Covered Entity Details

PED393303-31 THE CHILDREN'S HOSPITAL OF PHILADELPHIA (Active) - information as of 4/27/2025 12:53:55 AM

Main Details

Name

THE CHILDREN'S HOSPITAL OF PHILADELPHIA

Subdivision Name

Botox Therapy at Bryn Mawr - Botox Therapy at Bryn Mawr

Type

Children's Hospital

Rural

340B ID

PED393303-31

Medicare Provider Number

393303

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/10/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/27/2025

Last Recertification Date

Contacts

Authorizing Official

Children's Hospital of Philadelphia
Jan Pieter Boswinkel, Senior Vice President & Chief Operating Officer, Hospital Operations
(215) 590-3055

Primary Contact

Children's Hospital of Philadelphia
Richard J. Dyke, Director of Pharmacy Business Operations
(267) 426-5834

Addresses

Street Address

135 S. Bryn Mawr Avenue Suite 240
Bryn Mawr, PA 19010

Billing Address

The Children's Hospital of Philadelphia
PO Box 2015
Secaucus, NJ 07096

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
PA	1007709910056	1215921457,1760576052,1548330350,1053917302,1982325361
DE	200017920	1215921457,1760576052,1548330350,1053917302,1982325361
NJ	4204301,0729272	1215921457,1760576052,1548330350,1053917302,1982325361

Shipping Addresses

Shipping Address 1

THE CHILDREN'S HOSPITAL OF PHILADELPHIA KING OF PRUSSIA
550 South Goddard Blvd
Hospital Pharmacy, Room 2420
King of Prussia, PA 19406

Shipping Address 2

CHILDRENS HOSPITAL OF PHILADELPHIA PHARMACY
3401 Civic Center Blvd
Philadelphia, PA 19104

