Covered Entity Details

DSH330136DJ MARY IMOGENE BASSETT HOSPITAL (Approved) - information as of 5/6/2025 11:09:27 PM

Main Details

Name

MARY IMOGENE BASSETT HOSPITAL

Subdivision Name

BASSETT HEALTHCARE Herkimer Pediatrics - Herkimer Pediatrics Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330136DJ

Medicare Provider Number

330136

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/1/2025

Last Recertification Date

Contacts

Authorizing Official

Bassett Healthcare Network
James Vielkind, Vice President Finance
(315) 823-5281

Primary Contact

Bassett Healthcare - Cooperstown, NY
Kim Metcalf, Chief Pharmacy Officer
(860) 975-5636

Addresses

Street Address

321 E Albany Street
Herkimer, NY 13350

Billing Address

Mary Imogene Bassett Hospital
1 Atwell Road
Cooperstown, NY 13326

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
NY		1063572733,1083664221,1093897910,1700198652,1780600577,1851452890

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
DSH330136A	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITA - LITTLE FALLS SPECIALTY CLINIC	140 BURWELL ST	LITTLE FALLS	NY	Approved
DSH330136AA	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Otolaryngology Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136AB	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Hematology/Oncology	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136AC	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITA - Herkimer Specialty Clinic	690 W GERMAN ST	HERKIMER	NY	Terminated
DSH330136AD	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	UNADILLA HEALTH CENTER - Unadilla Health Center	16 Clifton Street	Unadilla	NY	Terminated
DSH330136AE	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Radiology, Diagnostic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136AF	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Health Pediatrics	321 E ALBANY ST	HERKIMER	NY	Terminated
DSH330136AG	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Ophthalmology Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136AH	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	WORCESTER SCHOOL HEALTH CNT - WORCESTER SCHOOL HEALTH CNT	195 Main Street	Worcester	NY	Terminated
DSH330136AJ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MILFORD CENTRAL SCHOOL - MILFORD CENTRAL SCHOOL	42 WEST MAIN STREET	MILFORD	NY	Terminated
DSH330136AK	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NORWICH - Bassett Healthcare Norwich	55 CALVARY DR	NORWICH	NY	Terminated
DSH330136AL	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Obstetrics & Gynecology Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136AM	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE AT FOX CARE - Hematology/Oncology	1 FOXCARE DR	ONEONTA	NY	Approved
DSH330136AN	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MIDDLEBURGH SCHOOL HEALTH CNT - MIDDLEBURGH SCHOOL HEALTH CNT	291 Main Street	Middleburgh	NY	Terminated
DSH330136AP	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Hemotology/Oncology	321E ALBANY ST	HERKIMER	NY	Approved
DSH330136AQ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Edmeston Clinic - Bassett Healthcare Edmeston Clinic	Route 80	Edmeston	NY	Terminated
DSH330136AR	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	HARTWICK SEMINARY SPECIALTY SERVICE - CENTER FOR WOUND HEALING	4580 STATE HIGHWAY 28	MILFORD	NY	Terminated
DSH330136AS	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	SHERBURNE SCHOOL HEALTH CTR - SHERBURNE SCHOOL HEALTH CTR	13 School Street	Sherburne	NY	Terminated
DSH330136AT	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Renal Dialysis	1 ASSOCIATE DR	ONEONTA	NY	Terminated
DSH330136AU	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE MORRIS - Bassett Healthcare Morris Health Center	93 MAIN ST	MORRIS	NY	Terminated
DSH330136AV	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NETWORK HAMILTON - Hamilton Specialty Center	1055 MADISON MARKETPLACE	HAMILTON	NY	Terminated
DSH330136AW	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE ONEONTA - Oneonta Clinic	125 MAIN ST	ONEONTA	NY	Terminated
DSH330136AX	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITA - Oneonta Surgical Associates	7 Associate Drive	ONEONTA	NY	Terminated
DSH330136AY	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE DELHI - Delhi Dental Office	460 ANDES ROAD FLINT OFFICE BLDG	DELHI	NY	Terminated
DSH330136AZ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Bassett Healthcare Psychiatric Clinic	1 ATWELL RD	COOPERSTOWN	NY	Terminated
