Covered Entity Details

DSH330197BG CANTON-POTSDAM HOSPITAL (Active) - information as of 4/24/2025 11:12:50 PM

Main Details

Name

CANTON-POTSDAM HOSPITAL

Subdivision Name

CPH CARDIO POTSDAM - cardiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330197BG

Medicare Provider Number

330197

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/15/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/23/2024

Last Recertification Date

Contacts

Authorizing Official

Rochester Regional Health
Shawn Bishop, Vice President, RRH Revenue & Reimbursement
(585) 922-0056

Primary Contact

RRH
Robert Michael Scardino, 340B Pharmacy System Manager
(585) 319-6750

Addresses

Street Address

201 MARKET ST
c
potsdam, NY 13676

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	00354196	1568548782

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
DSH330197A	Child	DSH	CANTON-POTSDAM HOSPITAL	AFTERHOURS HEALTHCARE	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197AA	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PHYSIATRY	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Terminated
DSH330197AB	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY PRACTICE	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197AC	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY PRACTICE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AD	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH RHEUMATOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AE	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR GENERAL SURGERY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AF	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR INTERNAL MEDICINE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AG	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR OB/GYN	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AH	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ENDOCRINOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AJ	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR PAIN PRACTICE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AK	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CANTON PAIN PRACTICE	80 EAST MAIN STREET	CANTON	NY	Terminated
DSH330197AL	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR MEDICAL ONCOLOGY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AM	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR ORTHOPEDICS	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AN	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OTOLARYNGOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AP	Child	DSH	CANTON-POTSDAM HOSPITAL	GASTROENTEROLOGY-SHAH	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AQ	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH INFECTIOUS DISEASE	80 East Main Street	CANTON	NY	Active
DSH330197AR	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH INTERNAL MEDICINE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Terminated
DSH330197AS	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PSYCHIATRY AND ADDICTION MEDICINE - PSYCHIATRY AND ADDICTION MEDICINE	12 ELM STREET	POTSDAM	NY	Active
DSH330197AT	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH DERMATOLOGY - DERMATOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AU	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GENERAL SURGERY - GENERAL SURGERY	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AV	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OTOLARYNGOLOGY - POTSDAM - OTOLARYNGOLOGY	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AW	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH URGENT CARE - URGENT CARE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197AX	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PULMONOLOGY - PULMONOLOGY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AY	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH BEHAVIORAL HEALTH - BEHAVIORAL HEALTH	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AZ	Child	DSH	CANTON-POTSDAM HOSPITAL	NEUROLOGY - NEUROLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197B	Child	DSH	CANTON-POTSDAM HOSPITAL	BRASHER FALLS HEALTH CLINIC	899 STATE HIGHWAY 11C	BRASHER FALLS	NY	Active
DSH330197BA	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH POTSDAM DERM - dermatology	49 Lawrence Ave	POTSDAM	NY	Active
DSH330197BB	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CANTON GEN SURG - General Surgery	80 E Main St	Canton	NY	Active
DSH330197BC	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH UROLOGY CANTON - Urology	80 E Main St	Canton	NY	Active
DSH330197BD	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ORTHO AT LAW AVE - Orthopedic Surgery	49 Lawrence Ave	Potsdam	NY	Active
DSH330197BE	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH O/P SUBSTANCE USE - Behavioral Health	12 Elm St	POTSDAM	NY	Active
DSH330197BF	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY AT MH - podiatry	181 MAPLE ST	Massena	NY	Active
DSH330197BG	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CARDIO POTSDAM - cardiology	201 MARKET ST	potsdam	NY	Active
DSH330197BH	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GENERAL SURG MH - General Surgery	181 Maple St	MASSENA	NY	Active
DSH330197C	Child	DSH	CANTON-POTSDAM HOSPITAL	Canton OB/GYN	80 E MAIN ST	CANTON	NY	Active
