Covered Entity Details

DSH260141EE University of Missouri Health Care (Active) - information as of 4/25/2025 6:34:47 PM

Main Details

Name

University of Missouri Health Care

Subdivision Name

ENT & AUDIOLOGY CLINIC - JC - ENT and Audiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260141EE

Medicare Provider Number

260141

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2025

Participating Start Date

4/1/2025

Participating Approval Date

3/6/2025

Last Recertification Date

Contacts

Authorizing Official

University of Missouri Health Care
KERI SIMON, Chief Operating Officer, Hospital Services
(573) 882-8359

Primary Contact

University of Missouri Health Care
Jacob Simons, Pharmacy Business Director
(573) 884-4614

Addresses

Street Address

1125 MADISON ST
JEFFERSON CITY, MO 65101-5227

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
MO	010565406,600092645,608080909	1699769901,1316931546,1427645613

Shipping Addresses

Shipping Address 1

Capital Region Medical Center
1125 Madison St
Jefferson City, MO 65101

Shipping Address 2

University Hospital
One Hospital Drive
Columbia, MO 65212

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
DSH260141A	Child	DSH	University of Missouri Health Care	SPMB Family Medicine Clinic	551 Veterans United Dr	Columbia	MO	Active
DSH260141AA	Child	DSH	University of Missouri Health Care	WCH Labor and Delivery	404 N. Keene Street	Columbia	MO	Terminated
DSH260141AB	Child	DSH	University of Missouri Health Care	WCH Endoscopy	404 N. Keene Street	Columbia	MO	Active
DSH260141AC	Child	DSH	University of Missouri Health Care	WCH CT	404 N. Keene Street	Columbia	MO	Active
DSH260141AD	Child	DSH	University of Missouri Health Care	Center for Reproductive Endocrinology and Fertility	500 N. Keene Street, Suite 203	Columbia	MO	Active
DSH260141AE	Child	DSH	University of Missouri Health Care	WCH Outpatient Pediatric OT	500 N. Keene St.	Columbia	MO	Terminated
DSH260141AF	Child	DSH	University of Missouri Health Care	WCH Urology & Continence Center	500 N. Keene Street	Columbia	MO	Terminated
DSH260141AG	Child	DSH	University of Missouri Health Care	Center for Female Incontinence and Pelvis Surgery	500 N. Keene Street	Columbia	MO	Active
DSH260141AH	Child	DSH	University of Missouri Health Care	WCH Ped Ortho Surgery Clinic	204 N. Keene Street	Columbia	MO	Active
DSH260141AJ	Child	DSH	University of Missouri Health Care	WCH Pre Operative Clinic	404 N. Keene Street	Columbia	MO	Terminated
DSH260141AK	Child	DSH	University of Missouri Health Care	WCH Surgery Clinic	404 N. Keene Street	Columbia	MO	Terminated
DSH260141AL	Child	DSH	University of Missouri Health Care	Children's Specialty Center	1020 Hitt Street	Columbia	MO	Active
DSH260141AM	Child	DSH	University of Missouri Health Care	UP- Rheumatology Clinic	1020 Hitt Street	Columbia	MO	Terminated
DSH260141AN	Child	DSH	University of Missouri Health Care	Weight Management and Metabolic Center	500 N Keene Street	Columbia	MO	Active
DSH260141AP	Child	DSH	University of Missouri Health Care	WCH Outpatient Pediatric PT	525 N. Keene St.	Columbia	MO	Terminated
DSH260141AQ	Child	DSH	University of Missouri Health Care	WCH Outpatient Pediatric SLP	500 N. Keene St.	Columbia	MO	Terminated
DSH260141AS	Child	DSH	University of Missouri Health Care	SPMB GENERAL PEDIATRICS CLINIC	551 Veterans United Dr	Columbia	MO	Active
DSH260141AT	Child	DSH	University of Missouri Health Care	SPMB ADULT PSYCHIATRY CLINIC	551 Veterans United Dr	Columbia	MO	Active
