Covered Entity Details

DSH070024J THE WILLIAM W. BACKUS HOSPITAL (Approved) - information as of 4/27/2025 11:39:01 PM

Main Details

Name

THE WILLIAM W. BACKUS HOSPITAL

Subdivision Name

Backus Infusion Center - Willimantic - infusion

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070024J

Medicare Provider Number

070024

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/3/2025

Last Recertification Date

Contacts

Authorizing Official

Hartford HealthCare
Anthony Mastroianni, Regional Vice President, Finance
(860) 889-8331 Ext: 2311

Primary Contact

Hartford HealthCare
Elyse Anna Lanteigne, 340B Program Manager
(860) 972-5030

Addresses

Street Address

5 Founders Street
Suite 200
Willimantic, CT 06226

Billing Address

The William W. Backus Hospital
PO BOX 5037
Attn: Accounts Payable
Hartford, CT 06102

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
CT	004041851,004025144	1639135718,1730243536,1467517235

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
DSH070024A	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Hartford Healthcare Cancer Institute Backus Hospital - Waterford Infusion Center - Infusion	5 Dayton Road	Waterford	CT	Active
DSH070024B	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	BACKUS CENTER FOR SPECIALTY CARE - Plainfield Infusion Center - Infusion	584 NORWICH RD	Plainfield	CT	Active
DSH070024C	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Waterford Med ONC CI - Medical Oncology Group at Waterford - oncology	5 Dayton Road	Waterford	CT	Active
DSH070024D	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	BH Infectious Disease - Infectious Disease - Infectious Disease	107 Lafayette St	Norwich	CT	Active
DSH070024E	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Backus Outpatient Care Center Nutrition - BH Diabetes and Nutrition Services - Diabetes	111 Salem Turnpike	Norwich	CT	Active
DSH070024F	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Plainfield ED / Emergency Department - Emergency	582 Norwich Road	Plainfield	CT	Active
DSH070024G	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Backus Outpatient Care Center Rheumatology - Rheumatology	111 Salem Turnkpike	Norwich	CT	Active
DSH070024H	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Backus Outpatient Care Center Endocrinology - Endocrinology	111 Salem Turnkpike	Norwich	CT	Active
DSH070024J	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Backus Infusion Center - Willimantic - infusion	5 Founders Street	Willimantic	CT	Approved
DSH070024K	Child	DSH	THE WILLIAM W. BACKUS HOSPITAL	Backus MED ONC CI- Willimantic - Oncology	5 Founders Street	Willimantic	CT	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Mastroianni, Anthony Regional Vice President, Finance Hartford HealthCare 8608898331-2311	4/3/2025 12:30 PM
Details	340B ID	Update	New Registration		DSH070024J	4/3/2025 12:30 PM
Details	Entity Subname	Update	New Registration	Backus Infusion Center - Willimantic	Backus Infusion Center - Willimantic - infusion	4/3/2025 12:30 PM
Dates	Participating Approval Date	Update	New Registration		4/3/2025 12:30:18 PM	4/3/2025 12:30 PM
Details	State	Update	New Registration	Pending	Approved	4/3/2025 12:30 PM
Dates	Signed By Date	Update	New Registration		4/2/2025 3:12:07 PM	4/3/2025 12:30 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/3/2025 12:30 PM
Addresses	Main Address	Insert	New Registration		5 Founders Street Suite 200 Willimantic, CT 06226	4/1/2025 10:43 AM
Addresses	Billing Address	Insert	New Registration		The William W. Backus Hospital PO BOX 5037 Attn: Accounts Payable Hartford, CT 06102	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004041851	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004025144	4/1/2025 10:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/1/2025 10:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1639135718	4/1/2025 10:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/1/2025 10:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1730243536	4/1/2025 10:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/1/2025 10:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1467517235	4/1/2025 10:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/1/2025 10:43 AM
Contacts	Authorizing Official	Insert	New Registration		Mastroianni, Anthony Regional Vice President, Finance Hartford HealthCare 8608898331-2311	4/1/2025 10:43 AM
Contacts	Primary Contact	Insert	New Registration		Lanteigne, Elyse Anna 340B Program Manager Hartford HealthCare 8609725030	4/1/2025 10:43 AM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 10:43 AM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 10:43 AM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 10:43 AM
Details	Grant Number	Insert	New Registration			4/1/2025 10:43 AM
Details	340B ID	Insert	New Registration			4/1/2025 10:43 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 10:43 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 10:43 AM
Details	Medicare Provider Number	Insert	New Registration		070024	4/1/2025 10:43 AM
Details	Entity Name	Insert	New Registration		THE WILLIAM W. BACKUS HOSPITAL	4/1/2025 10:43 AM
Details	NOFO Number	Insert	New Registration			4/1/2025 10:43 AM
Details	Program Code	Insert	New Registration		DSH	4/1/2025 10:43 AM
Details	Entity Subname	Insert	New Registration		Backus Infusion Center - Willimantic	4/1/2025 10:43 AM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 10:43 AM
Details	State	Insert	New Registration		Pending	4/1/2025 10:43 AM
Dates	Registration Date	Insert	New Registration		4/1/2025 10:43:42 AM	4/1/2025 10:43 AM
Dates	Signed By Date	Insert	New Registration			4/1/2025 10:43 AM
Dates	Start Date	Insert	New Registration			4/1/2025 10:43 AM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 10:43 AM
Terminations	Termination Date	Insert	New Registration			4/1/2025 10:43 AM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 10:43 AM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 10:43 AM