Covered Entity Details

DSH390111DV THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA (Approved) - information as of 4/23/2025 10:53:21 PM

Main Details

Name

THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA

Subdivision Name

Department of Surgery Valley Forge - Surg Onc, Thoracic, Breast Surgery

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390111DV

Medicare Provider Number

390111

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/4/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/10/2025

Last Recertification Date

Contacts

Authorizing Official

Hospital of the University of Pennsylvania
Elaine Maria Shiffler, Chief Financial Officer
(215) 662-6684

Primary Contact

The Hospital of the University of Pennsylvania
Alison Apple, Chief Pharmacy Officer
(215) 615-4710

Addresses

Street Address

1001 Chesterbrook Blvd
2nd Floor
Berwyn, PA 19312

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	100125877,1001258770050,1001258770069,1001258770178,1001258770208,1001258770210,1001258770265,1001258770270,1001258770281,1001258770285,1001258770288,1001258770289,1001258770290,1001258770291,1001258770292,1001258770294,1001258770295,1001258770296,1001258770297,1001258770298,1001258770299,1001258770300,1001258770301,1001258770302,1001258770303,1001258770304,1001258770305,1001258770306,1001258770307,1001258770308,1001258770309,1001258770312,1001258770313,1001258770314,1001258770315,1001258770316,1001258770317,1001258770318,1001258770319,1001258770320,1001258770321,1001258770322,1001258770323,1001258770324	1124882949,1295438182,1295706422,1366835910,1417114117,1487865036,1629128814,1659047611,1659829877,1679544803,1699782664,1770647133,1780311654,1821760604,1851370910,1922029982,1972279917,1972780419,1992788350