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
PED393303-01	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	CHILDRENS HOSPITAL SPECIALTY CARE CTR AT VOORHEES	1012-1014 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
PED393303-02	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	ONCOLOGY CLINIC AT BUERGER CENTER	3500 Civic Center Blvd	PHILADELPHIA	PA	Active
PED393303-03	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Children's Hospital Home Care	3000 Horizon Drive	KING OF PRUSSIA	PA	Active
PED393303-04	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Oncology Clinic at King of Prussia	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-05	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Ambulatory Surgery at Bucks County	500 West Butler Rt 202 And Schoolhouse	Chalfont	PA	Active
PED393303-06	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Sedation Unit at King of Prussia	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-07	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Sedation Unit at Buerger Center	3500 Civic Center Boulevard	Philadelphia	PA	Active
PED393303-08	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Day Medicine at Buerger Center	3500 Civic Center Boulevard	Philadelphia	PA	Active
PED393303-09	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Ambulatory Surgery at Voorhees	1012 Laurel Oak Rd.	Voorhees	NJ	Active
PED393303-10	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Ambulatory Surgery at King of Prussia	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-11	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Dialysis	3500 Civic Center Blvd	Philadelphia	PA	Active
PED393303-12	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Apheresis	3500 Civic Center Blvd	Philadelphia	PA	Active
PED393303-13	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Botox Therapy at Buerger Center	3500 Civic Center Blvd	Philadelphia	PA	Active
PED393303-14	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Ultrasound at Buerger Center - Ultrasound	3500 Civic Center Blvd 2nd Floor	Philadelphia	PA	Active
PED393303-15	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Oncology Clinic at Voorhees - Oncology	1012 Laurel Oak Rd	Voorhees	NJ	Active
PED393303-16	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	CT Scan at King of Prussia - CT Scan	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-17	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Pet Scan at Buerger Center - Pet Scan	3500 Civic Center Blvd 2nd Floor	Philadelphia	PA	Active
PED393303-18	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Botox Therapy at Exton - Botox Therapy	481 John Young Way	Exton	PA	Terminated
PED393303-19	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Ambulatory Surgery at Brandywine Valley - Ambulatory Surgery	819 Baltimore Pike	Glen Mills	PA	Active
PED393303-20	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Fluoroscopy at King of Prussia - Fluoroscopy	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-21	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	MRI at King of Prussia - MRI	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-22	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Nuclear Medicine at King of Prussia - Nuclear Medicine	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-23	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Pulmonary Function Lab at Buerger Center - Pulmonary Function Lab	3500 Civic Center Blvd 7th Floor	Philadelphia	PA	Active
PED393303-24	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	MRI at Buerger Center - MRI	3500 Civic Center Blvd - 2nd Floor	Philadelphia	PA	Active
PED393303-25	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - Sleep Center	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-26	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - Ultrasound - Hospital Services	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-27	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - Pulmonary Function	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-28	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - Emergency Department	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-29	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - PACU	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-30	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	King of Prussia - OR General Anesthesia	550 South Goddard Blvd	King of Prussia	PA	Active
PED393303-31	Child	PED	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	Botox Therapy at Bryn Mawr - Botox Therapy at Bryn Mawr	135 S. Bryn Mawr Avenue Suite 240	Bryn Mawr	PA	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		Boswinkel, Jan Pieter Senior Vice President & Chief Operating Officer, Hospital Operations Children's Hospital of Philadelphia 2155903055	2/27/2025 1:49 PM
Details	340B ID	Update	New Registration		PED393303-31	2/27/2025 1:49 PM
Details	Entity Name	Update	New Registration	THE CHILDRENS HOSPITAL OF PHILADELP	THE CHILDREN'S HOSPITAL OF PHILADELPHIA	2/27/2025 1:49 PM
Details	Entity Subname	Update	New Registration	Botox Therapy at Bryn Mawr	Botox Therapy at Bryn Mawr - Botox Therapy at Bryn Mawr	2/27/2025 1:49 PM
Dates	Participating Approval Date	Update	New Registration		2/27/2025 1:49:47 PM	2/27/2025 1:49 PM
Details	State	Update	New Registration	Pending	Approved	2/27/2025 1:49 PM
Dates	Signed By Date	Update	New Registration		1/24/2025 10:06:07 AM	2/27/2025 1:49 PM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	2/27/2025 1:49 PM
Addresses	Main Address	Insert	New Registration		135 S. Bryn Mawr Avenue Suite 240 Bryn Mawr, PA 19010	1/10/2025 11:32 AM
Addresses	Billing Address	Insert	New Registration		The Children's Hospital of Philadelphia PO Box 2015 Secaucus, NJ 07096	1/10/2025 11:32 AM
Addresses	Shipping Address	Insert	New Registration		THE CHILDREN'S HOSPITAL OF PHILADELPHIA KING OF PRUSSIA 550 South Goddard Blvd Hospital Pharmacy, Room 2420 King of Prussia, PA 19406	1/10/2025 11:32 AM
Addresses	Shipping Address	Insert	New Registration		CHILDRENS HOSPITAL OF PHILADELPHIA PHARMACY 3401 Civic Center Blvd Philadelphia, PA 19104	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007709910056	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		200017920	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4204301	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0729272	1/10/2025 11:32 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1215921457	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760576052	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1548330350	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1053917302	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1982325361	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1215921457	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760576052	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1548330350	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1053917302	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1982325361	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1215921457	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760576052	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1548330350	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1053917302	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1982325361	1/10/2025 11:32 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/10/2025 11:32 AM
Contacts	Primary Contact	Insert	New Registration		Dyke, Richard J. Director of Pharmacy Business Operations Children's Hospital of Philadelphia 2674265834	1/10/2025 11:32 AM
Contacts	Authorizing Official	Insert	New Registration		Boswinkel, Jan Pieter Senior Vice President & Chief Operating Officer, Hospital Operations Children's Hospital of Philadelphia 2155903055	1/10/2025 11:32 AM
Details	Assistance Received From Date	Insert	New Registration			1/10/2025 11:32 AM
Details	Assistance Received To Date	Insert	New Registration			1/10/2025 11:32 AM
Details	Last Recertification Date	Insert	New Registration			1/10/2025 11:32 AM
Details	Grant Number	Insert	New Registration			1/10/2025 11:32 AM
Details	340B ID	Insert	New Registration			1/10/2025 11:32 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2025 11:32 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2025 11:32 AM
Details	Medicare Provider Number	Insert	New Registration		393303	1/10/2025 11:32 AM
Details	Entity Name	Insert	New Registration		THE CHILDRENS HOSPITAL OF PHILADELP	1/10/2025 11:32 AM
Details	NOFO Number	Insert	New Registration			1/10/2025 11:32 AM
Details	Program Code	Insert	New Registration		PED	1/10/2025 11:32 AM
Details	Entity Subname	Insert	New Registration		Botox Therapy at Bryn Mawr	1/10/2025 11:32 AM
Dates	Participating Approval Date	Insert	New Registration			1/10/2025 11:32 AM
Details	State	Insert	New Registration		Pending	1/10/2025 11:32 AM
Dates	Registration Date	Insert	New Registration		1/10/2025 11:32:10 AM	1/10/2025 11:32 AM
Dates	Signed By Date	Insert	New Registration			1/10/2025 11:32 AM
Dates	Start Date	Insert	New Registration			1/10/2025 11:32 AM
Terminations	Termination Comments	Insert	New Registration			1/10/2025 11:32 AM
Terminations	Termination Date	Insert	New Registration			1/10/2025 11:32 AM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2025 11:32 AM
Terminations	Termination Reason	Insert	New Registration			1/10/2025 11:32 AM