DSH330136B	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	STAMFORD CENTRAL SCHOOL - STAMFORD CENTRAL SCHOOL	1 River Street	Stamford	NY	Terminated
DSH330136BA	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE LITTLE FALLS - Renal Dialysis	170 BURWELL ST	LITTLE FALLS	NY	Terminated
DSH330136BB	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Anti-Coagulation Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136BC	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	HARTWICK SEMINARY SPECIALTY SERVICE - HARTWICK SEMINARY SPEC SVCS	4580 STATE HIGHWAY 28	MILFORD	NY	Terminated
DSH330136BD	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	SCHENEVUS CENTRAL SCHOOL - SCHENEVUS CENTRAL SCHOOL	159 Main Street	Schenevus	NY	Approved
DSH330136BE	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE CLINTON - Clinton Health Center	34 CHENANGO AVE	CLINTON	NY	Approved
DSH330136BF	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Oneonta Surgeons & Specialists	1 ASSOCIATE DR	ONEONTA	NY	Terminated
DSH330136BG	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Pediatric Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136BH	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE STAMFORD - Stamford Clinic	28650 STATE HIGHWAY 23	STAMFORD	NY	Terminated
DSH330136BJ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Health Center	321 E ALBANY ST	HERKIMER	NY	Approved
DSH330136BK	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	SOUTH KORTRIGHT CLINIC - SOUTH KORTRIGHT	58200 State Highway 10	South Kortright	NY	Terminated
DSH330136BL	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Surgical Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136BM	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	HARTWICK SEMINARY SPECIALTY SERVICE - INTERVENTIONAL PAIN MANAGEMENT	4580 STATE HIGHWAY 28	MILFORD	NY	Terminated
DSH330136BN	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - RCP - Radiation Therapy	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136BP	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITA - Family Medicine Oneonta	739 STATE HIGHWAY 28	ONEONTA	NY	Terminated
DSH330136BQ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Prime Care Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136BR	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Bassett Healthcare Cobleskill Clinic	136 PARKWAY DR	COBLESKILL	NY	Terminated
DSH330136BS	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	RICHFIELD SPA CENTRAL SCHOOL - RICHFIELD SPA CENTRAL SCHOOL	93 Main Street	Richfield Springs	NY	Terminated
DSH330136BT	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	OSS RADIOLOGY - OSS Radiology	7 Associate Drive	Oneonta	NY	Terminated
DSH330136BU	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Cooperstown Middle/High School Based Health Center - Cooperstown Middle/High School Based Health Center	39 Linden Avenue	Cooperstown	NY	Approved
DSH330136BV	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	ANDES HEALTH CENTER - Andes Health Center	245 LOWER MAIN STREET	ANDES	NY	Approved
DSH330136BW	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Hartwick Specialty Services - Hartwick Specialty Services	4580 State Highway 28	Milford	NY	Approved
DSH330136BX	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE COBLESKILL - Cobleskill Health Center	136 PARKWAY DR	COBLESKILL	NY	Approved
DSH330136BY	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE DELANSON - Delanson HealthCare Center	1 COOLEY HTS	DELANSON	NY	Approved
DSH330136BZ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Sidney Central School Based Health - Sidney Central School Based Health Center	15 Pearl Street	Sidney	NY	Approved
DSH330136C	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	DELHI SCHOOL HEALTH PROGRAM - DELHI SCHOOL HEALTH PROGRAM	2 Sheldon Drive	Delhi	NY	Terminated
DSH330136CA	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Sherburne-Earlville Elementary School Based Health - Sherburne-Earlville Elementary School Based Health	15 School Street	Sherburne	NY	Approved
DSH330136CB	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SIDNEY - Sidney Primary Care Clinic	43 PEARL ST W	SIDNEY	NY	Approved
DSH330136CC	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Delhi Dental - Delhi Family Dental Services	460 Andes Road	Delhi	NY	Approved
DSH330136CD	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE ONEONTA - Oneonta Healthcare Center	125 MAIN ST	ONEONTA	NY	Approved
DSH330136CE	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE GREENE - Greene Health Center	29 N CHENANGO ST	GREENE	NY	Approved
