Covered Entity Details

DSH050360T MARIN GENERAL HOSPITAL (Active) - information as of 5/7/2025 10:40:58 PM

Main Details

Name

MARIN GENERAL HOSPITAL

Subdivision Name

MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050360T

Medicare Provider Number

050360

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2024

Participating Start Date

1/1/2025

Participating Approval Date

11/13/2024

Last Recertification Date

Contacts

Authorizing Official

Marin General Hospital
Elizabeth Lasnier, Controller
(415) 925-7449

Primary Contact

Marin General Hospital
Megan Engler, 340B Coordinator
(415) 328-1454

Addresses

Street Address

2 BON AIR ROAD
120A
LARKSPUR, CA 94939

Billing Address

Marin Health Medical Center
250 Bon Air Road
Greenbrae, CA 94904

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	MSM003606	1396725677

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
DSH050360A	Child	DSH	MARIN GENERAL HOSPITAL	RADIATION ONCOLOGY	1350 S. ELISEO DR	GREENBRAE	CA	Terminated
DSH050360B	Child	DSH	MARIN GENERAL HOSPITAL	Marin Outpatient Imaging Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360C	Child	DSH	MARIN GENERAL HOSPITAL	Eliseo Vascular Testing	1100 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360D	Child	DSH	MARIN GENERAL HOSPITAL	BRADEN DIABETES CENTER	1100 S ELISEO DR 2	GREENBRAE	CA	Terminated
DSH050360E	Child	DSH	MARIN GENERAL HOSPITAL	Breast Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360F	Child	DSH	MARIN GENERAL HOSPITAL	75 Rowland Vascular and Cardiovascular Testing	75 Rowland Way	Novato	CA	Terminated
DSH050360G	Child	DSH	MARIN GENERAL HOSPITAL	2 Bon Air Cardiovascular Testing	2 Bon Air Rd	Greenbrae	CA	Terminated
DSH050360H	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT PHYSICAL THERAPY - MARINHEALTH OUTPATIENT PHYSICAL THERAPY	1350 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360J	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH VASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Active
DSH050360K	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE	2 BON AIR ROAD	LARKSPUR	CA	Active
DSH050360L	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH UROLOGY	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360M	Child	DSH	MARIN GENERAL HOSPITAL	BREAST HEALTH CENTER - MARINHEALTH BREAST HEALTH CENTER	100A DRAKES LANDING RD	GREENBRAE	CA	Terminated
DSH050360N	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - IMAGING	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360P	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT MRI	1260 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360Q	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE - MARINHEALTH CARDIOVASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Terminated
DSH050360R	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH BRADEN DIABETES CENTER - BRADEN DIABETES CENTER	1100 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360S	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	75 Rowland Way	NOVATO	CA	Terminated
DSH050360T	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	2 BON AIR ROAD	LARKSPUR	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Change Request		Marin Health Medical Center 250 Bon Air Road Greenbrae, CA 94904	1/20/2025 2:30 PM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Lasnier, Elizabeth Controller Marin General Hospital 4159257449	11/13/2024 11:28 AM
Details	340B ID	Update	New Registration		DSH050360T	11/13/2024 11:28 AM
Details	Entity Name	Update	New Registration	MARINHEALTH MEDICAL CENTER	MARIN GENERAL HOSPITAL	11/13/2024 11:28 AM
Details	Entity Subname	Update	New Registration	MARINHEALTH OUTPATIENT IMAGING CENTER	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	11/13/2024 11:28 AM
Dates	Participating Approval Date	Update	New Registration		11/13/2024 11:28:02 AM	11/13/2024 11:28 AM
Details	State	Update	New Registration	Pending	Approved	11/13/2024 11:28 AM
Dates	Signed By Date	Update	New Registration		11/7/2024 11:12:49 AM	11/13/2024 11:28 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	11/13/2024 11:28 AM
Addresses	Main Address	Insert	New Registration		2 BON AIR ROAD 120A LARKSPUR, CA 94939	10/14/2024 1:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2024 1:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		MSM003606	10/14/2024 1:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/14/2024 1:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396725677	10/14/2024 1:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/14/2024 1:18 PM
Contacts	Authorizing Official	Insert	New Registration		Lasnier, Elizabeth Controller Marin General Hospital 4159257449	10/14/2024 1:18 PM
Contacts	Primary Contact	Insert	New Registration		Engler, Megan 340B Coordinator Marin General Hospital 4153281454	10/14/2024 1:18 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2024 1:18 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2024 1:18 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2024 1:18 PM
Details	Grant Number	Insert	New Registration			10/14/2024 1:18 PM
Details	340B ID	Insert	New Registration			10/14/2024 1:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2024 1:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2024 1:18 PM
Details	Medicare Provider Number	Insert	New Registration		050360	10/14/2024 1:18 PM
Details	Entity Name	Insert	New Registration		MARINHEALTH MEDICAL CENTER	10/14/2024 1:18 PM
Details	NOFO Number	Insert	New Registration			10/14/2024 1:18 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2024 1:18 PM
Details	Entity Subname	Insert	New Registration		MARINHEALTH OUTPATIENT IMAGING CENTER	10/14/2024 1:18 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2024 1:18 PM
Details	State	Insert	New Registration		Pending	10/14/2024 1:18 PM
Dates	Registration Date	Insert	New Registration		10/14/2024 1:18:04 PM	10/14/2024 1:18 PM
Dates	Signed By Date	Insert	New Registration			10/14/2024 1:18 PM
Dates	Start Date	Insert	New Registration			10/14/2024 1:18 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2024 1:18 PM
Terminations	Termination Date	Insert	New Registration			10/14/2024 1:18 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2024 1:18 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2024 1:18 PM