Covered Entity Details

DSH200001L ST JOSEPH HOSPITAL (Active) - information as of 4/23/2025 10:53:31 PM

Main Details

Name

ST JOSEPH HOSPITAL

Subdivision Name

St. Joseph Internal Medicine - St. Joseph Internal Medicine - Same Day Care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH200001L

Medicare Provider Number

200001

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/30/2024

Last Recertification Date

Contacts

Authorizing Official

St. Joseph Hospital
Michael Allan Hendrix, Vice of President of Finance
(207) 907-1600

Primary Contact

St. Joseph Hospital
Courtney Mcvey, Pharmacy Operations Manager
(207) 907-1823

Addresses

Street Address

900 Broadway
Bangor, ME 04401

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
ME	1154321545	1154321545

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
DSH200001A	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH ENDOCRINOLOGY - St. Joseph Endocrinology	900 BROADWAY	BANGOR	ME	Active
DSH200001B	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE 900 - St. Joseph Family Medicine - Broadway	900 BROADWAY	BANGOR	ME	Active
DSH200001C	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE HAMPDEN - St. Jospeh Family Medicine - Hampden	21 WESTERN AVE	HAMPDEN	ME	Active
DSH200001D	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE MT HOPE - St. Joseph Family Medicine - Evergreen Woods	700 MOUNT HOPE AVE	BANGOR	ME	Active
DSH200001E	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH GASTROENTEROLOGY - St. Joseph Gastroenterology	360 BROADWAY	BANGOR	ME	Active
DSH200001F	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH GENERAL SURGERY AND UROLO - St. Joseph General Surgery and Urology	360 BROADWAY	BANGOR	ME	Active
DSH200001G	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH NEUROSURGERY - St. Joseph Neuroscience	360 BROADWAY	BANGOR	ME	Active
DSH200001H	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH RESPIRATORY CARE - St. Joseph Pulmonary Medicine	360 BROADWAY	BANGOR	ME	Active
DSH200001J	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH RHEUMATOLOGY - St. Joseph Rheumatology	900 BROADWAY	BANGOR	ME	Active
DSH200001K	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Cardiology - St. Joseph Cardiovascular Care	360 Broadway	Bangor	ME	Active
DSH200001L	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Internal Medicine - St. Joseph Internal Medicine - Same Day Care	900 Broadway	Bangor	ME	Active
DSH200001M	Child	DSH	ST JOSEPH HOSPITAL	SKIN AND WOUND HEALING CENTER WITH - St. Joseph Wound Care	360 BROADWAY	BANGOR	ME	Active
DSH200001N	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Psych - St. Joseph Psych	900 Broadway	Bangor	ME	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		Hendrix, Michael Allan Vice of President of Finance St. Joseph Hospital 2079071600	10/30/2024 8:33 AM
Details	340B ID	Update	New Registration		DSH200001L	10/30/2024 8:33 AM
Details	Entity Subname	Update	New Registration	St. Joseph Internal Medicine	St. Joseph Internal Medicine - St. Joseph Internal Medicine - Same Day Care	10/30/2024 8:33 AM
Dates	Participating Approval Date	Update	New Registration		10/30/2024 8:33:19 AM	10/30/2024 8:33 AM
Details	State	Update	New Registration	Pending	Approved	10/30/2024 8:33 AM
Dates	Signed By Date	Update	New Registration		10/29/2024 8:51:55 AM	10/30/2024 8:33 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/30/2024 8:33 AM
Addresses	Main Address	Insert	New Registration		900 Broadway Bangor, ME 04401	10/14/2024 12:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2024 12:09 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1154321545	10/14/2024 12:09 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/14/2024 12:09 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1154321545	10/14/2024 12:09 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	10/14/2024 12:09 PM
Contacts	Authorizing Official	Insert	New Registration		Hendrix, Michael Allan Vice of President of Finance St. Joseph Hospital 2079071600	10/14/2024 12:09 PM
Contacts	Primary Contact	Insert	New Registration		Mcvey, Courtney Pharmacy Operations Manager St. Joseph Hospital 2079071823	10/14/2024 12:09 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2024 12:09 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2024 12:09 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2024 12:09 PM
Details	Grant Number	Insert	New Registration			10/14/2024 12:09 PM
Details	340B ID	Insert	New Registration			10/14/2024 12:09 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2024 12:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2024 12:09 PM
Details	Medicare Provider Number	Insert	New Registration		200001	10/14/2024 12:09 PM
Details	Entity Name	Insert	New Registration		ST JOSEPH HOSPITAL	10/14/2024 12:09 PM
Details	NOFO Number	Insert	New Registration			10/14/2024 12:09 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2024 12:09 PM
Details	Entity Subname	Insert	New Registration		St. Joseph Internal Medicine	10/14/2024 12:09 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2024 12:09 PM
Details	State	Insert	New Registration		Pending	10/14/2024 12:09 PM
Dates	Registration Date	Insert	New Registration		10/14/2024 12:09:57 PM	10/14/2024 12:09 PM
Dates	Signed By Date	Insert	New Registration			10/14/2024 12:09 PM
Dates	Start Date	Insert	New Registration			10/14/2024 12:09 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2024 12:09 PM
Terminations	Termination Date	Insert	New Registration			10/14/2024 12:09 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2024 12:09 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2024 12:09 PM