DSH330136CF	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Springbrook School Based Health - Springbrook School Based Health Center	105 Campus Drive	Oneonta	NY	Approved
DSH330136CG	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Hamilton SS Radiology - Hamilton Specialty Services Radiology	1055 Madison Marketplace	Hamilton	NY	Approved
DSH330136CH	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Gilbertsville-Mount Upton Central School Based Health - Gilbertsville-Mount Upton Central School Based Health	693 State Highway 51	Gilbertsville	NY	Approved
DSH330136CJ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NETWORK HAMILTON - Hamilton Healthcare Center	1055 MADISON MARKETPLACE	HAMILTON	NY	Approved
DSH330136CK	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHERBURNE - Sherburne Healthcare Center	20 CHAPEL ST	SHERBURNE	NY	Approved
DSH330136CL	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Richfield Springs Central School Based Health - Richfield Springs Central School Based Health	93 W Main Street	Richfield Springs	NY	Approved
DSH330136CM	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Sherburne-Earlville Middle/High School Based Health - Sherburne-Earlville Middle/High School Based Health	13 School Street	Sherburne	NY	Approved
DSH330136CN	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Oneonta Pediatrics Health Center - Pediatrics	125 Main Street	Oneonta	NY	Approved
DSH330136CP	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Radiology Services	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136CQ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE FoxCare Orthopedics Clinic - FoxCare Orthopedics Clinic	1 FoxCare Drive	Oneonta	NY	Approved
DSH330136CR	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Hamilton Dental Clinic - Hamilton-Madison Family Dental Clinic	1055 Madison Marketplace	Hamilton	NY	Approved
DSH330136CS	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Hartwick Seminary Specialty - Hartwick Seminary Specialty Services Wound Care Center	4580 State Highway 28	Milford	NY	Approved
DSH330136CT	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Unadilla Valley Central School Based Health - Unadilla Valley Central School Based Health Center	4238 State Highway 8	New Berlin	NY	Approved
DSH330136CU	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Anticoagulation Management Service at FoxCare - Anticoagulation Management Service at FoxCare	1 FoxCare Drive	Oneonta	NY	Approved
DSH330136CV	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Little Falls Home Hemodialysis - Little Falls SS Home Hemodialysis Service	140 Burwell Road	Little Falls	NY	Approved
DSH330136CW	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Stamford Central School Based Health - Stamford Central School Based Health Center	1 River Street	Stamford	NY	Approved
DSH330136CX	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NORWICH - Norwich Healthcare Center	55 CALVARY DR	NORWICH	NY	Approved
DSH330136CY	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Little Falls SS Peritoneal Dialysis - Little Falls Home Dialysis Program-Little Falls Hospital Peritoneal Dialysis	140 Burwell Street	Little Falls	NY	Approved
DSH330136CZ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Middleburgh School Based health - Middleburgh Elementary SBHC	245-1 Main Street	Middleburgh	NY	Approved
DSH330136D	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SCHOHARIE - Bassett Healthcare Schoharie	111 BARTON HILL RD	SCHOHARIE	NY	Approved
DSH330136DA	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Worcester Central School Based Health - Worcester Central School Based Health Center	198 Main Street	Worcester	NY	Approved
DSH330136DB	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Oneonta Specialty Services	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136DC	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Milford Central School Based Health - Milford Central School Based Health	42 West Main Street	Milford	NY	Approved
DSH330136DD	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Hamilton Specialty Services - Hamilton Specialty Services	1055 Madison Marketplace	Hamilton	NY	Approved
DSH330136DE	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Oneonta Specialty Services Eye Clinic - Oneonta Specialty Services Eye Clinic	1 Associate Drive	Oneonta	NY	Approved
DSH330136DF	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE South Kortright Central School Based Health - South Kortright Central School Based Health Center	58200 State Highway 10	South Kortright	NY	Approved
