Covered Entity Details

DSH100307D ASCENSION ST. VINCENTS SOUTHSIDE HO (Active) - information as of 4/23/2025 10:53:22 PM

Main Details

Name

ASCENSION ST. VINCENTS SOUTHSIDE HO

Subdivision Name

CR210 PRIMARY CARE - Primary-care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100307D

Medicare Provider Number

100307

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/1/2025

Participating Start Date

1/21/2025

Participating Approval Date

1/21/2025

Last Recertification Date

Contacts

Authorizing Official

Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206

Primary Contact

Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859

Addresses

Street Address

2001 COUNTY ROAD 210 W
STE 200
SAINT JOHNS, FL 32259-1181

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?
No

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
DSH100307A	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	BARIATRICS DEPAUL - Bariatrics	2 SHIRCLIFF WAY	JACKSONVILLE	FL	Active
DSH100307B	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	ARLINGTON PRIMARY CARE - Primary-care	858 MONUMENT RD	JACKSONVILLE	FL	Active
DSH100307C	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	BAYMEADOWS PRIMARY CARE - Primary-care	10058 BAYMEADOWS RD	JACKSONVILLE	FL	Active
DSH100307D	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	CR210 PRIMARY CARE - Primary-care	2001 COUNTY ROAD 210 W	SAINT JOHNS	FL	Active
DSH100307E	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	DILLION PRIMARY CARE - Primary-care	3 SHIRCLIFF WAY	JACKSONVILLE	FL	Active
DSH100307F	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	GATE PARKWAY PRIMARY CARE - Primary-care	8075 GATE PKWY W	JACKSONVILLE	FL	Active
DSH100307G	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	NORTHSIDE PRIMARY CARE - Primary-Care	1760 W EDGEWOOD AVENUE	JACKSONVILLE	FL	Active
DSH100307H	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	ORANGE PARK PRIMARY CARE - Primary-care	2300 PARK AVE	ORANGE PARK	FL	Active
DSH100307J	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	ORANGE PARK RHEUMATOLOGY - Rheumatology	2300 PARK AVE	ORANGE PARK	FL	Active
DSH100307K	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	ST. VINCENT'S EMERGENCY ROOM - Emergency	9820 HUTCHINSON PARK DR	JACKSONVILLE	FL	Active
DSH100307L	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	PULMONARY CLAY - Pulmonology	1658 ST VINCENTS WAY	MIDDLEBURG	FL	Active
DSH100307M	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	PULMONARY RIVERSIDE - Pulmonary	3 SHIRCLIFF WAY	JACKSONVILLE	FL	Active
DSH100307N	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Riverside Encocrinology - Endocrinology	3 Shircliff Way, Suite 527	Jacksonville	FL	Active
DSH100307P	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	RIVERSIDE INTERNAL MEDICINE - Internal Med	2332 RIVERSIDE AVE	JACKSONVILLE	FL	Active
DSH100307Q	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	RIVERSIDE RHEUMATOLOGY - Rheumatology	3 SHIRCLIFF WAY	JACKSONVILLE	FL	Active
DSH100307R	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	ST. JOHNS MOB - Primary- care	300 SAINT ELIZABETH WAY	SAINT JOHNS	FL	Active
DSH100307S	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	TOWN CENTER PRIMARY CARE - Primary-care	6699 GATE PKWY	JACKSONVILLE	FL	Active
DSH100307T	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Cardiology Clinic - Cardiology	4205 Belfort Road, Suite 2069	Jacksonville	FL	Active
DSH100307U	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Pulmonology - Pulmonology	4203 Belfort Road, Suite 108	Jacksonville,	FL	Active
DSH100307V	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Endocrinology - Endocrinology	4203 Belfort Road, Suite 204	Jacksonville	FL	Active
DSH100307W	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Rheumatology - Rheumatology	4203 Belfort Road, Suite 215	Jacksonville	FL	Active
DSH100307X	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Bariatrics - Bariatrics	4205 Belfort Road, Suite 4030	Jacksonville	FL	Active
DSH100307Y	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Internal Medicine - Internal Medicine	4205 Belfort Road, Suite 3004	Jacksonville	FL	Active
DSH100307Z	Child	DSH	ASCENSION ST. VINCENTS SOUTHSIDE HO	Southside Neurology & Neuro Surgery - Neurology	4205 Belfort Road, Suite 1100	Jacksonville	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update	OPA Edit	Approved	Active	1/21/2025 8:06 AM
Dates	Start Date	Update	OPA Edit	4/1/2025 12:00:00 AM	1/21/2025 12:00:00 AM	1/21/2025 8:06 AM
Contacts	Signed By	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	1/21/2025 8:05 AM
Details	340B ID	Update	New Registration		DSH100307D	1/21/2025 8:05 AM
Details	Entity Subname	Update	New Registration	CR210 PRIMARY CARE	CR210 PRIMARY CARE - Primary-care	1/21/2025 8:05 AM
Dates	Participating Approval Date	Update	New Registration		1/21/2025 8:05:03 AM	1/21/2025 8:05 AM
Details	State	Update	New Registration	Pending	Approved	1/21/2025 8:05 AM
Dates	Signed By Date	Update	New Registration		1/7/2025 4:39:27 PM	1/21/2025 8:05 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/21/2025 8:05 AM
Addresses	Main Address	Insert	New Registration		2001 COUNTY ROAD 210 W STE 200 SAINT JOHNS, FL 32259-1181	1/1/2025 4:47 PM
Contacts	Primary Contact	Insert	New Registration		Russo, Troy 340B Coordinator Sacred Heart Health System, Inc. 8504162859	1/1/2025 4:47 PM
Contacts	Authorizing Official	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	1/1/2025 4:47 PM
Details	Assistance Received From Date	Insert	New Registration			1/1/2025 4:47 PM
Details	Assistance Received To Date	Insert	New Registration			1/1/2025 4:47 PM
Details	Last Recertification Date	Insert	New Registration			1/1/2025 4:47 PM
Details	Grant Number	Insert	New Registration			1/1/2025 4:47 PM
Details	340B ID	Insert	New Registration			1/1/2025 4:47 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/1/2025 4:47 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/1/2025 4:47 PM
Details	Medicare Provider Number	Insert	New Registration		100307	1/1/2025 4:47 PM
Details	Entity Name	Insert	New Registration		ASCENSION ST. VINCENTS SOUTHSIDE HO	1/1/2025 4:47 PM
Details	NOFO Number	Insert	New Registration			1/1/2025 4:47 PM
Details	Program Code	Insert	New Registration		DSH	1/1/2025 4:47 PM
Details	Entity Subname	Insert	New Registration		CR210 PRIMARY CARE	1/1/2025 4:47 PM
Dates	Participating Approval Date	Insert	New Registration			1/1/2025 4:47 PM
Details	State	Insert	New Registration		Pending	1/1/2025 4:47 PM
Dates	Registration Date	Insert	New Registration		1/1/2025 4:47:56 PM	1/1/2025 4:47 PM
Dates	Signed By Date	Insert	New Registration			1/1/2025 4:47 PM
Dates	Start Date	Insert	New Registration			1/1/2025 4:47 PM
Terminations	Termination Comments	Insert	New Registration			1/1/2025 4:47 PM
Terminations	Termination Date	Insert	New Registration			1/1/2025 4:47 PM
Terminations	Termination Effective Date	Insert	New Registration			1/1/2025 4:47 PM
Terminations	Termination Reason	Insert	New Registration			1/1/2025 4:47 PM