DSH260141AU	Child	DSH	University of Missouri Health Care	Comprehensive Pain Management Center	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141AV	Child	DSH	University of Missouri Health Care	Missouri Imaging Center	551 Veterans United Dr	Columbia	MO	Active
DSH260141AW	Child	DSH	University of Missouri Health Care	FAIRVIEW DIGESTIVE HEALTH CENTER	101 S. FAIRVIEW RD	COLUMBIA	MO	Active
DSH260141AX	Child	DSH	University of Missouri Health Care	DIGESTIVE HEALTH CENTER	101 S. FAIRVIEW RD	COLUMBIA	MO	Active
DSH260141AY	Child	DSH	University of Missouri Health Care	WOODRAIL RADIOLOGY	1000 W. NIFONG BLVD	COLUMBIA	MO	Terminated
DSH260141AZ	Child	DSH	University of Missouri Health Care	SMILEY LANE OB CLINIC	2325 SMILEY LANE	COLUMBIA	MO	Active
DSH260141BA	Child	DSH	University of Missouri Health Care	RAD PM AND R	315 BUSINESS LOOP 70W	COLUMBIA	MO	Terminated
DSH260141BB	Child	DSH	University of Missouri Health Care	PAIN CLINIC	3211 S. Providence	COLUMBIA	MO	Terminated
DSH260141BC	Child	DSH	University of Missouri Health Care	MISSOURI OCCUPATIONAL INJURY CENTER	1100 VIRGINIA AVE	COLUMBIA	MO	Terminated
DSH260141BD	Child	DSH	University of Missouri Health Care	MOI PRE-OP & POST-OP	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BE	Child	DSH	University of Missouri Health Care	MOI OPERATING ROOM	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BF	Child	DSH	University of Missouri Health Care	MOI DIAGNOSTIC RADIOLOGY	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BG	Child	DSH	University of Missouri Health Care	MOI-MRI	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BH	Child	DSH	University of Missouri Health Care	MOI ORTHOPEDIC CLINIC	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BJ	Child	DSH	University of Missouri Health Care	MOI PRE OPERATIVE CLINIC	1100 VIRGINIA AVE	COLUMBIA	MO	Active
DSH260141BK	Child	DSH	University of Missouri Health Care	ORTHOPAEDIC TRAUMA CLINIC	One Hospital Drive	COLUMBIA	MO	Active
DSH260141BL	Child	DSH	University of Missouri Health Care	RAD UP MED BLDG	1020 HITT ST	COLUMBIA	MO	Terminated
DSH260141BM	Child	DSH	University of Missouri Health Care	MIZZOU URGENT CARE	3916 S. Providence Rd, Suite 101	COLUMBIA	MO	Active
DSH260141BN	Child	DSH	University of Missouri Health Care	HEARING CENTER	525 N. KEENE STREET	COLUMBIA	MO	Active
DSH260141BP	Child	DSH	University of Missouri Health Care	HEARING, BALANCE & VOICE CENTER	525 N. KEENE STREET	COLUMBIA	MO	Active
DSH260141BQ	Child	DSH	University of Missouri Health Care	NEUROLOGY CLINIC	1020 HITT ST	COLUMBIA	MO	Active
DSH260141BR	Child	DSH	University of Missouri Health Care	DERMATOLOGY AND SKIN SURGERY CENTER	4230 Philips Farm Road	COLUMBIA	MO	Active
DSH260141BS	Child	DSH	University of Missouri Health Care	WCH ORTHOPEDICS MED SURG UNIT	404 N KEENE ST	COLUMBIA	MO	Terminated
DSH260141BT	Child	DSH	University of Missouri Health Care	WCH RECOVERY	404 N. KEENE ST	COLUMBIA	MO	Active
DSH260141BU	Child	DSH	University of Missouri Health Care	MATERNAL NURSING UNIT	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141BV	Child	DSH	University of Missouri Health Care	WCH NEONATAL INTENSIVE UNIT	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141BW	Child	DSH	University of Missouri Health Care	WCH WELLBABY NURSERY	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141BX	Child	DSH	University of Missouri Health Care	WCH PEDIATRIC ICU	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141BY	Child	DSH	University of Missouri Health Care	Children's Specialty Center - Cardiology	1020 Hitt Street	Columbia	MO	Active
