Covered Entity Details

DSH330250AC CHAMPLAIN VALLEY PHYSICIANS HOSPITAL (Active) - information as of 4/29/2025 11:49:43 PM

Main Details

Name

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL

Subdivision Name

CHAMPLAIN VALLEY PHYSICIANS HOSPITA - Infectious Disease Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330250AC

Medicare Provider Number

330250

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/7/2024

Last Recertification Date

Contacts

Authorizing Official

Alice Hyde Medical Center/Champlain Valley Physicians Hospital
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065

Primary Contact

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
MELISSA ANNE BRESNAHAN, PHARMACY AND 340B PROGRAM MANAGER
(518) 562-7911

Addresses

Street Address

75 BEEKMAN ST
PLATTSBURGH, NY 12901-1438

Billing Address

Infectious Disease Cllinic
159 Margaret Street
Plattsburgh, NY 12901

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
NY	00318814,00319604,02205434	1033270699,1124189782,1215098876,1376607531,1629282314

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
DSH330250A	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Family Medicine Center	159 Margaret St.	Plattsburgh	NY	Active
DSH330250AA	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Gastroenterology Clinic - Gastroenterology	77 Plaza Boulevard	Plattsburgh	NY	Active
DSH330250AB	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	CHAMPLAIN VALLEY PHYSICIANS HOSPITA - Wound Care Clinic	75 BEEKMAN ST	PLATTSBURGH	NY	Active
DSH330250AC	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	CHAMPLAIN VALLEY PHYSICIANS HOSPITA - Infectious Disease Clinic	75 BEEKMAN ST	PLATTSBURGH	NY	Active
DSH330250B	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Ambulatory Surgery Center	77 Plaza Blvd.	Plattsburgh	NY	Active
DSH330250C	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER	Ology Clinic	206 Cornelia St.	Plattsburgh	NY	Terminated
DSH330250D	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Adult Medicine	23 Hammond Lane	Plattsburgh	NY	Active
DSH330250E	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	CVPH CENTER UROLOGY	15 DEGRANDPRE WAY	PLATTSBURGH	NY	Active
DSH330250F	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Endocrinology Clinic - Endocrinology Clinic	210 Cornelia Street	Plattsburgh	NY	Active
DSH330250G	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Ortho and Sports Medicine Clinic - Ortho and Sports Medicine Clinic	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250H	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Rheumatology Clinic - Rheumatology Clinic	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250J	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Plastic Surgery Clinic - Plastic Surgery Clinic	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250K	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Electrophysiology Clinic - Electrophysiology Clinic	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250L	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Fitzpatrick Cancer Center Clinic - Fitzpatrick Cancer Center Clinic	212 Cornelia Street	Plattsburgh	NY	Active
DSH330250M	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Neurology Clinic - Neurology Clinic	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250N	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	General Surgery Clinic - General Surgery Clinic	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250P	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Interventional Cardiology Clinic - Interventional Cardiology Clinic	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250Q	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Cardiology Clinic - Cardiology Clinic	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250R	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Pulmonology Clinic - Pulmonology Clinic	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250S	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Orthopedic Medicine Clinic - Orthopedic Medicine Clinic	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250T	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Fitzpatrick Cancer Center Infusion - Fitzpatrick Cancer Center Infusion	212 Cornelia Street	Plattsburgh	NY	Active
DSH330250U	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Heart Center - Heart Center	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250V	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Ear Nose Throat Clinic - Ear Nose Throat Clinic	210 Cornelia Street	Plattsburgh	NY	Active
DSH330250W	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Pain Management Clinic - Pain Management	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250X	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Neurosurgery - Neurosurgery	206 Cornelia Street	Plattsburgh	NY	Active
DSH330250Y	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	Dermatology Clinic - Dermatology	214 Cornelia Street	Plattsburgh	NY	Active
DSH330250Z	Child	DSH	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	OB/GYN Clinic - Obstetrics and Gynecology	206 Cornelia Street	Plattsburgh	NY	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		Kollar, Matej Vice President/Chief Financial Officer Alice Hyde Medical Center/Champlain Valley Physicians Hospital 5184818065	8/7/2024 11:46 AM
Details	340B ID	Update	New Registration		DSH330250AC	8/7/2024 11:46 AM
Details	Entity Subname	Update	New Registration	CHAMPLAIN VALLEY PHYSICIANS HOSPITA	CHAMPLAIN VALLEY PHYSICIANS HOSPITA - Infectious Disease Clinic	8/7/2024 11:46 AM
Dates	Participating Approval Date	Update	New Registration		8/7/2024 11:46:06 AM	8/7/2024 11:46 AM
Details	State	Update	New Registration	Pending	Approved	8/7/2024 11:46 AM
Dates	Signed By Date	Update	New Registration		8/6/2024 3:13:56 PM	8/7/2024 11:46 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/7/2024 11:46 AM
Addresses	Main Address	Insert	New Registration		75 BEEKMAN ST PLATTSBURGH, NY 12901-1438	7/11/2024 11:28 AM
Addresses	Billing Address	Insert	New Registration		Infectious Disease Cllinic 159 Margaret Street Plattsburgh, NY 12901	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00318814	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00319604	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02205434	7/11/2024 11:28 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1033270699	7/11/2024 11:28 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124189782	7/11/2024 11:28 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1215098876	7/11/2024 11:28 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1376607531	7/11/2024 11:28 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629282314	7/11/2024 11:28 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 11:28 AM
Contacts	Primary Contact	Insert	New Registration		BRESNAHAN, MELISSA ANNE PHARMACY AND 340B PROGRAM MANAGER CHAMPLAIN VALLEY PHYSICIANS HOSPITAL 5185627911	7/11/2024 11:28 AM
Contacts	Authorizing Official	Insert	New Registration		Kollar, Matej Vice President/Chief Financial Officer Alice Hyde Medical Center/Champlain Valley Physicians Hospital 5184818065	7/11/2024 11:28 AM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 11:28 AM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 11:28 AM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 11:28 AM
Details	Grant Number	Insert	New Registration			7/11/2024 11:28 AM
Details	340B ID	Insert	New Registration			7/11/2024 11:28 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 11:28 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 11:28 AM
Details	Medicare Provider Number	Insert	New Registration		330250	7/11/2024 11:28 AM
Details	Entity Name	Insert	New Registration		CHAMPLAIN VALLEY PHYSICIANS HOSPITAL	7/11/2024 11:28 AM
Details	NOFO Number	Insert	New Registration			7/11/2024 11:28 AM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 11:28 AM
Details	Entity Subname	Insert	New Registration		CHAMPLAIN VALLEY PHYSICIANS HOSPITA	7/11/2024 11:28 AM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 11:28 AM
Details	State	Insert	New Registration		Pending	7/11/2024 11:28 AM
Dates	Registration Date	Insert	New Registration		7/11/2024 11:28:27 AM	7/11/2024 11:28 AM
Dates	Signed By Date	Insert	New Registration			7/11/2024 11:28 AM
Dates	Start Date	Insert	New Registration			7/11/2024 11:28 AM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 11:28 AM
Terminations	Termination Date	Insert	New Registration			7/11/2024 11:28 AM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 11:28 AM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 11:28 AM