Covered Entity Details

DSH490022W MARY WASHINGTON HOSPITAL (Active) - information as of 4/28/2025 1:44:19 AM

Main Details

Name

MARY WASHINGTON HOSPITAL

Subdivision Name

MW PT PLANK RD - Physical Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH490022W

Medicare Provider Number

490022

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/8/2024

Participating Start Date

10/1/2024

Participating Approval Date

7/10/2024

Last Recertification Date

Contacts

Authorizing Official

Mary Washington Healthcare
Sean Timothy Barden, Executive VP & CFO
(540) 741-1494

Primary Contact

Mary Washington Hospital
John Michael Coggins, Director of Pharmacy
(540) 741-7525

Addresses

Street Address

4900 Plank Road
102
Fredericksburg, VA 22407

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
VA	1942288527	1942288527

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
DSH490022A	Child	DSH	MARY WASHINGTON HOSPITAL	SNOWDEN AT FREDERICKSBURG - SNOWDEN OUTPATIENT PSYCH	1200 SAM PERRY BLVD	FREDERICKSBURG	VA	Active
DSH490022B	Child	DSH	MARY WASHINGTON HOSPITAL	MWH HOME HEALTH - Home Health	2300 Fall Hill Avenue, Suite 401	Fredericksburg	VA	Active
DSH490022C	Child	DSH	MARY WASHINGTON HOSPITAL	MW PEDIATRIC THERAPY - Pediatric Therapy	200 Executive Center Parkway, Suite 106	Fredericksburg	VA	Active
DSH490022D	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL, INC - MW PT LADYSMITH	8051 PROSPERITY WAY	RUTHER GLEN	VA	Active
DSH490022E	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - MW PT CARR DRIVE	4400 CARR DR	FREDERICKSBURG	VA	Active
DSH490022F	Child	DSH	MARY WASHINGTON HOSPITAL	MWH ELECTRONEURODIAG - EEG Lab	1101 Sam Perry Blvd, Suite 411	Fredericksburg	VA	Active
DSH490022G	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - MWH SLEEP LAB	2216 PRINCESS ANNE ST	FREDERICKSBURG	VA	Active
DSH490022H	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL INC. - MWH DIABETES MGMT	4710 SPOTSYLVANIA PKWY	FREDERICKSBURG	VA	Active
DSH490022J	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL INC - MWH ANTICOAG CLINIC	4710 SPOTSYLVANIA PKWY	FREDERICKSBURG	VA	Active
DSH490022K	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL, INC. - MWH RADIATION ONC	1300 HOSPITAL DR	FREDERICKSBURG	VA	Active
DSH490022L	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL, INC. - MWH MATERNAL FETAL	1300 HOSPITAL DR	FREDERICKSBURG	VA	Active
DSH490022M	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - MWH OP INFUSION	405 Chatham Heights Rd	FREDERICKSBURG	VA	Active
DSH490022N	Child	DSH	MARY WASHINGTON HOSPITAL	MWH REHAB SVCS OP - OP rehab/PT	1201 Sam Perry Blvd, Suite 240	Fredericksburg	VA	Active
DSH490022P	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - MWH CARDIO HLTH FIT	1201 SAM PERRY BLVD	FREDERICKSBURG	VA	Active
DSH490022Q	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - MWH FSED LEES HILL	10401 SPOTSYLVANIA AVE	FREDERICKSBURG	VA	Active
DSH490022R	Child	DSH	MARY WASHINGTON HOSPITAL	MARY WASHINGTON HOSPITAL - Wound Clinic	10401 SPOTSYLVANIA AVE	FREDERICKSBURG	VA	Active
DSH490022S	Child	DSH	MARY WASHINGTON HOSPITAL	MWH Trauma - Trauma Surgery	1101 Sam Perry Blvd, Suite 221	Fredericksburg	VA	Terminated
DSH490022T	Child	DSH	MARY WASHINGTON HOSPITAL	GME Internal Medicine - Internal Medicine	1201 Sam Perry Blvd	Fredericksburg	VA	Active
DSH490022U	Child	DSH	MARY WASHINGTON HOSPITAL	GME Family Medicine - Family Medicine	12101 Carol Lane	Fredericksburg	VA	Active