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
DSH390111A	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PENN HOME INFUSION THERAPY	625 CLARK AVENUE	KING OF PRUSSIA	PA	Active
DSH390111AA	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Renal	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AB	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rheumatology-HUP	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AC	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Gen Med - Silverstein Suite A	3701 Market St	Philadelphia	PA	Active
DSH390111AD	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Cardiology Heart Failure	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AE	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Endocrinology-1MAL (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AF	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	HEM/ONC - 12 Penn Tower	3400 Civic Center Blvd	Philadelphia	PA	Terminated
DSH390111AG	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Dr Michael Cirigliano (MAPS)	3701 Market St	Philadelphia	PA	Active
DSH390111AH	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Neuroendocrine (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AJ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN-General Practice	3701 Market St	Philadelphia	PA	Active
DSH390111AK	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN - Reproductive Endocrinology	3701 Market St	Philadelphia	PA	Active
DSH390111AL	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN - Oncology	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AM	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN - IVF Lab Practice	3701 Market St	Philadelphia	PA	Terminated
DSH390111AN	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN - RSF	3701 Market St	Philadelphia	PA	Terminated
DSH390111AP	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Ophthalmology (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AQ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rehab Services	1800 Lombard St	Philadelphia	PA	Active
DSH390111AR	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Surgery-HUP MAPS	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AS	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Surgery - Plastic	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AT	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	CAM West MAPS	3400 Civic Center Blvd	Philadelphia	PA	Terminated
DSH390111AU	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Urology-HUP	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AV	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	EXERCISE LAB	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AW	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	GASTROENTEROLOGY	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AX	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PCAM HEART VASCULAR CTR (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AY	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	CARDIO GROUND RHOADS	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111AZ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB/GYN - REI Urology	3701 Market Street	Philadelphia	PA	Active
DSH390111B	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA		3400 SPRUCE STREET	PHILADELPHIA	PA	Terminated
DSH390111BA	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Chemotherapy Valley Forge	1001 Chesterbrook Boulevard	Berwyn	PA	Active
DSH390111BB	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	OB-GYN SHARED POD 5	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BC	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - UROLOGY	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BD	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - NEUROLOGY	250 KING OF PRUSSIA ROAD	RADNOR	PA	Terminated
DSH390111BE	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	COUMADIN CLINIC	3701 MARKET STREET	PHILADELPHIA	PA	Active
DSH390111BG	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - ORTHO	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BH	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	ALLERGY	3737 MARKET ST	PHILADELPHIA	PA	Terminated
DSH390111BJ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - REHAB	145 KING OF PRUSSIA RD	RADNOR	PA	Active
DSH390111BK	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	BUCKS CLINIC- DERM / MEDICAL DERM, SURGICAL DERM, PHOTOTHERAPY	1000 FLORAL VALE BLVD	YARDLEY	PA	Active
DSH390111BL	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PSYCHIATRY	3535 MARKET ST	PHILADELPHIA	PA	Active
DSH390111BM	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	CLINIC - DERMATOLOGY / DERM, DERMPATH, DERM SURG PCAM, IMMUNO, PHOTOTHERAPY, PIGMENTED LESION, PSORIASIS	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111BN	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PHOTOTHERAPY	3600 SPRUCE ST	PHILADELPHIA	PA	Terminated
DSH390111BP	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - OPTH	145 KING OF PRUSSIA RD	RADNOR	PA	Active
DSH390111BQ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - ORAL MAX	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BR	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - OTO / OTO, AUDIOLOGY	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BS	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC / OBGYN	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BT	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC / DERM MEDICAL, SURGICAL, COSMETIC	145 KING OF PRUSSIA RD	RADNOR	PA	Active
DSH390111BU	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC / MEDICINE	145 KING OF PRUSSIA ROAD	RADNOR	PA	Active
DSH390111BV	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	DIABETES-DR SCHWARTZ	3737 MARKET ST	PHILADELPHIA	PA	Terminated
DSH390111BW	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Clinic-Orthopaedics - Perelman Center for Advanced Medicine	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111BX	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Hyperbaric Medicine	3620 Hamilton Walk	Philadelphia	PA	Active
DSH390111BY	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	MALVERN SLEEP LAB	12 E Swedesford Rd	Malvern	PA	Active
DSH390111BZ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	DOYLESTOWN/SLEEP DISORDERS	599 W State St	Doylestown	PA	Terminated
DSH390111C	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PENN MEDICINE RADNOR	250 King of Prussia Road	Radnor	PA	Terminated
DSH390111CA	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Clinic-Oral Surgery Perelman Center for Advanced Medicine	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CB	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Clinic-Rehabilitation Perelman Center for Advanced Medicine	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CC	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	TRAVEL MEDICINE ER-RADNOR MAPS	250 King of Prussia Road	Radnor	PA	Terminated
DSH390111CD	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Clinic-Medicine Perelman Center for Advanced Medicine / Pulmonary/Perelman Center for Advanced Medicine Lung Center	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CE	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Physical Therapy Perelman Center for Advanced Medicine / OP Lung Rehab	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CF	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Speech Pathology Perelman Center for Advanced Medicine / Hearing/Speech/Taste/Smell	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CH	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	MRI Perelman Center for Advanced Medicine	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CJ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RAD - LANGHORNE	777 Township Line Road	Yardley	PA	Active
