Covered Entity Details

DSH390223AL PENN PRESBYTERIAN MEDICAL CENTER (Approved) - information as of 6/25/2025 12:49:02 AM

Main Details

Name

PENN PRESBYTERIAN MEDICAL CENTER

Subdivision Name

PMUC MRI - MRI

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390223AL

Medicare Provider Number

390223

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/27/2025

Last Recertification Date

Contacts

Authorizing Official

Penn Presbyterian Medical Center
Gene Gofman, Chief Financial Officer
(215) 662-9863

Primary Contact

Penn Presbyterian Medical Center
Justin Kuratnick, Director of Pharmacy
(215) 662-9291

Addresses

Street Address

3737 Market Street
7th Floor
Philadelphia, PA 19104

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	100729707,1007297070008,1007297070014,1007297070017,1007297070027,1007297070028,1007297070029,1007297070032,1007297070033,1007297070034,1007297070035,1007297070036,1007297070037,1007297070038,1007297070039,1007297070040	1134278989,1245207521,1265518682,1760624944,1801202817,1902063605,1992746366,1073581005,1760450779,1750445110,1033259627,1902948813,1649310103

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
DSH390223A	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER		51 North 39th Street	PHILADELPHIA	PA	Terminated
DSH390223AA	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	CRIP-MAPS / Pain Mgt	51 N 39th Street	Philadelphia	PA	Terminated
DSH390223AB	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PPMC 4PHI Office / Cardiology	51 N 39th Street	Philadelphia	PA	Active
DSH390223AC	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Neurosurgery (PMUC) - Neurosurgery	3737 Market Street	Philadelphia	PA	Active
DSH390223AD	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Wound Care Center - Wound Care	3737 Market Street	Philadelphia	PA	Active
DSH390223AE	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Medicine - PCPC - Internal Medicine	51 N. 39th Street	Philadelphia	PA	Active
DSH390223AF	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Hematology-Oncology - Hematology-Oncology	51 N. 39th Street	Philadelphia	PA	Active
DSH390223AG	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC - 12TH FLOOR - OBGYN (General OBGYN)	3737 MARKET ST	PHILADELPHIA	PA	Active
DSH390223AH	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	OUTPATIENT DRUG AND ALCOHOL - Outpatient Detox	4040 MARKET ST	PHILADELPHIA	PA	Active
DSH390223AJ	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC-PDLH 11th Floor - PMUC-PDLH 11th Floor ENDO PROC	3737 Market Street	Philadelphia	PA	Active
DSH390223AK	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC CT Radiology - Radiology	3737 Market Street	Philadelphia	PA	Approved
DSH390223AL	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC MRI - MRI	3737 Market Street	Philadelphia	PA	Approved
DSH390223AM	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC Ultrasound - Ultrasound	3737 Market Street	Philadelphia	PA	Approved
DSH390223AN	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	GI Medicine PMUC - GI Medicine	3737 Market Street	Philadelphia	PA	Approved
DSH390223B	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	INFUSION SERVICES	1865 Route 70 East	CHERRY HILL	NJ	Active
DSH390223C	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Family Practice	3819 Chestnut Street	Philadelphia	PA	Terminated
DSH390223D	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Mayfair Cardiology	7133 Roosevelt Blvd	Philadelphia	PA	Active
DSH390223E	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Operating Room (PMUC)	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223F	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Medicine - Neurology	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223G	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Otolaryngology (PMUC)	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223H	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Allergy and Immunology (PMUC)	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223J	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Surgery - PMUC	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223K	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Medicine - Rheumatology	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223L	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Orthopedics (PMUC)	3737 Market Street	PHILADELPHIA	PA	Active
DSH390223M	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Medicine / Endocrinology (Diabetes- PMUC)	3737 Market Street	Phila	PA	Active
DSH390223N	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Medicine / Pulmonary (PMUC)	3737 Market Street	Phila	PA	Active
DSH390223P	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC Family Practice / Family Practice (PMUC)	3737 Market Street	Phila	PA	Active
DSH390223Q	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC - Radiology	3737 MARKET ST	PHILADELPHIA	PA	Active
DSH390223R	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	PMUC - Dermatology	3737 Market Street	Philadelphia	PA	Active
DSH390223S	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Department of Urology	3737 Market Street	Phila	PA	Active