DSH260141BZ	Child	DSH	University of Missouri Health Care	WCH PEDIATRIC URGENT CARE	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141C	Child	DSH	University of Missouri Health Care	MEDICINE SPECIALTY CLINIC UNIVERSITY HOSPITAL	1020 HITT ST	COLUMBIA	MO	Terminated
DSH260141CA	Child	DSH	University of Missouri Health Care	WCH RADIOLOGY DIAG	404 N. KEENE ST	COLUMBIA	MO	Active
DSH260141CB	Child	DSH	University of Missouri Health Care	WCH NUCLEAR MED	404 N. KEENE ST	COLUMBIA	MO	Active
DSH260141CC	Child	DSH	University of Missouri Health Care	WCH MRI	404 N. KEENE ST	COLUMBIA	MO	Active
DSH260141CD	Child	DSH	University of Missouri Health Care	WCH RADIOLOGY ORTHO CLINIC	404 N. KEENE ST	COLUMBIA	MO	Active
DSH260141CE	Child	DSH	University of Missouri Health Care	WCH OUTPATIENT SURGERY CENTER	404 N. KEENE ST	COLUMBIA	MO	Terminated
DSH260141CN	Child	DSH	University of Missouri Health Care	Cutaneous Micrographic Surgery	1020 Hitt St.	Columbia	MO	Terminated
DSH260141CO	Child	DSH	University of Missouri Health Care	Mizzou Therapy Services - Rangeline	4040 RANGELINE	Columbia	MO	Terminated
DSH260141CP	Child	DSH	University of Missouri Health Care	Woodrail Dermatology Clinic	1000 W. Nifong, Bldg. 2, Ste. 150	Columbia	MO	Terminated
DSH260141CQ	Child	DSH	University of Missouri Health Care	Mizzou PT Boonville	1420 West Ashley Rd.	Boonville	MO	Terminated
DSH260141CR	Child	DSH	University of Missouri Health Care	THOMPSON CENTER FOR AUTISM AND NEUR	205 PORTLAND STREET	COLUMBIA	MO	Active
DSH260141CS	Child	DSH	University of Missouri Health Care	WCH Interventional Radiology	404 N. Keene St.	Columbia	MO	Active
DSH260141CT	Child	DSH	University of Missouri Health Care	MIZZOU THERAPY SERVICES CHERRY HILL	2001 CORONA RD	COLUMBIA	MO	Terminated
DSH260141CU	Child	DSH	University of Missouri Health Care	MIZZOU THERAPY SERVICES PROVIDENCE	3916 S PROVIDENCE RD, STE 103	COLUMBIA	MO	Terminated
DSH260141CV	Child	DSH	University of Missouri Health Care	PM&R Clinic - Rangeline - Physical Medicine and Rehabilitation	4040 Range Line St	Columbia	MO	Terminated
DSH260141CW	Child	DSH	University of Missouri Health Care	WCH Med/Surgery Unit	404 N. Keene Street	Columbia	MO	Terminated
DSH260141CX	Child	DSH	University of Missouri Health Care	DIABETES CLINIC - Cosmopolitan International Diabetes & Endocrinology Center	3315 Berrywood Dr	COLUMBIA	MO	Active
DSH260141CY	Child	DSH	University of Missouri Health Care	COLUMBIA SURGICAL ASSOCIATES - Surgery	3220 BLUFF CREEK DR	COLUMBIA	MO	Active
DSH260141CZ	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE - ASHLAND - Family Medicine	101 REDTAIL DR	ASHLAND	MO	Active
DSH260141D	Child	DSH	University of Missouri Health Care	FAIRVIEW GENERAL INTERNAL MEDICINE CLINIC	101 SOUTH FAIRVIEW	COLUMBIA	MO	Active
DSH260141DA	Child	DSH	University of Missouri Health Care	COLUMBIA ENT - ENT	303 N KEENE ST	COLUMBIA	MO	Active
DSH260141DB	Child	DSH	University of Missouri Health Care	BATTLE MEDICAL CLINICS - Multispecialty Clinic	7115 E ST CHARLES RD	COLUMBIA	MO	Active
DSH260141DC	Child	DSH	University of Missouri Health Care	CHILD & ADOL PSYCHIATRY CLINIC - Child and Adolescent Psychiatry	1000 W NIFONG BLVD	COLUMBIA	MO	Active
DSH260141DD	Child	DSH	University of Missouri Health Care	COLUMBIA FAMILY MEDICAL GROUP - Family Medicine	303 N KEENE ST	COLUMBIA	MO	Terminated
DSH260141DE	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE - FULTON FAM HEALTH - Family Medicine	2613 FAIRWAY DR	FULTON	MO	Active
DSH260141DF	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE - BOONVILLE - Family Medicine	102 ISLE OF CAPRI BLVD	BOONVILLE	MO	Terminated
DSH260141DG	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE MEXICO - Family Medicine	3626 S CLARK STREET	MEXICO	MO	Active
