Covered Entity Details

RRC330106-07 NORTH SHORE UNIVERSITY HOSPITAL (Active) - information as of 4/25/2025 5:36:55 PM

Main Details

Name

NORTH SHORE UNIVERSITY HOSPITAL

Subdivision Name

North Shore LIJ Imaging at Garden City

Type

Rural Referral Center

Rural

340B ID

RRC330106-07

Medicare Provider Number

330106

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

7/23/2024

Last Recertification Date

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

711 STEWART AVE
GARDEN CITY, NY 11530-4731

Billing Address

NORTH SHORE UNIVERSITY HOSPITAL
300 Community Drive
Manhasset, NY 11030

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	00245510,02995408,3313980	1366459570,1467695023
OR	210846	1366459570,1467695023
NC	3300106	1366459570,1467695023

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
RRC330106-01	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Center for Advanced Medicine – Urology	450 LAKEVILLE RD	New Hyde Park	NY	Active
RRC330106-02	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH Imaging at Great Neck	611 NORTHERN BLVD	GREAT NECK	NY	Active
RRC330106-03	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	North Shore LIJ Imaging at Great South Bay	620 MAIN ST	ISLIP	NY	Active
RRC330106-04	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Irving Goldman Family Care Center - Internal Medicine	865 NORTHERN BLVD	GREAT NECK	NY	Active
RRC330106-05	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Irving Goldman Family Care Center - Allergy and Immunology	865 NORTHERN BLVD	GREAT NECK	NY	Active
RRC330106-06	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Irving Goldman Family Care Center - OB/GYN Services	865 NORTHERN BLVD	GREAT NECK	NY	Active
RRC330106-07	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	North Shore LIJ Imaging at Garden City	711 STEWART AVE	GARDEN CITY	NY	Active
RRC330106-08	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH Imaging at Huntington	284 PULASKI RD	GREENLAWN	NY	Active
RRC330106-09	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	The NSUH Imaging Center at Smithtown	226 MIDDLE COUNTRY RD	SMITHTOWN	NY	Active
RRC330106-10	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Emergency Room	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-11	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Pre-Admission Testing	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-12	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Ambulatory Surgery	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-13	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Radiology at Syosset	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-14	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Dental Clinic	400 Community Drive	Manhasset	NY	Active
RRC330106-15	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Infectious Disease Clinic	400 Community Drive	Manhasset	NY	Active
RRC330106-16	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH LIJ Imaging at Syosset	100 LAFAYETTE DR	SYOSSET	NY	Active
RRC330106-17	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	Center for Advanced Medicine - Imaging	450 LAKEVILLE RD	Lake Success	NY	Active
RRC330106-18	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH Comprehensive Wound Care Center and Vascular Access Program	1999 Marcus Ave	Lake Success	NY	Active
RRC330106-19	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH Sleep Studies Center	100 Community Drive	Great Neck	NY	Active
RRC330106-20	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Electroconvulsive therapy	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-21	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - OPHTHALMOLOGY	221 JERICHO TPKE	SYOSSET	NY	Active
RRC330106-22	Child	RRC	NORTH SHORE UNIVERSITY HOSPITAL	NSUH AT SYOSSET - Pain management	221 JERICHO TPKE	SYOSSET	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	03313980 (NY)		1/14/2025 11:03 AM
Details	Entity Subname	Update	Change Request	NORTH SHORE UNIVERSITY HOSPITAL - Imaging at Garden City	North Shore LIJ Imaging at Garden City	10/22/2024 7:19 AM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/30/2024 1:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		3313980	9/30/2024 1:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	9/30/2024 1:13 PM
Contacts	Signed By	Insert	New Registration		Cusack, Michele L Executive Vice President Northwell Health 5163216058	7/23/2024 8:42 AM
Details	340B ID	Update	New Registration		RRC330106-07	7/23/2024 8:42 AM
Details	Entity Subname	Update	New Registration	NORTH SHORE UNIVERSITY HOSPITAL	NORTH SHORE UNIVERSITY HOSPITAL - Imaging at Garden City	7/23/2024 8:42 AM
Dates	Participating Approval Date	Update	New Registration		7/23/2024 8:42:06 AM	7/23/2024 8:42 AM
Details	State	Update	New Registration	Pending	Approved	7/23/2024 8:42 AM
Dates	Signed By Date	Update	New Registration		7/11/2024 1:32:28 PM	7/23/2024 8:42 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	7/23/2024 8:42 AM
Addresses	Main Address	Insert	New Registration		711 STEWART AVE GARDEN CITY, NY 11530-4731	7/11/2024 1:32 PM
Addresses	Billing Address	Insert	New Registration		NORTH SHORE UNIVERSITY HOSPITAL 300 Community Drive Manhasset, NY 11030	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00245510	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02995408	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03313980	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		210846	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3300106	7/11/2024 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366459570	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467695023	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366459570	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467695023	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366459570	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/11/2024 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467695023	7/11/2024 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/11/2024 1:32 PM
Contacts	Primary Contact	Insert	New Registration		Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	7/11/2024 1:32 PM
Contacts	Authorizing Official	Insert	New Registration		Cusack, Michele L Executive Vice President Northwell Health 5163216058	7/11/2024 1:32 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 1:32 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 1:32 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 1:32 PM
Details	Grant Number	Insert	New Registration			7/11/2024 1:32 PM
Details	340B ID	Insert	New Registration			7/11/2024 1:32 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 1:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 1:32 PM
Details	Medicare Provider Number	Insert	New Registration		330106	7/11/2024 1:32 PM
Details	Entity Name	Insert	New Registration		NORTH SHORE UNIVERSITY HOSPITAL	7/11/2024 1:32 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 1:32 PM
Details	Program Code	Insert	New Registration		RRC	7/11/2024 1:32 PM
Details	Entity Subname	Insert	New Registration		NORTH SHORE UNIVERSITY HOSPITAL	7/11/2024 1:32 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 1:32 PM
Details	State	Insert	New Registration		Pending	7/11/2024 1:32 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 1:32:23 PM	7/11/2024 1:32 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 1:32 PM
Dates	Start Date	Insert	New Registration			7/11/2024 1:32 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 1:32 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 1:32 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 1:32 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 1:32 PM