DSH390223T	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Clinic - Oral Surgery	51 N. 39th Street	Philadelphia	PA	Active
DSH390223U	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Clinic - Audiology	3737 Market St.	Philadelphia	PA	Active
DSH390223V	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Clinic - Ophthalmology	51 N. 39th Street	Philadelphia	PA	Active
DSH390223W	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Infectious Disease-MAPS	51 N 39th Street	Philadelphia	PA	Active
DSH390223X	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Renal-MAPS	51 N. 39th Street	Philadelphia	PA	Active
DSH390223Y	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Gastro Clinic-MAPS	51 N. 39th Street	Philadelphia	PA	Terminated
DSH390223Z	Child	DSH	PENN PRESBYTERIAN MEDICAL CENTER	Cardiology Clinic-MAPS	51 N. 39th Street	Philadelphia	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Gofman, Gene Chief Financial Officer Penn Presbyterian Medical Center 2156629863	5/27/2025 8:36 AM
Details	340B ID	Update	New Registration		DSH390223AL	5/27/2025 8:36 AM
Details	Entity Name	Update	New Registration	PRESBYTERIAN MEDICAL CENTER	PENN PRESBYTERIAN MEDICAL CENTER	5/27/2025 8:36 AM
Details	Entity Subname	Update	New Registration	PMUC MRI	PMUC MRI - MRI	5/27/2025 8:36 AM
Dates	Participating Approval Date	Update	New Registration		5/27/2025 8:36:52 AM	5/27/2025 8:36 AM
Details	State	Update	New Registration	Pending	Approved	5/27/2025 8:36 AM
Dates	Signed By Date	Update	New Registration		4/11/2025 12:04:04 PM	5/27/2025 8:36 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/27/2025 8:36 AM
Addresses	Main Address	Insert	New Registration		3737 Market Street 7th Floor Philadelphia, PA 19104	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100729707	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070008	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070014	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070017	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070027	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070028	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070029	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070032	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070033	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070034	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070035	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070036	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070037	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070038	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070039	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007297070040	4/8/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1134278989	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1245207521	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265518682	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760624944	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801202817	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1902063605	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992746366	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073581005	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760450779	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750445110	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1033259627	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1902948813	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649310103	4/8/2025 3:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2025 3:14 PM
Contacts	Authorizing Official	Insert	New Registration		Gofman, Gene Chief Financial Officer Penn Presbyterian Medical Center 2156629863	4/8/2025 3:14 PM
Contacts	Primary Contact	Insert	New Registration		Kuratnick, Justin Director of Pharmacy Penn Presbyterian Medical Center 2156629291	4/8/2025 3:14 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 3:14 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 3:14 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 3:14 PM
Details	Grant Number	Insert	New Registration			4/8/2025 3:14 PM
Details	340B ID	Insert	New Registration			4/8/2025 3:14 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 3:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 3:14 PM
Details	Medicare Provider Number	Insert	New Registration		390223	4/8/2025 3:14 PM
Details	Entity Name	Insert	New Registration		PRESBYTERIAN MEDICAL CENTER	4/8/2025 3:14 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 3:14 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2025 3:14 PM
Details	Entity Subname	Insert	New Registration		PMUC MRI	4/8/2025 3:14 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 3:14 PM
Details	State	Insert	New Registration		Pending	4/8/2025 3:14 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 3:14:38 PM	4/8/2025 3:14 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 3:14 PM
Dates	Start Date	Insert	New Registration			4/8/2025 3:14 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 3:14 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 3:14 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 3:14 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 3:14 PM