DSH260141DH	Child	DSH	University of Missouri Health Care	MIZZOU URGENT CARE MEXICO - Urgent Care	3626 S CLARK STREET	MEXICO	MO	Active
DSH260141DJ	Child	DSH	University of Missouri Health Care	URGENT CARE - JACKSON ROAD - Urgent Care	516 JACKSON RD	BOONVILLE	MO	Active
DSH260141DK	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE - JACKSON ROAD - Family Medicine	516 JACKSON RD	BOONVILLE	MO	Active
DSH260141DL	Child	DSH	University of Missouri Health Care	DIGESTIVE HEALTH CLINIC - JC - Digestive Health	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DM	Child	DSH	University of Missouri Health Care	GOLDSCHMIDT CANCER CENTER - Oncology	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141DN	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC CALIFORNIA - Family Medicine	704 W Buchanan Highway 50 West	California	MO	Active
DSH260141DP	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - MADISON - Family Medicine	1014 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DQ	Child	DSH	University of Missouri Health Care	EMERGENCY DEPARTMENT JC - Emergency Medicine	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DR	Child	DSH	University of Missouri Health Care	CARDIAC REHABILITATION - SW BLVD - Cardiac Rehabilitation	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141DS	Child	DSH	University of Missouri Health Care	VASCULAR SURGERY CLINIC - JC - Vascular	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DT	Child	DSH	University of Missouri Health Care	EEG JC - Electroencephalography	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DU	Child	DSH	University of Missouri Health Care	URGENT CARE - TRUMAN BLVD - Urgent Care	3527 W TRUMAN BLVD, STE 100A	JEFFERSON CITY	MO	Active
DSH260141DV	Child	DSH	University of Missouri Health Care	RADIOLOGY MRI JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DW	Child	DSH	University of Missouri Health Care	RADIOLOGY CT GCC - Diagnostic Imaging	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141DX	Child	DSH	University of Missouri Health Care	RADIOLOGY CT JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141DY	Child	DSH	University of Missouri Health Care	PULMONARY REHABILITATION - SW BLVD - Outpatient Rehabilitation	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141DZ	Child	DSH	University of Missouri Health Care	NEUROLOGY CLINIC - JC - Neurology	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141E	Child	DSH	University of Missouri Health Care	SMILEY LANE FAMILY MEDICINE	2325 SMILEY LANE	COLUMBIA	MO	Active
DSH260141EA	Child	DSH	University of Missouri Health Care	NEXTGEN - PET - Diagnostic Imaging	1030 HITT ST	COLUMBIA	MO	Active
DSH260141EB	Child	DSH	University of Missouri Health Care	SURGERY CLINIC - MADISON - Surgery	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EC	Child	DSH	University of Missouri Health Care	PACU JC - Post Anesthesia Care Unit	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141ED	Child	DSH	University of Missouri Health Care	SLEEP DISORDER CENTER JC - Sleep Disorder Center	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EE	Child	DSH	University of Missouri Health Care	ENT & AUDIOLOGY CLINIC - JC - ENT and Audiology	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EF	Child	DSH	University of Missouri Health Care	RADIOLOGY DEXA JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EG	Child	DSH	University of Missouri Health Care	CARDIOLOGY JC - Cardiology	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EH	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - ELDON - Family Medicine	103 N BUSINESS 54	ELDON	MO	Active