DSH330136DG	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Herkimer Specialty Services - Herkimer Specialty Services	321 E Albany Street	Herkimer	NY	Approved
DSH330136DH	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE - Morris Healthzone Center - Morris Healthzone Center	65 Main Street	Morris	NY	Approved
DSH330136DJ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Herkimer Pediatrics - Herkimer Pediatrics Clinic	321 E Albany Street	Herkimer	NY	Approved
DSH330136DK	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Tri-Town Specialty Services - Tri-Town Specialty Services Clinic	43 Pearl Street	Sidney	NY	Approved
DSH330136DL	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Oneonta Renal Dialysis	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136DM	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE DELHI - Delhi Healthcare Center	460 ANDES RD	DELHI	NY	Approved
DSH330136DN	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE AT FOX CARE - Bassett Heart Care Institute at FoxCare	1 FOXCARE DR	ONEONTA	NY	Approved
DSH330136DP	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Oneonta Peritoneal Dialysis	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136DQ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - OSS Home Hemodialysis	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136DR	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Edmeston Healthzone Center - Edmeston Healthzone Center	11 North Street	Edmeston	NY	Approved
DSH330136DS	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE EDMESTON - Edmeston Health Center	15 TURNER LANE	EDMESTON	NY	Approved
DSH330136DT	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHARON SPRINGS - Sharon Springs Healthcare Center	591 HIGHWAY ROUTE 20	SHARON SPRINGS	NY	Approved
DSH330136DU	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Laurens Healthzone Center - Laurens Healthzone Center	55 Main Street	Laurens	NY	Approved
DSH330136DV	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE WALTON - Walton Healthcare Center	130 NORTH ST	WALTON	NY	Approved
DSH330136DW	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Cherry Valley-Springfield School Based Health Center - Cherry Valley-Springfield SBHC	597 County Highway 54	Cherry Valley	NY	Approved
DSH330136DX	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Delaware Academy School Based Health - Delaware Academy Elementary/Middle/High School Based Health	2 Sheldon Drive	Delhi	NY	Approved
DSH330136DY	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE LITTLE FALLS - Cardiology Services	140 BURWELL ST	LITTLE FALLS	NY	Approved
DSH330136DZ	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Little Falls Renal Dialysis Center - Little Falls Renal Dialysis Center	140 Burwell Street	Little Falls	NY	Approved
DSH330136E	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - North Regional Lab	321 E ALBANY ST	HERKIMER	NY	Terminated
DSH330136EA	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Ambulatory Surgery	321 E ALBANY ST	HERKIMER	NY	Approved
DSH330136EB	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE AT FOX CARE - Orthopedic Radiology Services	1 FOXCARE DR	ONEONTA	NY	Approved
DSH330136EC	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE Oneonta SS Eyewear Center - Oneonta Specialty Services Eyewear Center	1 Associate Drive	Oneonta	NY	Approved
DSH330136F	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE CANAJOHARIE - Bassett Healthcare Canajoharie	56 MONTGOMERY ST	CANAJOHARIE	NY	Approved
DSH330136G	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Gastroenterology Laboratory	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136H	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	COOPERSTOWN SCHOOL HEALTH CNT - COOPERSTOWN SCHOOL HEALTH CNT	21 Walnut Street	Cooperstown	NY	Approved
DSH330136J	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NETWORK HAMILTON - Bassett Healthcare Hamilton Clinic	1055 MADISON MARKETPLACE	HAMILTON	NY	Terminated
DSH330136K	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - Medical Clinic	60 RIVER STREET	COOPERSTOWN	NY	Terminated
DSH330136L	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE ONEONTA - Oneonta Pediatrics	125 MAIN ST	ONEONTA	NY	Terminated
DSH330136M	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	MARY IMOGENE BASSETT HOSPITAL - ONEONTA WOMEN'S HEALTH SVC	1 Foxcare Drive Suite 303	Oneonta	NY	Terminated
DSH330136N	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Radiology	321 E ALBANY ST	HERKIMER	NY	Approved
DSH330136P	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Ambulatory Surgery	1 ASSOCIATE DR	ONEONTA	NY	Approved
