Covered Entity Details

DSH240080CA UNIVERSITY OF MINNESOTA MEDICAL CENTER (Active) - information as of 6/6/2025 12:34:19 PM

Main Details

Name

UNIVERSITY OF MINNESOTA MEDICAL CENTER

Subdivision Name

MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient - Behavioral Health

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240080CA

Medicare Provider Number

240080

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/6/2024

Last Recertification Date

Contacts

Authorizing Official

Fairview Health Services
Trudi Noel Trysla, Chief Legal Officer
(612) 672-6382

Primary Contact

Fairview Health Services
Bryan John Lundberg, VP 340B Program
(218) 340-4695

Addresses

Street Address

525 23rd Ave S
Minneapolis, MN 55454

Billing Address

Fairview Health Services
PO Box 59318
Minneapolis, MN 55459

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
MN		1013994359,1104956929,1427193937,1942345210,1093919482,1063557320,1770628034,1659632743,1649531732,1003289257,1407833643

Shipping Addresses

Shipping Address 1

Department of Pharmacy Riverside
2450 Riverside Ave
Minneapolis, MN 55454

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
DSH240080AA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Physical Med and Rehab Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Gynecologic Cancer Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Diagnostic Imaging Center	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Surgery Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AE	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Outpatient Interventional & Diagnostic Centers	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AF	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Solid Organ Transplant	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AG	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Primary Care Center	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AH	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Dermatology Surgery and Laser Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AJ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Cardiology Clinics	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AK	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Derm Rheumatology Clinic	909 Fulton Street SE	Minneapolis	MN	Terminated
DSH240080AL	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Blood and Marrow Transplant Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AM	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medicine Specialty Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AN	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Bleeding and Clotting Disorders	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AP	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Infectious Disease Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080AQ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Ear, Nose, and Throat Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AR	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Eye Clinics	516 Delaware St. SE	Minneapolis	MN	Active
DSH240080AS	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric ENT Clinics	701 25th Ave S	Minneapolis	MN	Active
DSH240080AT	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	University Specialists in Women's Health	606 24th Ave S	Minneapolis	MN	Active
DSH240080AU	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Eye Clinics	701 25th Ave S	Minneapolis	MN	Active
DSH240080AV	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Palliative Care Clinic	516 Delaware St. SE	Minneapolis	MN	Terminated
DSH240080AW	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Lakes Cancer Infusion Center	5200 Fairview Blvd	Wyoming	MN	Terminated
DSH240080AX	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Southdale Cancer Clinic and Infusion	6363 France Ave So	Edina	MN	Active
DSH240080AY	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Autism Clinic	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080AZ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Aphaeresis Blood Donation	2450 Riverside Ave	Minneapolis	MN	Terminated
DSH240080BA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Emergency Room	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Emergency Room	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Electroconvulsive Therapy	525 23rd Ave. South	Minneapolis	MN	Active
DSH240080BD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Psychiatric Emergency Room	2312 S. 6th Street	Minneapolis	MN	Terminated
DSH240080BE	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Ridges Cancer Clinic and Infusion	14101 Fairview Drive Suite 200	Burnsville	MN	Active
DSH240080BF	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Advanced Treatment Center - Apheresis	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BG	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Center for Lung Science	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BH	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Hepatology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BJ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Nephrology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BK	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Rheumatology Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BL	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Multiple Sclerosis & Neuro Specialty Clinic	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BM	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Riverside Operating Suites - Same Day Surgery	2450 Riverside Ave.	Minneapolis	MN	Active
DSH240080BN	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Sedation - Pediatrics	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080BP	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Riverside CT Scan - Imaging Services	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080BQ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Sleep Center - Sleep Medicine	606 24th Avenue South	Minneapolis	MN	Terminated
DSH240080BR	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Breast Center - Oncology	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BS	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Interventional Radiology - Interventional Imaging	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080BT	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Voyager Pediatric Specialty Clinic - Pediatric	2512 South 7th Street	Minneapolis	MN	Active
DSH240080BU	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Rheumatology - Rheumatology	606 24th Avenue South	Minneapolis	MN	Active
DSH240080BV	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMCH Heart Catheterization - Pediatric Cardiac Cath Lab	2450 RIVERSIDE AVE	Minneapolis	MN	Active
DSH240080BW	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medication Management Clinic - Medication Therapy Management	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080BX	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Maple Grove Cancer Infusion - Infusion Therapy	14500 99th Avenue North	Maple Grove	MN	Active