DSH260141EJ	Child	DSH	University of Missouri Health Care	SURGERY CLINIC - CHRISTY - Surgery Clinic	1705 CHRISTY DR, STE 215	JEFFERSON CITY	MO	Active
DSH260141EK	Child	DSH	University of Missouri Health Care	RADIOLOGY MRI GCC - Diagnostic Imaging	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141EL	Child	DSH	University of Missouri Health Care	RADIOLOGY INTERVENTIONAL JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EM	Child	DSH	University of Missouri Health Care	WEIGHT MGMT & METABOLIC CTR - JC - Weight Management and Metabolic Center	3527 W TRUMAN BLVD, STE 300	JEFFERSON CITY	MO	Active
DSH260141EN	Child	DSH	University of Missouri Health Care	RADIOLOGY ULTRASOUND JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EP	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - OWENSVILLE - Family Medicine	3536 KUHNE RD	OWENSVILLE	MO	Active
DSH260141EQ	Child	DSH	University of Missouri Health Care	CATH LAB JC - Heart and Vascular	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141ER	Child	DSH	University of Missouri Health Care	EMERGENCY DEPARTMENT OBSERVATION JC - Emergency Medicine	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141ES	Child	DSH	University of Missouri Health Care	NEXTGEN - MRI - Diagnostic Imaging	1030 HITT ST	COLUMBIA	MO	Active
DSH260141ET	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - LINN - Family Medicine	916 E MAIN ST	LINN	MO	Active
DSH260141EU	Child	DSH	University of Missouri Health Care	VEIN CLINIC - JC - Vein Clinic	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EV	Child	DSH	University of Missouri Health Care	PODIATRY CLINIC - JC - Podiatry	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141EW	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - SW STE B - Family Medicine	1500 SOUTHWEST BLVD, STE B	JEFFERSON CITY	MO	Active
DSH260141EX	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - SW STE D - Family Medicine	1500 SOUTHWEST BLVD, STE D	JEFFERSON CITY	MO	Active
DSH260141EY	Child	DSH	University of Missouri Health Care	RADIOLOGY PET GCC - Diagnostic Imaging	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141EZ	Child	DSH	University of Missouri Health Care	DIALYSIS JC - Dialysis	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141F	Child	DSH	University of Missouri Health Care	UHC MISSOURI ORTHOPEDIC INSTITUTE	1100 VIRGINIA AVENUE	COLUMBIA	MO	Terminated
DSH260141FA	Child	DSH	University of Missouri Health Care	PAIN MANAGEMENT CLINIC - JC - Pain Management	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FB	Child	DSH	University of Missouri Health Care	RESPIRATORY THERAPY JC - Respiratory Therapy	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FC	Child	DSH	University of Missouri Health Care	MISSOURI ORTHOPAEDIC INSTITUTE - JC - Orthopedics	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FD	Child	DSH	University of Missouri Health Care	FAMILY MEDICINE CLINIC - VERSAILLES - Family Medicine	901 KIDWELL DR	VERSAILLES	MO	Active
DSH260141FE	Child	DSH	University of Missouri Health Care	Goldschmidt Cancer Center - Infusion - Infusion	1432 Southwest Blvd	Jefferson City	MO	Active
DSH260141FF	Child	DSH	University of Missouri Health Care	MENTAL WELLNESS CLINIC - Mental Wellness	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141FG	Child	DSH	University of Missouri Health Care	ENDOSCOPY GSC - Endoscopy	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FH	Child	DSH	University of Missouri Health Care	RADIATION THERAPY GCC - Radiation Therapy	1432 SOUTHWEST BLVD	JEFFERSON CITY	MO	Active
