sudley Road	Manassas	VA	Active
DSH490045H	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	Med Onc Gainesville - 3184 - Oncology Clinic	7901 Lake Manassas Drive	Gainsville	VA	Active
DSH490045J	Child	DSH	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	Rad Onc Gainesville - 3185 - Oncology Clinic	7901 Lake Manassas Drive	Gainsville	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/12/2024 9:39:13 AM	8/12/2024 9:39 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Wilmoth, Brian Strategic Planning and Reimbursement Officer UVA Health System 4342439802	5/8/2024 8:07 AM
Details	340B ID	Update	New Registration		DSH490045G	5/8/2024 8:07 AM
Details	Entity Name	Update	New Registration	UVA HEALTH PRINCE WILLIAM MEDICAL	UVA HEALTH PRINCE WILLIAM MEDICAL CENTER	5/8/2024 8:07 AM
Details	Entity Subname	Update	New Registration	PWMC Mobile Mammography - 3159	PWMC Mobile Mammography - 3159 - Mammography	5/8/2024 8:07 AM
Dates	Participating Approval Date	Update	New Registration		5/8/2024 8:07:12 AM	5/8/2024 8:07 AM
Details	State	Update	New Registration	Pending	Approved	5/8/2024 8:07 AM
Dates	Signed By Date	Update	New Registration		4/15/2024 2:01:26 PM	5/8/2024 8:07 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	5/8/2024 8:07 AM
Addresses	Main Address	Insert	New Registration		8700 Sudley Road Manassas, VA 20110	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		005495000	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1417005760	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4900456	4/15/2024 1:59 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	4/15/2024 1:59 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417005760	4/15/2024 1:59 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/15/2024 1:59 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417005760	4/15/2024 1:59 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	4/15/2024 1:59 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417005760	4/15/2024 1:59 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/15/2024 1:59 PM
Contacts	Authorizing Official	Insert	New Registration		Wilmoth, Brian Strategic Planning and Reimbursement Officer UVA Health System 4342439802	4/15/2024 1:59 PM
Contacts	Primary Contact	Insert	New Registration		DeAngelis, Jordan T Director Pharmacy UVA Health System 4349821950	4/15/2024 1:59 PM
Details	Assistance Received From Date	Insert	New Registration			4/15/2024 1:59 PM
Details	Assistance Received To Date	Insert	New Registration			4/15/2024 1:59 PM
Details	Last Recertification Date	Insert	New Registration			4/15/2024 1:59 PM
Details	Grant Number	Insert	New Registration			4/15/2024 1:59 PM
Details	340B ID	Insert	New Registration			4/15/2024 1:59 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2024 1:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2024 1:59 PM
Details	Medicare Provider Number	Insert	New Registration		490045	4/15/2024 1:59 PM
Details	Entity Name	Insert	New Registration		UVA HEALTH PRINCE WILLIAM MEDICAL	4/15/2024 1:59 PM
Details	NOFO Number	Insert	New Registration			4/15/2024 1:59 PM
Details	Program Code	Insert	New Registration		DSH	4/15/2024 1:59 PM
Details	Entity Subname	Insert	New Registration		PWMC Mobile Mammography - 3159	4/15/2024 1:59 PM
Dates	Participating Approval Date	Insert	New Registration			4/15/2024 1:59 PM
Details	State	Insert	New Registration		Pending	4/15/2024 1:59 PM
Dates	Registration Date	Insert	New Registration		4/15/2024 1:59:43 PM	4/15/2024 1:59 PM
Dates	Signed By Date	Insert	New Registration			4/15/2024 1:59 PM
Dates	Start Date	Insert	New Registration			4/15/2024 1:59 PM
Terminations	Termination Comments	Insert	New Registration			4/15/2024 1:59 PM
Terminations	Termination Date	Insert	New Registration			4/15/2024 1:59 PM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2024 1:59 PM
Terminations	Termination Reason	Insert	New Registration			4/15/2024 1:59 PM