Covered Entity Details

DSH390115T Jefferson Health Northeast (Active) - information as of 6/13/2025 3:00:35 PM

Main Details

Name

Jefferson Health Northeast

Subdivision Name

Bucks Campus Speech - - Speech Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH390115T

Medicare Provider Number

390115

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/27/2025

Last Recertification Date

Contacts

Authorizing Official

Jefferson Health
CARRIE FREY, Director of Finance
(215) 612-4313

Primary Contact

Jefferson Health
Dustin Ottemiller, VP, Finance
(215) 503-5219

Addresses

Street Address

380 N. Oxford Valley Road
Langhorne, PA 19047

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
PA	1007705250041	1205904885

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
DSH390115A	Child	DSH	Jefferson Health Northeast	Frankford Campus - Emergency Room	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AA	Child	DSH	Jefferson Health Northeast	Bucks Campus X-Ray - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AB	Child	DSH	Jefferson Health Northeast	Frankford Campus X-Ray - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AC	Child	DSH	Jefferson Health Northeast	Bucks Campus Nuc Med - - Nuclear Medicine	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AD	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Nuclear Medicine	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AE	Child	DSH	Jefferson Health Northeast	Bucks Campus Electrocardiology - - Cardiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AF	Child	DSH	Jefferson Health Northeast	Bucks Campus Mammography - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AG	Child	DSH	Jefferson Health Northeast	Bucks Campus - - Respiratory Therapy	380 N. Oxford Valley Road	Philadelphia	PA	Active
DSH390115AH	Child	DSH	Jefferson Health Northeast	Bucks Campus - - Heart Station - EEG	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AJ	Child	DSH	Jefferson Health Northeast	Frankford Campus CT - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AK	Child	DSH	Jefferson Health Northeast	Frankford Campus US - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AL	Child	DSH	Jefferson Health Northeast	Frankford Campus Mammo - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AM	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Cardiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AN	Child	DSH	Jefferson Health Northeast	Frankford Campus Heart Station - - EEG	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AP	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Respiratory Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115B	Child	DSH	Jefferson Health Northeast	Frankford Campus - OP Operating Room	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115C	Child	DSH	Jefferson Health Northeast	Bucks Campus - Cardiac Cath Lab	380 N. Oxford Valley Rd.	Langhorne	PA	Active
DSH390115D	Child	DSH	Jefferson Health Northeast	Bucks Campus - Operating Room	380 N. Oxford Valley Rd.	Langhorne	PA	Active
DSH390115E	Child	DSH	Jefferson Health Northeast	Bucks Campus - Emergency Room	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115F	Child	DSH	ARIA HEALTH	Aria Health Bucks Wound Care - Wound Care	380 N. Oxford Valley Rd.	Langhorne	PA	Terminated
DSH390115G	Child	DSH	ARIA HEALTH	Aria Health Frankford Wound Care - Wound Care	5000 Frankford Ave.	Philadelphia	PA	Terminated
DSH390115H	Child	DSH	Jefferson Health Northeast	Torresdale Cardiac Rehabilitation - Cardiac Rehabilitation	3998 Red Lion Rd	Philadelphia	PA	Active
DSH390115J	Child	DSH	Jefferson Health Northeast	PET Roosevelt Blvd - PET Scan	2451 Grant Ave.	Philadelphia	PA	Active
DSH390115K	Child	DSH	Jefferson Health Northeast	MRI Roosevelt Blvd - MRI	2451 Grant Ave.	Philadelphia	PA	Active
DSH390115L	Child	DSH	Jefferson Health Northeast	Bucks OP Physical Therapy - Physical Therapy	131 Lincoln Highway	Fairless Hills	PA	Active
DSH390115M	Child	DSH	Jefferson Health Northeast	Bucks Hospital - Sleep Lab - Sleep Lab	131 Lincoln Highway	Fairless Hills	PA	Active
DSH390115N	Child	DSH	Jefferson Health Northeast	Torresdale Hospital - OP Rehab - Physical and Occupational Therapy	10700 Knights Rd.	Philadelphia	PA	Active
DSH390115P	Child	DSH	Jefferson Health Northeast	Torresdale Hospital - OP Speech Therapy - Speech Therapy	10700 Knights Rd.	Philadelphia	PA	Active