DSH330197D	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH FAMILY & PEDIATRICS SERVICES - CANTON	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197E	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PSYCHIATRY SERVICES	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197F	Child	DSH	CANTON-POTSDAM HOSPITAL	NORFOLK COMMUNITY HEALTH CENTER	35 W. MAIN STREET	NORFOLK	NY	Active
DSH330197G	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PRIMARY CARE AND INTERNAL MEDICINE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197I	Child	DSH	CANTON-POTSDAM HOSPITAL	CHEMICAL DEPENDENCY	12 ELM STREET	POTSDAM	NY	Terminated
DSH330197K	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology and Surgical Services-Wilson	15 Raymond Street	Potsdam	NY	Terminated
DSH330197L	Child	DSH	CANTON-POTSDAM HOSPITAL	ORTHOPEDICS AND SPORTS MEDICINE	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197M	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PEDIATRICS PRACTICE	15 Raymond Street	Potsdam	NY	Active
DSH330197N	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH POTSDAM OB/GYN PRACTICE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197P	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Eye Care	Lawrence Avenue Medical Campus	Potsdam	NY	Active
DSH330197Q	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology and Surgical Services-Stoin	15 Raymond Street	Potsdam	NY	Terminated
DSH330197R	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Pain Management	LAWRENCE AVENUE MEDICAL CAMPUS	Potsdam	NY	Active
DSH330197S	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Gastroenterology Services	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197T	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OB/GYN Lawrence Avenue	Lawrence Avenue Medical Campus	Potsdam	NY	Terminated
DSH330197U	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology Lawrence Avenue	50 LEROY STREET	Potsdam	NY	Terminated
DSH330197V	Child	DSH	CANTON-POTSDAM HOSPITAL	ALLERGY AND IMMUNOLOGY	6119 US HIGHWAY 11	Canton	NY	Active
DSH330197X	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ORTHOPEDICS PRACTICE	EJ NOBLE BUILDING	CANTON	NY	Terminated
DSH330197Y	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PULMONOLOGY	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197Z	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PHYSIATRY	6119 US HIGHWAY 11	CANTON	NY	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		Bishop, Shawn Vice President, RRH Revenue & Reimbursement Rochester Regional Health 5859220056	10/23/2024 12:30 PM
Details	340B ID	Update	New Registration		DSH330197BG	10/23/2024 12:30 PM
Details	Entity Subname	Update	New Registration	CPH CARDIO POTSDAM	CPH CARDIO POTSDAM - cardiology	10/23/2024 12:30 PM
Dates	Participating Approval Date	Update	New Registration		10/23/2024 12:30:17 PM	10/23/2024 12:30 PM
Details	State	Update	New Registration	Pending	Approved	10/23/2024 12:30 PM
Dates	Signed By Date	Update	New Registration		10/15/2024 2:50:16 PM	10/23/2024 12:30 PM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/23/2024 12:30 PM
Addresses	Main Address	Insert	New Registration		201 MARKET ST c potsdam, NY 13676	10/15/2024 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2024 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00354196	10/15/2024 2:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/15/2024 2:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568548782	10/15/2024 2:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/15/2024 2:00 PM
Contacts	Primary Contact	Insert	New Registration		Scardino, Robert Michael 340B Pharmacy System Manager RRH 5853196750	10/15/2024 2:00 PM
Contacts	Authorizing Official	Insert	New Registration		Bishop, Shawn Vice President, RRH Revenue & Reimbursement Rochester Regional Health 5859220056	10/15/2024 2:00 PM
Details	Assistance Received From Date	Insert	New Registration			10/15/2024 2:00 PM
Details	Assistance Received To Date	Insert	New Registration			10/15/2024 2:00 PM
Details	Last Recertification Date	Insert	New Registration			10/15/2024 2:00 PM
Details	Grant Number	Insert	New Registration			10/15/2024 2:00 PM
Details	340B ID	Insert	New Registration			10/15/2024 2:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/15/2024 2:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/15/2024 2:00 PM
Details	Medicare Provider Number	Insert	New Registration		330197	10/15/2024 2:00 PM
Details	Entity Name	Insert	New Registration		CANTON-POTSDAM HOSPITAL	10/15/2024 2:00 PM
Details	NOFO Number	Insert	New Registration			10/15/2024 2:00 PM
Details	Program Code	Insert	New Registration		DSH	10/15/2024 2:00 PM
Details	Entity Subname	Insert	New Registration		CPH CARDIO POTSDAM	10/15/2024 2:00 PM
Dates	Participating Approval Date	Insert	New Registration			10/15/2024 2:00 PM
Details	State	Insert	New Registration		Pending	10/15/2024 2:00 PM
Dates	Registration Date	Insert	New Registration		10/15/2024 2:00:39 PM	10/15/2024 2:00 PM
Dates	Signed By Date	Insert	New Registration			10/15/2024 2:00 PM
Dates	Start Date	Insert	New Registration			10/15/2024 2:00 PM
Terminations	Termination Comments	Insert	New Registration			10/15/2024 2:00 PM
Terminations	Termination Date	Insert	New Registration			10/15/2024 2:00 PM
Terminations	Termination Effective Date	Insert	New Registration			10/15/2024 2:00 PM
Terminations	Termination Reason	Insert	New Registration			10/15/2024 2:00 PM