DSH390111CK	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	NEUROSURGERY (MAPS) Perelman Center for Advanced Medicine	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CL	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	NEUROLOGY (MAPS) PCAM	3400 Civic Center Blvd	Phildelphia	PA	Active
DSH390111CM	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RAD ONCOLOGY CHESTNUT HILL	8835 Germantown Avenue	Philadelphia	PA	Active
DSH390111CN	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RAD ONC DOYLESTOWN	599 West State Street	Doylestown	PA	Active
DSH390111CP	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADIOLOGY-THERAPEUTIC Valley Forge	1001 Chesterbrook Boulevard	Berwyn	PA	Active
DSH390111CQ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADIOLOGY-DIAGNOSTIC Videoflouroscopy (VF) / Positron Emission Topography (PET) and Radiology	1001 Chesterbrook Boulevard	Berwyn	PA	Active
DSH390111CR	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	ANGIOGRAPHY	3400 Civic Center Blvd	Philadelphia	PA	Terminated
DSH390111CS	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	CLINIC - OTORHINOLARYNGOLOGY	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CT	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADNOR CLINIC - SURGERY	250 King of Prussia Road	Radnor	PA	Terminated
DSH390111CU	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	RADIOLOGY DIAGNOSTIC CAM	3400 Civic Center Blvd	Phildelphia	PA	Active
DSH390111CV	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	ULTRASOUND	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CW	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	NUCLEAR MEDICINE	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111CX	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Infusion PMR - Infusion Therapy	145 King of Prussia	Radnor	PA	Active
DSH390111CY	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PMR ENDO Proc - Endoscopy	145 King of Prussia Rd	Radnor	PA	Active
DSH390111CZ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PMR OR - Ambulatory Surgery	145 King of Prussia Rd	Radnor	PA	Active
DSH390111D	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PCAM Surgicenter	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111DA	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Neurodiagnostics PMR - Neurodiagnostics	145 King of Prussia Rd	Radnor	PA	Active
DSH390111DB	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Radiation Oncology Treatment PMR - Rad Onc	145 King of Prussia Rd	Radnor	PA	Active
DSH390111DC	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Sleep Medicine University City - Sleep Medicine University City	3549 Chestnut Street	Philadelphia	PA	Active
DSH390111DD	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Hematology Oncology Valley Forge - Hem Onc	1001 Chesterbrook Blvd	Berwyn	PA	Active
DSH390111DE	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Radiation Oncology Valley Forge - Radiation Oncology	1001 Chesterbrook Blvd	Berwyn	PA	Active
DSH390111DF	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Sleep Lab Market Street - Sleep Lab	3624 Market Street	Philadelphia	PA	Active
DSH390111DG	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PBH Ralston House - Psychiatry Clinic	3615 Chestnut Street	Philadelphia	PA	Active
DSH390111DH	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	INFUSION EXTON - Infusion Exton	700 WEST LINCOLN HWY	EXTON	PA	Active
DSH390111DJ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	INFUSION KENNETT SQUARE - Infusion Kennett Square	400 MCFARLAN ROAD	KENNETT SQUARE	PA	Active
DSH390111DK	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	INFUSION WEST CHESTER - Infusion West Chester	440 E MARSHALL STREET	WEST CHESTER	PA	Active
DSH390111DL	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Radnor Clinic Department of Surgery - Radnor Department of Surgery	145 King of Prussia Road	Radnor	PA	Active
DSH390111DM	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	BREAST SURGERY HUP KENNETT SQUARE - Breast Surgery Kennett Square	400 MCFARLAN ROAD	KENNETT SQUARE	PA	Active
DSH390111DN	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	GYNECOLOGIC SURGERY HUP WESTCHESTER - Gynecologic Surgery Westchester	440 E MARSHALL STREET	WEST CHESTER	PA	Active
DSH390111DP	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	HEMONC KENNETT SQUARE - HemOnc Kennett Square	400 MCFARLAN ROAD	KENNETT SQUARE	PA	Active
DSH390111DQ	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	HEMONC WEST CHESTER - HemOnc West Chester	440 E MARSHALL STREET	WEST CHESTER	PA	Active
DSH390111DR	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	HEMONC EXTON - HemOnc Exton	700 WEST LINCOLN HWY	EXTON	PA	Active
DSH390111DS	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	THORACIC SURGERY HUP WEST CHESTER - Thoracic Surgery West Chester	440 E MARSHALL STREET	WEST CHESTER	PA	Active
DSH390111DT	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad Onc Clinic Radnor - Rad Onc	145 King of Prussia Road	Radnor	PA	Approved
DSH390111DU	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Neurology and Neurosurgery Radnor - Neurology and Neurosurgery	145 King of Prussia Road	Radnor	PA	Approved
DSH390111DV	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Department of Surgery Valley Forge - Surg Onc, Thoracic, Breast Surgery	1001 Chesterbrook Blvd	Berwyn	PA	Approved
DSH390111DW	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Gyn Onc Valley Forge - Gyn Onc Valley Forge	1001 Chesterbrook Blvd	Berwyn	PA	Approved
DSH390111E	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	PCAM Endo Proc	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111F	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Periop Anesth Materials SC	3400 Civic Center Blvd	Philadelphia	PA	Terminated
DSH390111G	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Chemotherapy	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111J	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Radiation Therapy	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111K	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Proton	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111L	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad IR CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111M	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad MR CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111N	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad PET CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111P	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad GI/GU CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111Q	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad CT CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111R	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Rad Mammography CAM	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111S	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Radiology - Radnor	145 King of Prussia Road	Radnor	PA	Active
DSH390111T	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Clinic	3400 Civic Center Blvd	Philadelphia	PA	Terminated