DSH490022V	Child	DSH	MARY WASHINGTON HOSPITAL	MWH CARDIOLOGY ASC - Cardiology	1201 Sam Perry Blvd	Fredericksburg	VA	Active
DSH490022W	Child	DSH	MARY WASHINGTON HOSPITAL	MW PT PLANK RD - Physical Therapy	4900 Plank Road	Fredericksburg	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Barden, Sean Timothy Executive VP & CFO Mary Washington Healthcare 5407411494	7/10/2024 7:58 AM
Details	340B ID	Update	New Registration		DSH490022W	7/10/2024 7:58 AM
Details	Entity Subname	Update	New Registration	MW PT PLANK RD	MW PT PLANK RD - Physical Therapy	7/10/2024 7:58 AM
Dates	Participating Approval Date	Update	New Registration		7/10/2024 7:58:59 AM	7/10/2024 7:58 AM
Details	State	Update	New Registration	Pending	Approved	7/10/2024 7:58 AM
Dates	Signed By Date	Update	New Registration		7/9/2024 3:05:47 PM	7/10/2024 7:58 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	7/10/2024 7:58 AM
Medicaid Billing	Medicaid: Number	Delete	New Registration	4900227 (VA)		7/9/2024 3:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2024 3:05 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1942288527	7/9/2024 3:05 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	7/9/2024 3:05 PM
Addresses	Main Address	Insert	New Registration		4900 Plank Road 102 Fredericksburg, VA 22407	7/8/2024 1:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/8/2024 1:05 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4900227	7/8/2024 1:05 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	7/8/2024 1:05 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942288527	7/8/2024 1:05 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	7/8/2024 1:05 PM
Contacts	Authorizing Official	Insert	New Registration		Barden, Sean Timothy Executive VP & CFO Mary Washington Healthcare 5407411494	7/8/2024 1:05 PM
Contacts	Primary Contact	Insert	New Registration		Coggins, John Michael Director of Pharmacy Mary Washington Hospital 5407417525	7/8/2024 1:05 PM
Details	Assistance Received From Date	Insert	New Registration			7/8/2024 1:05 PM
Details	Assistance Received To Date	Insert	New Registration			7/8/2024 1:05 PM
Details	Last Recertification Date	Insert	New Registration			7/8/2024 1:05 PM
Details	Grant Number	Insert	New Registration			7/8/2024 1:05 PM
Details	340B ID	Insert	New Registration			7/8/2024 1:05 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/8/2024 1:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/8/2024 1:05 PM
Details	Medicare Provider Number	Insert	New Registration		490022	7/8/2024 1:05 PM
Details	Entity Name	Insert	New Registration		MARY WASHINGTON HOSPITAL	7/8/2024 1:05 PM
Details	NOFO Number	Insert	New Registration			7/8/2024 1:05 PM
Details	Program Code	Insert	New Registration		DSH	7/8/2024 1:05 PM
Details	Entity Subname	Insert	New Registration		MW PT PLANK RD	7/8/2024 1:05 PM
Dates	Participating Approval Date	Insert	New Registration			7/8/2024 1:05 PM
Details	State	Insert	New Registration		Pending	7/8/2024 1:05 PM
Dates	Registration Date	Insert	New Registration		7/8/2024 1:05:47 PM	7/8/2024 1:05 PM
Dates	Signed By Date	Insert	New Registration			7/8/2024 1:05 PM
Dates	Start Date	Insert	New Registration			7/8/2024 1:05 PM
Terminations	Termination Comments	Insert	New Registration			7/8/2024 1:05 PM
Terminations	Termination Date	Insert	New Registration			7/8/2024 1:05 PM
Terminations	Termination Effective Date	Insert	New Registration			7/8/2024 1:05 PM
Terminations	Termination Reason	Insert	New Registration			7/8/2024 1:05 PM