DSH260141FJ	Child	DSH	University of Missouri Health Care	OPERATING ROOM JC - Surgery	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FK	Child	DSH	University of Missouri Health Care	NUCLEAR MEDICINE JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FL	Child	DSH	University of Missouri Health Care	PM&R CLINIC - JC - Physical Medicine and Rehabilitation	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FM	Child	DSH	University of Missouri Health Care	OB/GYN CLINIC - JC - Obstetrics and Gynecology	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FN	Child	DSH	University of Missouri Health Care	PEDIATRICS CLINIC - JC - Pediatrics	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FP	Child	DSH	University of Missouri Health Care	ENT CLINIC JC - ENT	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FQ	Child	DSH	University of Missouri Health Care	INTERNAL MEDICINE CLINIC - JC - Internal Medicine	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FR	Child	DSH	University of Missouri Health Care	MAMMOGRAPHY JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FS	Child	DSH	University of Missouri Health Care	RADIOLOGY DIAGNOSTIC JC - Diagnostic Imaging	1125 MADISON ST	JEFFERSON CITY	MO	Active
DSH260141FT	Child	DSH	University of Missouri Health Care	EFCC Ambulatory Infusion Unit - Infusion Services	One Hospital Drive	Columbia	MO	Approved
DSH260141G	Child	DSH	University of Missouri Health Care	Physical Medicine & Rehabilitation Clinic at Rusk	315 Business Loop 70 West	Columbia	MO	Active
DSH260141H	Child	DSH	University of Missouri Health Care	UP Callaway Physicians	110 N. Hospital Drive	Fulton	MO	Active
DSH260141J	Child	DSH	University of Missouri Health Care	UP Fayette Medical Clinic	308 S. Church Street	Fayette	MO	Active
DSH260141K	Child	DSH	University of Missouri Health Care	JEFFERSON CITY DERMATOLOGY	2707 W. Edgewood	Jefferson City	MO	Active
DSH260141L	Child	DSH	University of Missouri Health Care	Keene Family Medicine Clinic	303 N Keene Street	Columbia	MO	Active
DSH260141M	Child	DSH	University of Missouri Health Care	ENT & Allergy Center	812 N. Keene Street	Columbia	MO	Active
DSH260141N	Child	DSH	University of Missouri Health Care	Woodrail General Internal Medicine Clinic	1000 W. Nifong	Columbia	MO	Active
DSH260141P	Child	DSH	University of Missouri Health Care	UP- Woodrail Family Medicine Clinic	1000 W. Nifong	Columbia	MO	Terminated
DSH260141Q	Child	DSH	University of Missouri Health Care	WCH ER	404 N. Keene Street	Columbia	MO	Terminated
DSH260141R	Child	DSH	University of Missouri Health Care	Maternal Fetal Care Center	1020 Hitt Street	Columbia	MO	Active
DSH260141S	Child	DSH	University of Missouri Health Care	WCH Pediatric Short Stay and Children's Blood Disorders & Cancer Unit	500 N. Keene Street	Columbia	MO	Terminated
DSH260141T	Child	DSH	University of Missouri Health Care	University Eye Institute East	3215 Wingate Court	Columbia	MO	Active
DSH260141U	Child	DSH	University of Missouri Health Care	WCH Pediatrics	404 N. Keene Street	Columbia	MO	Terminated
DSH260141V	Child	DSH	University of Missouri Health Care	Obstetrics & Gynecology Clinic	1020 Hitt Street	Columbia	MO	Active
DSH260141W	Child	DSH	University of Missouri Health Care	WCH Adolescent Unit	404 N. Keene Street	Columbia	MO	Terminated
DSH260141X	Child	DSH	University of Missouri Health Care	WCH Surgery	404 N. Keene Street	Columbia	MO	Active
DSH260141Z	Child	DSH	University of Missouri Health Care	WCH ER OB Triage	404 N. Keene Street	Columbia	MO	Terminated

