Covered Entity Details

DSH330033X CHENANGO MEMORIAL HOSPITAL (Active) - information as of 5/5/2025 11:59:48 PM

Main Details

Name

CHENANGO MEMORIAL HOSPITAL

Subdivision Name

UHS CMH-GASTROENTEROLOGY - GASTROENTEROLOGY

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330033X

Medicare Provider Number

330033

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/10/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/21/2024

Last Recertification Date

Contacts

Authorizing Official

Chenango Memorial Hospital, Inc.
Desiree A Axley, Vice President Finance & CFO
(607) 373-6912

Primary Contact

United Health Services Hospitals, Inc
Ryan C. Decaro, Pharmacy Business Manager
(607) 763-1838

Addresses

Street Address

4 Newton Ave
Norwich, NY 13815

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
NY	00314723	1770593956

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
DSH330033A	Child	DSH	CHENANGO MEMORIAL HOSPITAL	CMH DENTAL CENTER / Dental	32 CONKEY AVE	NORWICH	NY	Terminated
DSH330033B	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS PRIM CARE SHERBURNE-FAMILY PRACTICE	38-A CLASSIC ST	SHERBURNE	NY	Active
DSH330033C	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS PRIM CARE OXFORD-FAMILY PRACTICE	21N CANAL ST	OXFORD	NY	Active
DSH330033Q	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS PRIM CARE SIDNEY-FAMILY PRACTICE	44 Pearl Street	Sidney	NY	Active
DSH330033R	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS PRIM CARE NORWICH-PEDIATRICS	4 Newton Ave	Norwich	NY	Active
DSH330033S	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS CMH-SURGERY	4 Newton Ave	Norwich	NY	Active
DSH330033T	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS CMH-ORTHOPEDICS	4 Newton Ave	Norwich	NY	Active
DSH330033U	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS Otolaryngology (ENT) / Otolaryngology (ENT)	32 Conkey Ave	Norwich	NY	Terminated
DSH330033V	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS PODIATRY NORWICH - Podiatry	24 CONKEY AVE	NORWICH	NY	Terminated
DSH330033W	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS CMH-OBGYN	32 CONKEY AVE.	NORWICH	NY	Active
DSH330033X	Child	DSH	CHENANGO MEMORIAL HOSPITAL	UHS CMH-GASTROENTEROLOGY - GASTROENTEROLOGY	4 Newton Ave	Norwich	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Lamen, Drake M President & CEO / CMO Chenango Memorial Hospital, Inc. 6073374113	Axley, Desiree A Vice President Finance & CFO Chenango Memorial Hospital, Inc. 6073736912	4/10/2025 1:59 PM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Lamen, Drake M President & CEO / CMO Chenango Memorial Hospital, Inc. 6073374113	10/21/2024 9:54 AM
Details	340B ID	Update	New Registration		DSH330033X	10/21/2024 9:54 AM
Details	Entity Subname	Update	New Registration	UHS CMH-GASTROENTEROLOGY	UHS CMH-GASTROENTEROLOGY - GASTROENTEROLOGY	10/21/2024 9:54 AM
Dates	Participating Approval Date	Update	New Registration		10/21/2024 9:54:08 AM	10/21/2024 9:54 AM
Details	State	Update	New Registration	Pending	Approved	10/21/2024 9:54 AM
Dates	Signed By Date	Update	New Registration		10/12/2024 11:45:11 AM	10/21/2024 9:54 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/21/2024 9:54 AM
Addresses	Main Address	Insert	New Registration		4 Newton Ave Norwich, NY 13815	10/10/2024 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2024 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00314723	10/10/2024 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/10/2024 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1770593956	10/10/2024 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/10/2024 11:56 AM
Contacts	Authorizing Official	Insert	New Registration		Lamen, Drake M President & CEO / CMO Chenango Memorial Hospital, Inc. 6073374113	10/10/2024 11:56 AM
Contacts	Primary Contact	Insert	New Registration		Decaro, Ryan C. Pharmacy Business Manager United Health Services Hospitals, Inc 6077631838	10/10/2024 11:56 AM
Details	Assistance Received From Date	Insert	New Registration			10/10/2024 11:56 AM
Details	Assistance Received To Date	Insert	New Registration			10/10/2024 11:56 AM
Details	Last Recertification Date	Insert	New Registration			10/10/2024 11:56 AM
Details	Grant Number	Insert	New Registration			10/10/2024 11:56 AM
Details	340B ID	Insert	New Registration			10/10/2024 11:56 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2024 11:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2024 11:56 AM
Details	Medicare Provider Number	Insert	New Registration		330033	10/10/2024 11:56 AM
Details	Entity Name	Insert	New Registration		CHENANGO MEMORIAL HOSPITAL	10/10/2024 11:56 AM
Details	NOFO Number	Insert	New Registration			10/10/2024 11:56 AM
Details	Program Code	Insert	New Registration		DSH	10/10/2024 11:56 AM
Details	Entity Subname	Insert	New Registration		UHS CMH-GASTROENTEROLOGY	10/10/2024 11:56 AM
Dates	Participating Approval Date	Insert	New Registration			10/10/2024 11:56 AM
Details	State	Insert	New Registration		Pending	10/10/2024 11:56 AM
Dates	Registration Date	Insert	New Registration		10/10/2024 11:56:38 AM	10/10/2024 11:56 AM
Dates	Signed By Date	Insert	New Registration			10/10/2024 11:56 AM
Dates	Start Date	Insert	New Registration			10/10/2024 11:56 AM
Terminations	Termination Comments	Insert	New Registration			10/10/2024 11:56 AM
Terminations	Termination Date	Insert	New Registration			10/10/2024 11:56 AM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2024 11:56 AM
Terminations	Termination Reason	Insert	New Registration			10/10/2024 11:56 AM