Covered Entity Details

DSH110079BA GRADY MEMORIAL HOSPITAL (Active) - information as of 5/9/2025 12:14:59 AM

Main Details

Name

GRADY MEMORIAL HOSPITAL

Subdivision Name

CORRELL PAVILION - Radiology X Ray

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110079BA

Medicare Provider Number

110079

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2024

Participating Start Date

10/1/2024

Participating Approval Date

7/17/2024

Last Recertification Date

Contacts

Authorizing Official

Grady Health System
John Haupert, Chief Executive Officer
(404) 616-4254

Primary Contact

Grady Health System
Kelcy Susannah Freeman, Pharmacy Program Coordinator
(404) 616-5909

Addresses

Street Address

80 GILMER ST SE
ATLANTA, GA 30303

Billing Address

Grady Health System Accounts Payable
50 Hurt Plaza SE
Suite 1300
Atlanta, GA 30303-2946

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
GA	000000855A,000000855C,000679808A,000937307A,000937307B,000937307D,000937307E,000937307F,000937307H,000937307I,003127124A,003213613A,003282215A,00679808,517281744A,556337752A	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
AL	179239,1992799050	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
CO	9000213335	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
CT	008056673,008062220	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
FL	913008000	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
LA	2355414	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
MS	05387022	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
NJ	0063649	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
NY	03061947	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
NC	110079	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
OH	0100489	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
SC	11516A,12050B	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
TN	Q034163	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
WI	1992799050	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050

