Covered Entity Details

DSH050045F EL CENTRO REGIONAL MEDICAL CENTER (Active) - information as of 4/25/2025 6:32:33 PM

Main Details

Name

EL CENTRO REGIONAL MEDICAL CENTER

Subdivision Name

Multispecialty - Women's Health

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050045F

Medicare Provider Number

050045

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2024

Participating Start Date

10/1/2024

Participating Approval Date

7/19/2024

Last Recertification Date

Contacts

Authorizing Official

ECRMC
David Momberg, CFO
(858) 208-7724

Primary Contact

EL CENTRO REGIONAL MEDICAL CENTER
Nghiem Ngoc Linh, pharmacist
(760) 339-7180

Addresses

Street Address

1415 Ross Ave.
El Centro, CA 92243

Billing Address

El Centro Regional Medical Center
1415 Ross Ave.
El Centro, CA 92243

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
CA	RHM18518F,RHM18536F,ZZT30045F,ZZT40045F	1144300476,1598840258,1861409823

Shipping Addresses

Shipping Address 1

El Centro Regional Medical Center
1415 Ross Ave.
El Centro, CA 92243

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
DSH050045A	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	El Centro Regional Medical Center Outpatient Clinic	385 West Main Street	El Centro	CA	Active
DSH050045B	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	Calexico Outpatient Center	495 Birch Street	Calexico	CA	Active
DSH050045C	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	Imperial Valley Wound Healing Center	1271 Ross Avenue, Suite C	El Centro	CA	Active
DSH050045D	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	ECRMC Oncology, Hematology & Infusion Center	1271 Ross Avenue	El Centro	CA	Active
DSH050045E	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	ECRMC Specialty Health Center - Specialty Services	1271 Ross Avenue	El Centro	CA	Active
DSH050045F	Child	DSH	EL CENTRO REGIONAL MEDICAL CENTER	Multispecialty - Women's Health	1415 Ross Ave.	El Centro	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Duong, Vu Pharmacy Director El Centro Regional Medical Center 7603397180	Linh, Nghiem Ngoc pharmacist EL CENTRO REGIONAL MEDICAL CENTER 7603397180	3/18/2025 12:56 PM
Contacts	Primary Contact	Update	PC Change Request	BALOG, BRUCE PHARMACIST IN CHARGE El Centro Regional Medical Center 7603397180	Duong, Vu Pharmacy Director El Centro Regional Medical Center 7603397180	10/28/2024 12:10 PM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Momberg, David CFO ECRMC 8582087724	7/19/2024 8:08 AM
Details	340B ID	Update	New Registration		DSH050045F	7/19/2024 8:08 AM
Details	Entity Subname	Update	New Registration	Multispecialty	Multispecialty - Women's Health	7/19/2024 8:08 AM
Dates	Participating Approval Date	Update	New Registration		7/19/2024 8:08:35 AM	7/19/2024 8:08 AM
Details	State	Update	New Registration	Pending	Approved	7/19/2024 8:08 AM
Dates	Signed By Date	Update	New Registration		7/18/2024 11:10:45 AM	7/19/2024 8:08 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	7/19/2024 8:08 AM
Addresses	Main Address	Insert	New Registration		1415 Ross Ave. El Centro, CA 92243	7/12/2024 5:25 PM
Addresses	Billing Address	Insert	New Registration		El Centro Regional Medical Center 1415 Ross Ave. El Centro, CA 92243	7/12/2024 5:25 PM
Addresses	Shipping Address	Insert	New Registration		El Centro Regional Medical Center 1415 Ross Ave. El Centro, CA 92243	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		RHM18518F	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		RHM18536F	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZT30045F	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZT40045F	7/12/2024 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144300476	7/12/2024 5:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598840258	7/12/2024 5:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1861409823	7/12/2024 5:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	7/12/2024 5:25 PM
Contacts	Primary Contact	Insert	New Registration		BALOG, BRUCE PHARMACIST IN CHARGE El Centro Regional Medical Center 7603397180	7/12/2024 5:25 PM
Contacts	Authorizing Official	Insert	New Registration		Momberg, David CFO ECRMC 8582087724	7/12/2024 5:25 PM
Details	Assistance Received From Date	Insert	New Registration			7/12/2024 5:25 PM
Details	Assistance Received To Date	Insert	New Registration			7/12/2024 5:25 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2024 5:25 PM
Details	Grant Number	Insert	New Registration			7/12/2024 5:25 PM
Details	340B ID	Insert	New Registration			7/12/2024 5:25 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2024 5:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2024 5:25 PM
Details	Medicare Provider Number	Insert	New Registration		050045	7/12/2024 5:25 PM
Details	Entity Name	Insert	New Registration		EL CENTRO REGIONAL MEDICAL CENTER	7/12/2024 5:25 PM
Details	NOFO Number	Insert	New Registration			7/12/2024 5:25 PM
Details	Program Code	Insert	New Registration		DSH	7/12/2024 5:25 PM
Details	Entity Subname	Insert	New Registration		Multispecialty	7/12/2024 5:25 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2024 5:25 PM
Details	State	Insert	New Registration		Pending	7/12/2024 5:25 PM
Dates	Registration Date	Insert	New Registration		7/12/2024 5:25:46 PM	7/12/2024 5:25 PM
Dates	Signed By Date	Insert	New Registration			7/12/2024 5:25 PM
Dates	Start Date	Insert	New Registration			7/12/2024 5:25 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2024 5:25 PM
Terminations	Termination Date	Insert	New Registration			7/12/2024 5:25 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2024 5:25 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2024 5:25 PM