DSH330136Q	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE DELHI - Delhi Family Practice	460 ANDES ROAD FLINT OFFICE BLDG	DELHI	NY	Terminated
DSH330136R	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	OSS CONVENIENT CARE - OSS CONVENIENT CARE	1 Associate Drive	Oneonta	NY	Approved
DSH330136S	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHERBURNE - Bassett Healthcare Sherburne Clinic	20 CHAPEL ST	SHERBURNE	NY	Terminated
DSH330136T	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHARON SPRINGS - Sharon Springs Clinic	591 HIGHWAY ROUTE 20	SHARON SPRINGS	NY	Terminated
DSH330136U	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Convenient Care	321 E ALBANY ST	HERKIMER	NY	Approved
DSH330136V	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE AT FOX CARE - Oneonta Cardiology	1 FOXCARE DR	ONEONTA	NY	Terminated
DSH330136W	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	UNADILLA VALLEY CENTRAL SCHOOL - UNADILLA VALLEY CENTRAL SCHOOL	4238 State Highway 8	New Berlin	NY	Terminated
DSH330136X	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NETWORK HAMILTON - Bassett Healthcare Hamilton Dental Clinic	1055 MADISON MARKETPLACE	HAMILTON	NY	Terminated
DSH330136Y	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Procedures	321 E ALBANY ST	HERKIMER	NY	Terminated
DSH330136Z	Child	DSH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE MIDDLEBURGH - Middleburgh Health Center	109 BAKER AVE	MIDDLEBURGH	NY	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Vielkind, James Vice President Finance Bassett Healthcare Network 3158235281	5/1/2025 11:07 AM
Details	340B ID	Update	New Registration		DSH330136DJ	5/1/2025 11:07 AM
Details	Entity Subname	Update	New Registration	BASSETT HEALTHCARE Herkimer Pediatrics	BASSETT HEALTHCARE Herkimer Pediatrics - Herkimer Pediatrics Clinic	5/1/2025 11:07 AM
Dates	Participating Approval Date	Update	New Registration		5/1/2025 11:07:44 AM	5/1/2025 11:07 AM
Details	State	Update	New Registration	Pending	Approved	5/1/2025 11:07 AM
Dates	Signed By Date	Update	New Registration		4/28/2025 12:09:06 PM	5/1/2025 11:07 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/1/2025 11:07 AM
Addresses	Main Address	Insert	New Registration		321 E Albany Street Herkimer, NY 13350	4/11/2025 4:48 AM
Addresses	Billing Address	Insert	New Registration		Mary Imogene Bassett Hospital 1 Atwell Road Cooperstown, NY 13326	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1063572733	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083664221	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1093897910	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700198652	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1780600577	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1851452890	4/11/2025 4:48 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/11/2025 4:48 AM
Contacts	Primary Contact	Insert	New Registration		Metcalf, Kim Chief Pharmacy Officer Bassett Healthcare - Cooperstown, NY 8609755636	4/11/2025 4:48 AM
Contacts	Authorizing Official	Insert	New Registration		Vielkind, James Vice President Finance Bassett Healthcare Network 3158235281	4/11/2025 4:48 AM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 4:48 AM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 4:48 AM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 4:48 AM
Details	Grant Number	Insert	New Registration			4/11/2025 4:48 AM
Details	340B ID	Insert	New Registration			4/11/2025 4:48 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 4:48 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 4:48 AM
Details	Medicare Provider Number	Insert	New Registration		330136	4/11/2025 4:48 AM
Details	Entity Name	Insert	New Registration		MARY IMOGENE BASSETT HOSPITAL	4/11/2025 4:48 AM
Details	NOFO Number	Insert	New Registration			4/11/2025 4:48 AM
Details	Program Code	Insert	New Registration		DSH	4/11/2025 4:48 AM
Details	Entity Subname	Insert	New Registration		BASSETT HEALTHCARE Herkimer Pediatrics	4/11/2025 4:48 AM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 4:48 AM
Details	State	Insert	New Registration		Pending	4/11/2025 4:48 AM
Dates	Registration Date	Insert	New Registration		4/11/2025 4:48:19 AM	4/11/2025 4:48 AM
Dates	Signed By Date	Insert	New Registration			4/11/2025 4:48 AM
Dates	Start Date	Insert	New Registration			4/11/2025 4:48 AM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 4:48 AM
Terminations	Termination Date	Insert	New Registration			4/11/2025 4:48 AM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 4:48 AM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 4:48 AM