DSH390111U	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Dermsurg	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111V	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Gen Med - 9 PT East (MAPS)	3701 Market St	Philadelphia	PA	Active
DSH390111W	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Gen Med - 10 Penn Tower	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111X	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Diabetes-3Ravdin (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active
DSH390111Y	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Geriatrics	3615 Chestnut St	Philadelphia	PA	Active
DSH390111Z	Child	DSH	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	Pulmonary (MAPS)	3400 Civic Center Blvd	Philadelphia	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Shiffler, Elaine Maria Chief Financial Officer Hospital of the University of Pennsylvania 2156626684	4/10/2025 9:55 AM
Details	340B ID	Update	New Registration		DSH390111DV	4/10/2025 9:55 AM
Details	Entity Name	Update	New Registration	HOSPITAL OF THE UNIV OF PENNA	THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA	4/10/2025 9:55 AM
Details	Entity Subname	Update	New Registration	Department of Surgery Valley Forge	Department of Surgery Valley Forge - Surg Onc, Thoracic, Breast Surgery	4/10/2025 9:55 AM
Dates	Participating Approval Date	Update	New Registration		4/10/2025 9:55:52 AM	4/10/2025 9:55 AM
Details	State	Update	New Registration	Pending	Approved	4/10/2025 9:55 AM
Dates	Signed By Date	Update	New Registration		4/4/2025 5:12:27 PM	4/10/2025 9:55 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/10/2025 9:55 AM
Addresses	Main Address	Insert	New Registration		1001 Chesterbrook Blvd 2nd Floor Berwyn, PA 19312	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100125877	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770050	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770069	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770178	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770208	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770210	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770265	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770270	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770281	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770285	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770288	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770289	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770290	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770291	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770292	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770294	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770295	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770296	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770297	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770298	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770299	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770300	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770301	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770302	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770303	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770304	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770305	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770306	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770307	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770308	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770309	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770312	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770313	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770314	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770315	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770316	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770317	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770318	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770319	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770320	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770321	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770322	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770323	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001258770324	4/4/2025 2:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124882949	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1295438182	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1295706422	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366835910	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417114117	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1487865036	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629128814	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659047611	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659829877	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1679544803	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1699782664	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770647133	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1780311654	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1821760604	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1851370910	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922029982	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972279917	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972780419	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992788350	4/4/2025 2:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/4/2025 2:52 PM
Contacts	Primary Contact	Insert	New Registration		Apple, Alison Chief Pharmacy Officer The Hospital of the University of Pennsylvania 2156154710	4/4/2025 2:52 PM
Contacts	Authorizing Official	Insert	New Registration		Shiffler, Elaine Maria Chief Financial Officer Hospital of the University of Pennsylvania 2156626684	4/4/2025 2:52 PM
Details	Assistance Received From Date	Insert	New Registration			4/4/2025 2:52 PM
Details	Assistance Received To Date	Insert	New Registration			4/4/2025 2:52 PM
Details	Last Recertification Date	Insert	New Registration			4/4/2025 2:52 PM
Details	Grant Number	Insert	New Registration			4/4/2025 2:52 PM
Details	340B ID	Insert	New Registration			4/4/2025 2:52 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/4/2025 2:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/4/2025 2:52 PM
Details	Medicare Provider Number	Insert	New Registration		390111	4/4/2025 2:52 PM
Details	Entity Name	Insert	New Registration		HOSPITAL OF THE UNIV OF PENNA	4/4/2025 2:52 PM
Details	NOFO Number	Insert	New Registration			4/4/2025 2:52 PM
Details	Program Code	Insert	New Registration		DSH	4/4/2025 2:52 PM
Details	Entity Subname	Insert	New Registration		Department of Surgery Valley Forge	4/4/2025 2:52 PM
Dates	Participating Approval Date	Insert	New Registration			4/4/2025 2:52 PM
Details	State	Insert	New Registration		Pending	4/4/2025 2:52 PM
Dates	Registration Date	Insert	New Registration		4/4/2025 2:52:02 PM	4/4/2025 2:52 PM
Dates	Signed By Date	Insert	New Registration			4/4/2025 2:52 PM
Dates	Start Date	Insert	New Registration			4/4/2025 2:52 PM
Terminations	Termination Comments	Insert	New Registration			4/4/2025 2:52 PM
Terminations	Termination Date	Insert	New Registration			4/4/2025 2:52 PM
Terminations	Termination Effective Date	Insert	New Registration			4/4/2025 2:52 PM
Terminations	Termination Reason	Insert	New Registration			4/4/2025 2:52 PM