DSH390115Q	Child	DSH	Jefferson Health Northeast	Frankford Campus PT - - Physical Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115R	Child	DSH	Jefferson Health Northeast	Bucks Campus PT - - Physical Therapy	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115S	Child	DSH	Jefferson Health Northeast	Frankford Campus Rehab - - Speech Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115T	Child	DSH	Jefferson Health Northeast	Bucks Campus Speech - - Speech Therapy	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115U	Child	DSH	Jefferson Health Northeast	Bucks Campus IR - - Interventional Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115V	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Interventional Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115W	Child	DSH	Jefferson Health Northeast	Bucks Campus Radiology - - CT	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115X	Child	DSH	Jefferson Health Northeast	Bucks Campus US - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115Y	Child	DSH	Jefferson Health Northeast	Bucks Campus MRI - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115Z	Child	DSH	Jefferson Health Northeast	Frankford Campus MRI - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2156124313	FREY, CARRIE Director of Finance Jefferson Health 2156124313	4/11/2025 8:54 AM
Contacts	Signed By	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2156124313	FREY, CARRIE Director of Finance Jefferson Health 2156124313	4/11/2025 8:54 AM
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		FREY, CARRIE Director of Finance Aria Health 2156124313	1/27/2025 9:03 AM
Details	340B ID	Update	New Registration		DSH390115T	1/27/2025 9:03 AM
Details	Entity Name	Update	New Registration	ARIA HEALTH	Jefferson Health Northeast	1/27/2025 9:03 AM
Details	Entity Subname	Update	New Registration	Bucks Campus Speech -	Bucks Campus Speech - - Speech Therapy	1/27/2025 9:03 AM
Dates	Participating Approval Date	Update	New Registration		1/27/2025 9:03:28 AM	1/27/2025 9:03 AM
Details	State	Update	New Registration	Pending	Approved	1/27/2025 9:03 AM
Dates	Signed By Date	Update	New Registration		1/15/2025 11:18:19 PM	1/27/2025 9:03 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/27/2025 9:03 AM
Addresses	Main Address	Insert	New Registration		380 N. Oxford Valley Road Langhorne, PA 19047	1/15/2025 11:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2025 11:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007705250041	1/15/2025 11:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2025 11:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205904885	1/15/2025 11:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2025 11:18 PM
Contacts	Primary Contact	Insert	New Registration		Ottemiller, Dustin VP, Finance Jefferson Health 2155035219	1/15/2025 11:18 PM
Contacts	Authorizing Official	Insert	New Registration		FREY, CARRIE Director of Finance Aria Health 2156124313	1/15/2025 11:18 PM
Details	Assistance Received From Date	Insert	New Registration			1/15/2025 11:18 PM
Details	Assistance Received To Date	Insert	New Registration			1/15/2025 11:18 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2025 11:18 PM
Details	Grant Number	Insert	New Registration			1/15/2025 11:18 PM
Details	340B ID	Insert	New Registration			1/15/2025 11:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2025 11:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2025 11:18 PM
Details	Medicare Provider Number	Insert	New Registration		390115	1/15/2025 11:18 PM
Details	Entity Name	Insert	New Registration		ARIA HEALTH	1/15/2025 11:18 PM
Details	NOFO Number	Insert	New Registration			1/15/2025 11:18 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2025 11:18 PM
Details	Entity Subname	Insert	New Registration		Bucks Campus Speech -	1/15/2025 11:18 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2025 11:18 PM
Details	State	Insert	New Registration		Pending	1/15/2025 11:18 PM
Dates	Registration Date	Insert	New Registration		1/15/2025 11:18:17 PM	1/15/2025 11:18 PM
Dates	Signed By Date	Insert	New Registration			1/15/2025 11:18 PM
Dates	Start Date	Insert	New Registration			1/15/2025 11:18 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2025 11:18 PM
Terminations	Termination Date	Insert	New Registration			1/15/2025 11:18 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2025 11:18 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2025 11:18 PM