DSH240080BY	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	M Health Fairview UMMC Pre Anesthesia Clinic - Surgery	2450 Riverside Ave	Minneapolis	MN	ToBeTerminated
DSH240080BZ	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	MHealth Fairview Mental Health and Addiction Clinic - CD Adult Eval - Behavioral Health	2312 SOUTH 6TH STREET	Minneapolis	MN	Active
DSH240080CA	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient - Behavioral Health	525 23rd Ave S	Minneapolis	MN	Active
DSH240080CB	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Maternal Fetal Med Clinic - Maternal Fetal Medicine	606 24TH AVE S	Minneapolis	MN	Active
DSH240080CC	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Maple Grove Cancer Clinic - Oncology	14500 99th Avenue North	Maple Grove	MN	Active
DSH240080CD	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Medication Management Clinic Riverside - Medication Therapy Management	2450 Riverside Avenue	Minneapolis	MN	Active
DSH240080J	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	ADVANCED TREATMENT CENTER	909 FULTON ST. SE	MINNEAPOLIS	MN	Active
DSH240080K	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Lakes Cancer Clinic and Infusion	5200 Fairview Blvd	Wyoming	MN	Active
DSH240080L	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Psychiatry Clinics	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080M	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Explorer Clinic	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080N	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Dialysis Clinic	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080P	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Journey Clinic and Infusion	2450 Riverside Ave	Minneapolis	MN	Active
DSH240080Q	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Behavioral Health Services	2312 S. 6th Street	Minneapolis	MN	Active
DSH240080R	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pediatric Discovery Clinic	2512 S 7th St	Minneapolis	MN	Active
DSH240080S	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Orthopaedic Clinic	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080T	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC-Fairview Rehabilitation Services	2512 S 7th St	Minneapolis	MN	Terminated
DSH240080U	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	UMMC Fairview Adult Infusion Clinic	606 24th Ave So	Minneapolis	MN	Active
DSH240080V	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Prostate, Urologic & Dialysis	420 Delaware St SE	Minneapolis	MN	Terminated
DSH240080W	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Cancer Clinics	909 Fulton Street SE	Minneapolis	MN	Active
DSH240080X	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Masonic Infusion Center	424 Harvard St. SE	Minneapolis	MN	Terminated
DSH240080Y	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Neurology Clinics	516 Delaware St SE	Minneapolis	MN	Terminated
DSH240080Z	Child	DSH	UNIVERSITY OF MINNESOTA MEDICAL CENTER	Pain Management Clinics	516 Delaware St. SE	Minneapolis	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan John 340B Program Director Fairview Health Services 2183404695	Lundberg, Bryan John VP 340B Program Fairview Health Services 2183404695	3/24/2025 12:48 PM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Trysla, Trudi Noel Chief Legal Officer Fairview Health Services 6126726382	8/6/2024 7:26 AM
Details	340B ID	Update	New Registration		DSH240080CA	8/6/2024 7:26 AM
Details	Entity Subname	Update	New Registration	MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient	MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient - Behavioral Health	8/6/2024 7:26 AM
Dates	Participating Approval Date	Update	New Registration		8/6/2024 7:26:25 AM	8/6/2024 7:26 AM
Details	State	Update	New Registration	Pending	Approved	8/6/2024 7:26 AM
Dates	Signed By Date	Update	New Registration		8/2/2024 11:49:51 AM	8/6/2024 7:26 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/6/2024 7:26 AM
Addresses	Main Address	Insert	New Registration		525 23rd Ave S Minneapolis, MN 55454	7/11/2024 2:30 PM
Addresses	Billing Address	Insert	New Registration		Fairview Health Services PO Box 59318 Minneapolis, MN 55459	7/11/2024 2:30 PM
Addresses	Shipping Address	Insert	New Registration		Department of Pharmacy Riverside 2450 Riverside Ave Minneapolis, MN 55454	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013994359	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104956929	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427193937	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942345210	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093919482	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063557320	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770628034	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659632743	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649531732	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1003289257	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1407833643	7/11/2024 2:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	7/11/2024 2:30 PM
Contacts	Authorizing Official	Insert	New Registration		Trysla, Trudi Noel Chief Legal Officer Fairview Health Services 6126726382	7/11/2024 2:30 PM
Contacts	Primary Contact	Insert	New Registration		Lundberg, Bryan John 340B Program Director Fairview Health Services 2183404695	7/11/2024 2:30 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 2:30 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 2:30 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 2:30 PM
Details	Grant Number	Insert	New Registration			7/11/2024 2:30 PM
Details	340B ID	Insert	New Registration			7/11/2024 2:30 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 2:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 2:30 PM
Details	Medicare Provider Number	Insert	New Registration		240080	7/11/2024 2:30 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF MINNESOTA MEDICAL CENTER	7/11/2024 2:30 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 2:30 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 2:30 PM
Details	Entity Subname	Insert	New Registration		MHealth Fairview Mental Health and Addiction Clinic - MH Senior Intensive Outpatient	7/11/2024 2:30 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 2:30 PM
Details	State	Insert	New Registration		Pending	7/11/2024 2:30 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 2:30:54 PM	7/11/2024 2:30 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 2:30 PM
Dates	Start Date	Insert	New Registration			7/11/2024 2:30 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 2:30 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 2:30 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 2:30 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 2:30 PM