Covered Entity Details

DSH330307R CAYUGA MEDICAL CENTER AT ITHACA (Active) - information as of 5/17/2025 11:04:11 PM

Main Details

Name

CAYUGA MEDICAL CENTER AT ITHACA

Subdivision Name

Cayuga Urology - Urology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330307R

Medicare Provider Number

330307

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/9/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/29/2025

Last Recertification Date

Contacts

Authorizing Official

Cayuga Medical Center at Ithaca
Rebecca J Gould, President & Chief Financial Officer
(607) 742-7390

Primary Contact

Schuyler Hospital
Kimyen Howard, Pharmacy Compliance Supervisor
(607) 274-4211

Addresses

Street Address

201 Dates Dr
Suite 102
ITHACA, NY 14850

Billing Address

Cayuga Medical Center at Ithaca - Ithaca, NY
101 Dates Dr
3RD FLOOR
Ithaca, NY 14850

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	03001085	1962422733

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
DSH330307A	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Urgent Care East Campus	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307B	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Urgent Care - Cortland	1129 Commons Ave	Cortland	NY	Active
DSH330307C	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA Main Oncology	401 Cayuga Park Lane	Ithaca	NY	Active
DSH330307D	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA East Campus Oncology	10 Arrowwood Drive	Ithaca	NY	Active
DSH330307E	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Surgicare	10 Arrowwood Drive	Ithaca	NY	Active
DSH330307F	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Sports Medicine	310 Taughannock Blvd	Ithaca	NY	Active
DSH330307G	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging - Cortland - MRI	1129 Commons Ave.	Cortland	NY	Terminated
DSH330307H	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging- Cortland - CT	1129 Commons Ave.	Cortland	NY	Terminated
DSH330307J	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging - East - MRI	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307K	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging-East-Cat Scan	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307L	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Infusion - Cortland Infusion - Infusion	1129 Commons Ave.	Cortland	NY	Active
DSH330307M	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Endoscopy - East - Gastro Intestinal Services	2435 North Triphammer Road	Ithaca	NY	Active
DSH330307N	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA Cortland Campus Oncology - Oncology	1081 Commons Ave	Cortland	NY	Active
DSH330307P	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Pain Clinic - East - Pain Clinic	10 Arrowwood Dr.	Ithaca	NY	Active
DSH330307Q	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CAYUGA CENTER FOR HEALTHLY LIVING - CCHL	310 TAUGHANNOCK BLVD	ITHACA	NY	Active
DSH330307R	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Cayuga Urology - Urology	201 Dates Dr	ITHACA	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Gould, Rebecca J President & Chief Financial Officer Cayuga Medical Center at Ithaca 6077427390	1/29/2025 1:49 PM
Details	340B ID	Update	New Registration		DSH330307R	1/29/2025 1:49 PM
Details	Entity Subname	Update	New Registration	Cayuga Urology	Cayuga Urology - Urology	1/29/2025 1:49 PM
Dates	Participating Approval Date	Update	New Registration		1/29/2025 1:49:58 PM	1/29/2025 1:49 PM
Details	State	Update	New Registration	Pending	Approved	1/29/2025 1:49 PM
Dates	Signed By Date	Update	New Registration		1/9/2025 12:36:01 PM	1/29/2025 1:49 PM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/29/2025 1:49 PM
Addresses	Main Address	Insert	New Registration		201 Dates Dr Suite 102 ITHACA, NY 14850	1/9/2025 11:31 AM
Addresses	Billing Address	Insert	New Registration		Cayuga Medical Center at Ithaca - Ithaca, NY 101 Dates Dr 3RD FLOOR Ithaca, NY 14850	1/9/2025 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/9/2025 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03001085	1/9/2025 11:31 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/9/2025 11:31 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1962422733	1/9/2025 11:31 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	1/9/2025 11:31 AM
Contacts	Authorizing Official	Insert	New Registration		Gould, Rebecca J President & Chief Financial Officer Cayuga Medical Center at Ithaca 6077427390	1/9/2025 11:31 AM
Contacts	Primary Contact	Insert	New Registration		Howard, Kimyen Pharmacy Compliance Supervisor Schuyler Hospital 6072744211	1/9/2025 11:31 AM
Details	Assistance Received From Date	Insert	New Registration			1/9/2025 11:31 AM
Details	Assistance Received To Date	Insert	New Registration			1/9/2025 11:31 AM
Details	Last Recertification Date	Insert	New Registration			1/9/2025 11:31 AM
Details	Grant Number	Insert	New Registration			1/9/2025 11:31 AM
Details	340B ID	Insert	New Registration			1/9/2025 11:31 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/9/2025 11:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/9/2025 11:31 AM
Details	Medicare Provider Number	Insert	New Registration		330307	1/9/2025 11:31 AM
Details	Entity Name	Insert	New Registration		CAYUGA MEDICAL CENTER AT ITHACA	1/9/2025 11:31 AM
Details	NOFO Number	Insert	New Registration			1/9/2025 11:31 AM
Details	Program Code	Insert	New Registration		DSH	1/9/2025 11:31 AM
Details	Entity Subname	Insert	New Registration		Cayuga Urology	1/9/2025 11:31 AM
Dates	Participating Approval Date	Insert	New Registration			1/9/2025 11:31 AM
Details	State	Insert	New Registration		Pending	1/9/2025 11:31 AM
Dates	Registration Date	Insert	New Registration		1/9/2025 11:31:44 AM	1/9/2025 11:31 AM
Dates	Signed By Date	Insert	New Registration			1/9/2025 11:31 AM
Dates	Start Date	Insert	New Registration			1/9/2025 11:31 AM
Terminations	Termination Comments	Insert	New Registration			1/9/2025 11:31 AM
Terminations	Termination Date	Insert	New Registration			1/9/2025 11:31 AM
Terminations	Termination Effective Date	Insert	New Registration			1/9/2025 11:31 AM
Terminations	Termination Reason	Insert	New Registration			1/9/2025 11:31 AM