Covered Entity Details

DSH170086N STORMONT-VAIL HEALTHCARE INC. (Active) - information as of 4/27/2025 11:36:54 PM

Main Details

Name

STORMONT-VAIL HEALTHCARE INC.

Subdivision Name

STORMONT VAIL MRI CENTER - CT-IMAGING CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH170086N

Medicare Provider Number

170086

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/8/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/31/2025

Last Recertification Date

Contacts

Authorizing Official

Stormont Vail Healthcare, Inc.
Stacie Mason, Senior Vice President & Chief Financial Officer & Treasurer
(785) 354-5770

Primary Contact

Stormont-Vail Health
Robert Alan Brewer, Pharmacy Manager - Finance and Medication Acquisition
(785) 354-5498

Addresses

Street Address

731 SW MULVANE ST
TOPEKA, KS 66606-1665

Billing Address

STORMONT VAIL HEALTHCARE INC.
1500 SW 10TH AVE
TOPEKA, KS 66604

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
KS	012691309	1194782409
MO	30003913380001	1194782409
NE		1194782409

Shipping Addresses

Shipping Address 1

STORMONT VAIL HEALTHCARE INC.
1500 SW 10TH AVE
TOPEKA, KS 66604

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
DSH170086A	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	DBA STORMONT-VAIL CARDIAC IMAGING AND REHABILITATION CENTER	929 SW MULVANE ST	TOPEKA	KS	Active
DSH170086B	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	DBA STORMONT VAIL WOUNDCARE CENTER	823 SW MULVANE ST	TOPEKA	KS	Active
DSH170086C	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL SINGLE DAY SURGERY	2660 SW 3rd Street, LL, Suite 002	TOPEKA	KS	Active
DSH170086D	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL WEST	3707 SW 6TH ST	TOPEKA	KS	Terminated
DSH170086E	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL CANCER CENTER RADIATION THERAPY	1414 SW 8TH AVE	TOPEKA	KS	Active
DSH170086F	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL MRI CENTER OF KANSAS	731 SW MULVANE	TOPEKA	KS	Active
DSH170086G	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL CANCER CENTER PET/CT	1414 SW 8TH AVE	TOPEKA	KS	Active
DSH170086H	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL CANCER CENTER TREATMENT ROOM	1414 SW 8TH AVE	TOPEKA	KS	Active
DSH170086J	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	Stormont Vail Infusion Center	909 Mulvane Street Lower Level	Topeka	KS	Terminated
DSH170086K	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL EXCELLENT SURGERY CENTER	920 SW LANE ST	TOPEKA	KS	Active
DSH170086L	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL PAIN MANAGEMENT CENTER	823 SW MULVANE ST	TOPEKA	KS	Active
DSH170086M	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL INFUSION CENTER - INFUSION SERVICES	1414 SW 8TH AVE	TOPEKA	KS	Active
DSH170086N	Child	DSH	STORMONT-VAIL HEALTHCARE INC.	STORMONT VAIL MRI CENTER - CT-IMAGING CENTER	731 SW MULVANE ST	TOPEKA	KS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Kongs, Michael Assistant CFO & System Director & Controller Stormont Vail Health inc. 7853545844-25844	Mason, Stacie Senior Vice President & Chief Financial Officer & Treasurer Stormont Vail Healthcare, Inc. 7853545770	2/25/2025 6:48 AM
Contacts	Signed By	Insert	New Registration		Kongs, Michael Assistant CFO & System Director & Controller Stormont Vail Health inc. 7853545844-25844	1/31/2025 8:39 AM
Details	340B ID	Update	New Registration		DSH170086N	1/31/2025 8:39 AM
Details	Entity Name	Update	New Registration	STORMONT-VAIL REGIONAL HEALTH CENTER	STORMONT-VAIL HEALTHCARE INC.	1/31/2025 8:39 AM
Details	Entity Subname	Update	New Registration	STORMONT VAIL MRI CENTER	STORMONT VAIL MRI CENTER - CT-IMAGING CENTER	1/31/2025 8:39 AM
Dates	Participating Approval Date	Update	New Registration		1/31/2025 8:39:00 AM	1/31/2025 8:39 AM
Details	State	Update	New Registration	Pending	Approved	1/31/2025 8:39 AM
Dates	Signed By Date	Update	New Registration		1/9/2025 9:43:31 AM	1/31/2025 8:39 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/31/2025 8:39 AM
Addresses	Main Address	Insert	New Registration		731 SW MULVANE ST TOPEKA, KS 66606-1665	1/8/2025 12:27 PM
Addresses	Billing Address	Insert	New Registration		STORMONT VAIL HEALTHCARE INC. 1500 SW 10TH AVE TOPEKA, KS 66604	1/8/2025 12:27 PM
Addresses	Shipping Address	Insert	New Registration		STORMONT VAIL HEALTHCARE INC. 1500 SW 10TH AVE TOPEKA, KS 66604	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		012691309	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003913380001	1/8/2025 12:27 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/8/2025 12:27 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1194782409	1/8/2025 12:27 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/8/2025 12:27 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1194782409	1/8/2025 12:27 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/8/2025 12:27 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1194782409	1/8/2025 12:27 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	1/8/2025 12:27 PM
Contacts	Primary Contact	Insert	New Registration		Brewer, Robert Alan Pharmacy Manager - Finance and Medication Acquisition Stormont-Vail Health 7853545498	1/8/2025 12:27 PM
Contacts	Authorizing Official	Insert	New Registration		Kongs, Michael Assistant CFO & System Director & Controller Stormont Vail Health inc. 7853545844-25844	1/8/2025 12:27 PM
Details	Assistance Received From Date	Insert	New Registration			1/8/2025 12:27 PM
Details	Assistance Received To Date	Insert	New Registration			1/8/2025 12:27 PM
Details	Last Recertification Date	Insert	New Registration			1/8/2025 12:27 PM
Details	Grant Number	Insert	New Registration			1/8/2025 12:27 PM
Details	340B ID	Insert	New Registration			1/8/2025 12:27 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/8/2025 12:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/8/2025 12:27 PM
Details	Medicare Provider Number	Insert	New Registration		170086	1/8/2025 12:27 PM
Details	Entity Name	Insert	New Registration		STORMONT-VAIL REGIONAL HEALTH CENTER	1/8/2025 12:27 PM
Details	NOFO Number	Insert	New Registration			1/8/2025 12:27 PM
Details	Program Code	Insert	New Registration		DSH	1/8/2025 12:27 PM
Details	Entity Subname	Insert	New Registration		STORMONT VAIL MRI CENTER	1/8/2025 12:27 PM
Dates	Participating Approval Date	Insert	New Registration			1/8/2025 12:27 PM
Details	State	Insert	New Registration		Pending	1/8/2025 12:27 PM
Dates	Registration Date	Insert	New Registration		1/8/2025 12:27:18 PM	1/8/2025 12:27 PM
Dates	Signed By Date	Insert	New Registration			1/8/2025 12:27 PM
Dates	Start Date	Insert	New Registration			1/8/2025 12:27 PM
Terminations	Termination Comments	Insert	New Registration			1/8/2025 12:27 PM
Terminations	Termination Date	Insert	New Registration			1/8/2025 12:27 PM
Terminations	Termination Effective Date	Insert	New Registration			1/8/2025 12:27 PM
Terminations	Termination Reason	Insert	New Registration			1/8/2025 12:27 PM