| Details | Last Recertification Date | Update | Recertification | 1/31/2024 1:42:16 PM | 2/21/2025 11:22:55 AM | 2/21/2025 11:22 AM |
| Details | Last Recertification Date | Update | Recertification | 2/24/2023 1:39:33 PM | 1/31/2024 1:42:16 PM | 1/31/2024 1:42 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 591315200 (MN) | | 2/24/2023 1:39 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1093753782 (MN) | | 2/24/2023 1:39 PM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2022 10:58:48 AM | 2/24/2023 1:39:33 PM | 2/24/2023 1:39 PM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2021 2:00:46 PM | 2/1/2022 10:58:48 AM | 2/1/2022 10:58 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1093753782 ( ) | | 2/15/2021 2:00 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1093753782 | 2/15/2021 2:00 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MN | 2/15/2021 2:00 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2020 10:43:22 AM | 2/15/2021 2:00:46 PM | 2/15/2021 2:00 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 2:06:44 PM | 1/29/2020 10:43:22 AM | 1/29/2020 10:43 AM |
| Details | Last Recertification Date | Update | Recertification | 2/12/2018 10:21:21 AM | 1/29/2019 2:06:44 PM | 1/29/2019 2:06 PM |
| Contacts | Primary Contact | Update | Recertification | Knutson, Steven J.
Executive Director
Neighborhood HealthSource
6122872428 | Gehrke, Cheryl
Director of Clinical Ops
Neighborhood HealthSource
6122872496 | 2/12/2018 10:21 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2017 12:00:00 AM | 2/12/2018 10:21:21 AM | 2/12/2018 10:21 AM |
| Details | Entity Subname | Update | Recertification | SHERIDAN WOMEN & CHILDREN CLINIC | SHERIDAN CLINIC | 2/12/2018 10:21 AM |
| Contacts | Authorizing Official | Update | | Knutson, Steven J.
Executive Director
6122872428 | Knutson, Steven J.
Executive Director
Neighborhood HealthSource
6122872428 | 9/26/2017 2:51 PM |
| Contacts | Primary Contact | Update | | Knutson, Steven J.
Executive Director
6122872428 | Knutson, Steven J.
Executive Director
Neighborhood HealthSource
6122872428 | 9/26/2017 2:51 PM |
| Addresses | Main Address | Insert | | |
342 13th Ave NE
Minneapolis, MN 55413-1265 | 1/30/2017 3:22 PM |
| Contacts | Authorizing Official | Update | | JANKOWSKI, RON
CHIEF MEDICAL OFFICER
6127813837 | Knutson, Steven J.
Executive Director
6122872428 | 1/30/2017 3:22 PM |
| Contacts | Primary Contact | Update | | JANKOWSKI, RON
CHIEF MEDICAL OFFICER
6127813837 | Knutson, Steven J.
Executive Director
6122872428 | 1/30/2017 3:22 PM |
| Details | Last Recertification Date | Update | | 2/29/2016 12:00:00 AM | 1/30/2017 12:00:00 AM | 1/30/2017 3:22 PM |
| Details | Last Recertification Date | Update | | 3/4/2015 12:00:00 AM | 2/29/2016 12:00:00 AM | 2/29/2016 10:50 AM |
| Details | Last Recertification Date | Update | | 3/19/2014 12:00:00 AM | 3/4/2015 12:00:00 AM | 3/4/2015 1:02 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 3/19/2014 12:40 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 591315200 | 3/19/2014 12:40 PM |
| Medicaid Billing | Medicaid: State | Insert | | | MN | 3/19/2014 12:40 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1093753782 | 3/19/2014 12:40 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/19/2014 12:00:00 AM | 3/19/2014 12:40 PM |
| Details | Entity Name | Update | | Neighborhood HealthSource | NEIGHBORHOOD HEALTHSOURCE | 3/19/2014 12:40 PM |
| Details | Entity Subname | Update | | SHERIDAN CLINIC | SHERIDAN WOMEN & CHILDREN CLINIC | 3/19/2014 12:40 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/4/2013 8:17 AM |
| Details | Entity Subname | Update | | SHERIDAN WOMEN & CHILDRENS CLINIC | SHERIDAN CLINIC | 1/30/2013 8:08 AM |
| Contacts | Authorizing Official | Insert | | | JANKOWSKI, RON
CHIEF MEDICAL OFFICER
6127813837 | 1/14/2013 12:18 PM |
| Contacts | Primary Contact | Insert | | | JANKOWSKI, RON
CHIEF MEDICAL OFFICER
6127813837 | 1/14/2013 12:18 PM |
| Details | Entity Name | Update | | FREMONT COMMUNITY HEALTH SERVICES, INC. | Neighborhood HealthSource | 9/30/2011 11:34 AM |
| Details | Last Recertification Date | Insert | | | | 1/21/2010 1:14 PM |
| Details | Grant Number | Insert | | | H80CS00516 | 1/21/2010 1:14 PM |
| Details | 340B ID | Insert | | | CH05675A | 1/21/2010 1:14 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/21/2010 1:14 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/21/2010 1:14 PM |
| Details | Medicare Provider Number | Insert | | | | 1/21/2010 1:14 PM |
| Details | Entity Name | Insert | | | FREMONT COMMUNITY HEALTH SERVICES, INC. | 1/21/2010 1:14 PM |
| Details | Program Code | Insert | | | CH | 1/21/2010 1:14 PM |
| Details | Entity Subname | Insert | | | SHERIDAN WOMEN & CHILDRENS CLINIC | 1/21/2010 1:14 PM |
| Dates | Participating Approval Date | Insert | | | 1/21/2010 12:00:00 AM | 1/21/2010 1:14 PM |
| Details | State | Insert | | | Active | 1/21/2010 1:14 PM |
| Dates | Registration Date | Insert | | | 4/1/2003 12:00:00 AM | 1/21/2010 1:14 PM |
| Dates | Signed By Date | Insert | | | | 1/21/2010 1:14 PM |
| Dates | Start Date | Insert | | | 4/1/2003 12:00:00 AM | 1/21/2010 1:14 PM |
| Terminations | Termination Comments | Insert | | | | 1/21/2010 1:14 PM |
| Terminations | Termination Date | Insert | | | | 1/21/2010 1:14 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/21/2010 1:14 PM |
| Terminations | Termination Reason | Insert | | | | 1/21/2010 1:14 PM |
| Details | Comments Public | Insert | | | 12/22/05 UPDATED ENTITY NAME | 1/21/2010 1:14 PM |