Covered Entity Details

RRC230146-34 HENRY FORD HEALTH WYANDOTTE HOSPITAL (Active) - information as of 5/7/2025 10:42:15 PM

Main Details

Name

HENRY FORD HEALTH WYANDOTTE HOSPITAL

Subdivision Name

HENRY FORD MEDICAL CENTER BROWNSTOWN - UROGYNECOLOGY

Type

Rural Referral Center

Rural

Yes

340B ID

RRC230146-34

Medicare Provider Number

230146

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/10/2024

Last Recertification Date

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020

Addresses

Street Address

23050 WEST RD
SUITE 230
BROWNSTOWN, MI 48183

Billing Address
Same as Street Address

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
MI	1892495	1992725352

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
RRC230146-01	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Cardiology	23050 West Road	Brownstown	MI	Terminated
RRC230146-02	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Family Medicine	23050 West Road, Ste 260	Brownstown	MI	Terminated
RRC230146-03	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Oncology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-04	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Orthopedics	2070 Biddle Avenue	Wyandotte	MI	Terminated
RRC230146-05	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Riverside Family Medicine	1640 Fort St, Ste D	Trenton	MI	Terminated
RRC230146-06	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Allen Park - Family Medicine	7226 Allen Road	Allen Park	MI	Terminated
RRC230146-07	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Women's Health	23050 West Road, Ste 210	Brownstown	MI	Terminated
RRC230146-08	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Internal Medicine	15450 Northline Rd, Ste 101	Southgate	MI	Terminated
RRC230146-09	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Northline Women's Health	15675 Northline	Southgate	MI	Terminated
RRC230146-10	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Women's Health/ OBGYN	15356 Trenton Road	Southgate	MI	Terminated
RRC230146-11	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Anesthesiology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-12	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Bariatric Surgery	3333 Biddle Avenue, Suite C	Wyandotte	MI	Active
RRC230146-13	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - OB-GYN	3333 Biddle Avenue, Suite A	Wyandotte	MI	Active
RRC230146-14	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Maternal Fetal/ Perinatology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-15	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Cardiovascular Neurology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-16	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Neuropsychology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-17	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Rockwood Family Medicine	21969 Huron River Rd	Rockwood	MI	Terminated
RRC230146-18	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - OPERATING ROOM	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-19	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - RADIOLOGY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-20	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - EMERGENCY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-21	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - PACU/AMBULATORY SURGERY	23050 West Road	Brownstown	MI	Active
RRC230146-22	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - ANESTHESIA	23050 West Road	Brownstown	MI	Active
RRC230146-23	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - MAMMOGRAPHY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-24	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - PET SCAN	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-25	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - PATHOLOGY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-26	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - ULTRASOUND	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-27	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - Physical Therapy	23050 West Road	Brownstown	MI	Active
RRC230146-28	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - CT Scan	23050 West Road	Brownstown	MI	Active
RRC230146-29	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Wyandotte - Physical Therapy	3323 Biddle Ave	Wyandotte	MI	Active
RRC230146-30	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Wyandotte - Occupational Therapy	3323 Biddle Ave	Wyandotte	MI	Active
RRC230146-31	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - Bone Densitometry	23050 West Road	Brownstown	MI	Active
RRC230146-32	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - SLEEP LAB	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-33	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER WYANDOTTE - SPEECH PATHOLOGY	3323 BIDDLE AVE	WYANDOTTE	MI	Active
RRC230146-34	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - UROGYNECOLOGY	23050 WEST RD	BROWNSTOWN	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/10/2024 1:04 PM
Details	340B ID	Update	New Registration		RRC230146-34	10/10/2024 1:04 PM
Details	Entity Subname	Update	New Registration	HENRY FORD MEDICAL CENTER BROWNSTOWN	HENRY FORD MEDICAL CENTER BROWNSTOWN - UROGYNECOLOGY	10/10/2024 1:04 PM
Dates	Participating Approval Date	Update	New Registration		10/10/2024 1:04:58 PM	10/10/2024 1:04 PM
Details	State	Update	New Registration	Pending	Approved	10/10/2024 1:04 PM
Dates	Signed By Date	Update	New Registration		10/9/2024 2:37:32 PM	10/10/2024 1:04 PM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/10/2024 1:04 PM
Addresses	Main Address	Insert	New Registration		23050 WEST RD SUITE 230 BROWNSTOWN, MI 48183	10/9/2024 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/9/2024 2:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1892495	10/9/2024 2:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	10/9/2024 2:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992725352	10/9/2024 2:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	10/9/2024 2:18 PM
Contacts	Primary Contact	Insert	New Registration		Mansour, Alexander 340B Compliance Officer Henry Ford Hospital 2487230020	10/9/2024 2:18 PM
Contacts	Authorizing Official	Insert	New Registration		Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/9/2024 2:18 PM
Details	Assistance Received From Date	Insert	New Registration			10/9/2024 2:18 PM
Details	Assistance Received To Date	Insert	New Registration			10/9/2024 2:18 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2024 2:18 PM
Details	Grant Number	Insert	New Registration			10/9/2024 2:18 PM
Details	340B ID	Insert	New Registration			10/9/2024 2:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2024 2:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2024 2:18 PM
Details	Medicare Provider Number	Insert	New Registration		230146	10/9/2024 2:18 PM
Details	Entity Name	Insert	New Registration		HENRY FORD HEALTH WYANDOTTE HOSPITAL	10/9/2024 2:18 PM
Details	NOFO Number	Insert	New Registration			10/9/2024 2:18 PM
Details	Program Code	Insert	New Registration		RRC	10/9/2024 2:18 PM
Details	Entity Subname	Insert	New Registration		HENRY FORD MEDICAL CENTER BROWNSTOWN	10/9/2024 2:18 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2024 2:18 PM
Details	State	Insert	New Registration		Pending	10/9/2024 2:18 PM
Dates	Registration Date	Insert	New Registration		10/9/2024 2:18:45 PM	10/9/2024 2:18 PM
Dates	Signed By Date	Insert	New Registration			10/9/2024 2:18 PM
Dates	Start Date	Insert	New Registration			10/9/2024 2:18 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2024 2:18 PM
Terminations	Termination Date	Insert	New Registration			10/9/2024 2:18 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2024 2:18 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2024 2:18 PM