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		SIMON, KERI Chief Operating Officer, Hospital Services University of Missouri Health Care 5738828359	3/6/2025 10:03 AM
Details	340B ID	Update	New Registration		DSH260141EE	3/6/2025 10:03 AM
Details	Entity Name	Update	New Registration	UNIV OF MISSOURI HEALTH CARE	University of Missouri Health Care	3/6/2025 10:03 AM
Details	Entity Subname	Update	New Registration	ENT & AUDIOLOGY CLINIC - JC	ENT & AUDIOLOGY CLINIC - JC - ENT and Audiology	3/6/2025 10:03 AM
Dates	Participating Approval Date	Update	New Registration		3/6/2025 10:03:31 AM	3/6/2025 10:03 AM
Details	State	Update	New Registration	Pending	Approved	3/6/2025 10:03 AM
Dates	Signed By Date	Update	New Registration		1/15/2025 6:19:41 PM	3/6/2025 10:03 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	3/6/2025 10:03 AM
Contacts	Authorizing Official	Update	Profile Change Request	SIMON, KERI Interim Chief Operating Officer University of Missouri Health Care 5738828359	SIMON, KERI Chief Operating Officer, Hospital Services University of Missouri Health Care 5738828359	1/28/2025 12:57 PM
Addresses	Main Address	Insert	New Registration		1125 MADISON ST JEFFERSON CITY, MO 65101-5227	1/13/2025 1:19 PM
Addresses	Shipping Address	Insert	New Registration		Capital Region Medical Center 1125 Madison St Jefferson City, MO 65101	1/13/2025 1:19 PM
Addresses	Shipping Address	Insert	New Registration		University Hospital One Hospital Drive Columbia, MO 65212	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010565406	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600092645	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		608080909	1/13/2025 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1699769901	1/13/2025 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316931546	1/13/2025 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427645613	1/13/2025 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/13/2025 1:19 PM
Contacts	Authorizing Official	Insert	New Registration		SIMON, KERI Interim Chief Operating Officer University of Missouri Health Care 5738828359	1/13/2025 1:19 PM
Contacts	Primary Contact	Insert	New Registration		Simons, Jacob Pharmacy Business Director University of Missouri Health Care 5738844614	1/13/2025 1:19 PM
Details	Assistance Received From Date	Insert	New Registration			1/13/2025 1:19 PM
Details	Assistance Received To Date	Insert	New Registration			1/13/2025 1:19 PM
Details	Last Recertification Date	Insert	New Registration			1/13/2025 1:19 PM
Details	Grant Number	Insert	New Registration			1/13/2025 1:19 PM
Details	340B ID	Insert	New Registration			1/13/2025 1:19 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2025 1:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2025 1:19 PM
Details	Medicare Provider Number	Insert	New Registration		260141	1/13/2025 1:19 PM
Details	Entity Name	Insert	New Registration		UNIV OF MISSOURI HEALTH CARE	1/13/2025 1:19 PM
Details	NOFO Number	Insert	New Registration			1/13/2025 1:19 PM
Details	Program Code	Insert	New Registration		DSH	1/13/2025 1:19 PM
Details	Entity Subname	Insert	New Registration		ENT & AUDIOLOGY CLINIC - JC	1/13/2025 1:19 PM
Dates	Participating Approval Date	Insert	New Registration			1/13/2025 1:19 PM
Details	State	Insert	New Registration		Pending	1/13/2025 1:19 PM
Dates	Registration Date	Insert	New Registration		1/13/2025 1:19:10 PM	1/13/2025 1:19 PM
Dates	Signed By Date	Insert	New Registration			1/13/2025 1:19 PM
Dates	Start Date	Insert	New Registration			1/13/2025 1:19 PM
Terminations	Termination Comments	Insert	New Registration			1/13/2025 1:19 PM
Terminations	Termination Date	Insert	New Registration			1/13/2025 1:19 PM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2025 1:19 PM
Terminations	Termination Reason	Insert	New Registration			1/13/2025 1:19 PM