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
DSH110079A	Child	DSH	GRADY MEMORIAL HOSPITAL	Kirkwood Health Center	1863 Memorial Drive SE	Atlanta	GA	Active
DSH110079AA	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - ENT Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AB	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GYN Oncology	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AC	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Hem-Oncology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AD	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Emergency Care Center	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AE	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpatient Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AF	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Outpatient Rehab	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AG	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Sickle Cell Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AH	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Asthma Ctr-Excellence	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AJ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Cerebral Palsy & Autism Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AK	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Child Abuse Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AL	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - ACT Team	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AM	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Radiology	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AN	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpt Internal Med Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AP	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Appointment Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AQ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Adolescent Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AR	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Respiratory Care	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AS	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY HEALTH SYSTEM - Geriatric Program	1000 White St. SW	ATLANTA	GA	Active
DSH110079AT	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology IR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AU	Child	DSH	GRADY MEMORIAL HOSPITAL	Cascade Outpatient Center - Cascade Road Outpatient Center	3355 Cascade Rd.	Atlanta	GA	Active
DSH110079AV	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology Ultrasound	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AW	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology MRI	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AX	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology OR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AY	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology CT	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AZ	Child	DSH	GRADY MEMORIAL HOSPITAL	CAMP CREEK COMPREHENSIVE CARE CENTE - Ambulatory Care Coordination	3896 PRINCETON LAKES WAY SW	ATLANTA	GA	Active
DSH110079BA	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology X Ray	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BB	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Pre- Post- PACU	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BC	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - GA Aide Mobile Mammo	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BD	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health South Clinic - PSY FC North-South Outpatient	5600 Stonewall Tell Road	College Park	GA	Active
DSH110079BE	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Correll Surgery	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079C	Child	DSH	GRADY MEMORIAL HOSPITAL	East Point Health Center	1595 W Cleveland Ave	East Point	GA	Active
DSH110079D	Child	DSH	GRADY MEMORIAL HOSPITAL	Asa G. Yancey Health Center	1247 Donald Lee Hollowell Pkwy NW	Atlanta	GA	Active
DSH110079F	Child	DSH	GRADY MEMORIAL HOSPITAL	NORTH DEKALB HEALTH CENTER	3807 CLAIRMONT RD, SE	CHAMBLEE	GA	Terminated
DSH110079G	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079H	Child	DSH	GRADY MEMORIAL HOSPITAL	Ponce De Leon Center	341 Ponce De Leon Ave NE	Atlanta	GA	Active
DSH110079L	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health Outpatient Center	10 Park Place NE	Atlanta	GA	Terminated
DSH110079M	Child	DSH	GRADY MEMORIAL HOSPITAL	North Fulton Health Center	7741 Roswell Rd	Sandy Springs	GA	Active
DSH110079N	Child	DSH	GRADY MEMORIAL HOSPITAL	Brookhaven Health Center	2695 Buford Hwy NE	Atlanta	GA	Active
DSH110079P	Child	DSH	GRADY MEMORIAL HOSPITAL	Edward C. Loughlin Radiation-Oncology Center	145 Edgewood Ave SE	Atlanta	GA	Active
DSH110079Q	Child	DSH	GRADY MEMORIAL HOSPITAL	Walk-In Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079R	Child	DSH	GRADY MEMORIAL HOSPITAL	Manuel J. Maloof Imaging Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079S	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Ophthalmology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079T	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Oral Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079U	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Digital Mammography Services	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079V	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079W	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY EMS - Mobile Integrated Health	745 MEMORIAL DR SE	ATLANTA	GA	Active
DSH110079X	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Infusion Center	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Y	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GI Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Z	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Orthopedic Trauma Clinic	80 Gilmer Street SE	Atlanta	GA	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		Haupert, John Chief Executive Officer Grady Health System 4046164254	7/17/2024 12:31 PM
Details	340B ID	Update	New Registration		DSH110079BA	7/17/2024 12:31 PM
Details	Entity Subname	Update	New Registration	CORRELL PAVILION	CORRELL PAVILION - Radiology X Ray	7/17/2024 12:31 PM
Dates	Participating Approval Date	Update	New Registration		7/17/2024 12:31:13 PM	7/17/2024 12:31 PM
Details	State	Update	New Registration	Pending	Approved	7/17/2024 12:31 PM
Dates	Signed By Date	Update	New Registration		7/12/2024 1:54:59 PM	7/17/2024 12:31 PM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	7/17/2024 12:31 PM
Addresses	Main Address	Insert	New Registration		80 GILMER ST SE ATLANTA, GA 30303	7/12/2024 9:20 AM
Addresses	Billing Address	Insert	New Registration		Grady Health System Accounts Payable 50 Hurt Plaza SE Suite 1300 Atlanta, GA 30303-2946	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000855A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000855C	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000679808A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307B	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307D	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307E	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307F	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307H	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307I	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003127124A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003213613A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003282215A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00679808	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		517281744A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		556337752A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		179239	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000213335	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		008056673	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		008062220	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		913008000	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2355414	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		05387022	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0063649	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03061947	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110079	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0100489	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11516A	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		12050B	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q034163	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	7/12/2024 9:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/12/2024 9:20 AM
Contacts	Authorizing Official	Insert	New Registration		Haupert, John Chief Executive Officer Grady Health System 4046164254	7/12/2024 9:20 AM
Contacts	Primary Contact	Insert	New Registration		Freeman, Kelcy Susannah Pharmacy Program Coordinator Grady Health System 4046165909	7/12/2024 9:20 AM
Details	Assistance Received From Date	Insert	New Registration			7/12/2024 9:20 AM
Details	Assistance Received To Date	Insert	New Registration			7/12/2024 9:20 AM
Details	Last Recertification Date	Insert	New Registration			7/12/2024 9:20 AM
Details	Grant Number	Insert	New Registration			7/12/2024 9:20 AM
Details	340B ID	Insert	New Registration			7/12/2024 9:20 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2024 9:20 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2024 9:20 AM
Details	Medicare Provider Number	Insert	New Registration		110079	7/12/2024 9:20 AM
Details	Entity Name	Insert	New Registration		GRADY MEMORIAL HOSPITAL	7/12/2024 9:20 AM
Details	NOFO Number	Insert	New Registration			7/12/2024 9:20 AM
Details	Program Code	Insert	New Registration		DSH	7/12/2024 9:20 AM
Details	Entity Subname	Insert	New Registration		CORRELL PAVILION	7/12/2024 9:20 AM
Dates	Participating Approval Date	Insert	New Registration			7/12/2024 9:20 AM
Details	State	Insert	New Registration		Pending	7/12/2024 9:20 AM
Dates	Registration Date	Insert	New Registration		7/12/2024 9:20:58 AM	7/12/2024 9:20 AM
Dates	Signed By Date	Insert	New Registration			7/12/2024 9:20 AM
Dates	Start Date	Insert	New Registration			7/12/2024 9:20 AM
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