Covered Entity Details

DSH470011N Brattleboro Memorial Hospital (Approved) - information as of 6/21/2025 10:42:34 PM

Main Details

Name

Brattleboro Memorial Hospital

Subdivision Name

BMH PODIATRY - Brattleboro Podiatry

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH470011N

Medicare Provider Number

470011

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/14/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/5/2025

Last Recertification Date

Contacts

Authorizing Official

Brattleboro Memorial Hospital
Laura Bruno, Interium Chief Financial Officer
(802) 257-8385

Primary Contact

Brattleboro Memorial Hospital
Shelly Gonthier, 340B Program Coordinator
(802) 257-8267

Addresses

Street Address

19 BELMONT AVE.
SUITE 1201
BRATTLEBORO, VT 05301-7601

Billing Address

Brattleboro Memorial Hospital
17 Belmont Ave
Brattleboro, VT 05301

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
VT		1306849708

Shipping Addresses

Shipping Address 1

Brattleboro Memorial Hospital
17 Belmont Ave
Brattleboro, VT 05301

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
DSH470011A	Child	DSH	Brattleboro Memorial Hospital	BMH UROLOGY	28 Belmont Ave	BRATTLEBORO	VT	Terminated
DSH470011B	Child	DSH	Brattleboro Memorial Hospital	BRATTLEBORO GENERAL SURGERY	19 BELMONT AVE.	BRATTLEBORO	VT	Active
DSH470011C	Child	DSH	Brattleboro Memorial Hospital	CENTER FOR CARDIOVASCULAR HEALTH	17 BELMONT AVE	BRATTLEBORO	VT	Terminated
DSH470011D	Child	DSH	Brattleboro Memorial Hospital	WINDHAM FAMILY PRACTICE	19 BELMONT AVE	BRATTLEBORO	VT	Active
DSH470011E	Child	DSH	Brattleboro Memorial Hospital	BRATTLEBORO INTERNAL MEDICINE	21 BELMONT AVE	BRATTLEBORO	VT	Active
DSH470011F	Child	DSH	Brattleboro Memorial Hospital	FOUR SEASONS OBGYN AND MIDWIFERY	17 Belmont Ave	BRATTLEBORO	VT	Terminated
DSH470011G	Child	DSH	Brattleboro Memorial Hospital	JUST SO PEDIATRICS	19 BELMONT AVE 102	BRATTLEBORO	VT	Terminated
DSH470011H	Child	DSH	Brattleboro Memorial Hospital	BMH ORTHOPAEDICS AND SPORTS MEDICIN	17 BELMONT AVE 1	BRATTLEBORO	VT	Terminated
DSH470011J	Child	DSH	Brattleboro Memorial Hospital	MAPLEWOOD FAMILY PRACTICE	63 Belmont Ave	BRATTLEBORO	VT	Active
DSH470011K	Child	DSH	Brattleboro Memorial Hospital	PUTNEY FAMILY HEALTHCARE	79 MAIN ST	PUTNEY	VT	Active
DSH470011L	Child	DSH	Brattleboro Memorial Hospital	BRATTLEBORO FAMILY MEDICINE	21 BELMONT AVE	BRATTLEBORO	VT	Active
DSH470011M	Child	DSH	Brattleboro Memorial Hospital	FOUR SEASONS OBGYN & MIDWIFERY - Obstetrics and Gynecology	29 Ridgewood Road	Springfield	VT	Terminated
DSH470011N	Child	DSH	Brattleboro Memorial Hospital	BMH PODIATRY - Brattleboro Podiatry	19 BELMONT AVE.	BRATTLEBORO	VT	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Bruno, Laura Interium Chief Financial Officer Brattleboro Memorial Hospital 8022578385	5/5/2025 9:28 AM
Details	340B ID	Update	New Registration		DSH470011N	5/5/2025 9:28 AM
Details	Entity Subname	Update	New Registration	BMH PODIATRY	BMH PODIATRY - Brattleboro Podiatry	5/5/2025 9:28 AM
Dates	Participating Approval Date	Update	New Registration		5/5/2025 9:28:22 AM	5/5/2025 9:28 AM
Details	State	Update	New Registration	Pending	Approved	5/5/2025 9:28 AM
Dates	Signed By Date	Update	New Registration		4/14/2025 11:34:09 AM	5/5/2025 9:28 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/5/2025 9:28 AM
Addresses	Main Address	Insert	New Registration		19 BELMONT AVE. SUITE 1201 BRATTLEBORO, VT 05301-7601	4/14/2025 8:36 AM
Addresses	Billing Address	Insert	New Registration		Brattleboro Memorial Hospital 17 Belmont Ave Brattleboro, VT 05301	4/14/2025 8:36 AM
Addresses	Shipping Address	Insert	New Registration		Brattleboro Memorial Hospital 17 Belmont Ave Brattleboro, VT 05301	4/14/2025 8:36 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1306849708	4/14/2025 8:36 AM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/14/2025 8:36 AM
Contacts	Primary Contact	Insert	New Registration		Gonthier, Shelly 340B Program Coordinator Brattleboro Memorial Hospital 8022578267	4/14/2025 8:36 AM
Contacts	Authorizing Official	Insert	New Registration		Bruno, Laura Interium Chief Financial Officer Brattleboro Memorial Hospital 8022578385	4/14/2025 8:36 AM
Details	Assistance Received From Date	Insert	New Registration			4/14/2025 8:36 AM
Details	Assistance Received To Date	Insert	New Registration			4/14/2025 8:36 AM
Details	Last Recertification Date	Insert	New Registration			4/14/2025 8:36 AM
Details	Grant Number	Insert	New Registration			4/14/2025 8:36 AM
Details	340B ID	Insert	New Registration			4/14/2025 8:36 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2025 8:36 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2025 8:36 AM
Details	Medicare Provider Number	Insert	New Registration		470011	4/14/2025 8:36 AM
Details	Entity Name	Insert	New Registration		Brattleboro Memorial Hospital	4/14/2025 8:36 AM
Details	NOFO Number	Insert	New Registration			4/14/2025 8:36 AM
Details	Program Code	Insert	New Registration		DSH	4/14/2025 8:36 AM
Details	Entity Subname	Insert	New Registration		BMH PODIATRY	4/14/2025 8:36 AM
Dates	Participating Approval Date	Insert	New Registration			4/14/2025 8:36 AM
Details	State	Insert	New Registration		Pending	4/14/2025 8:36 AM
Dates	Registration Date	Insert	New Registration		4/14/2025 8:36:06 AM	4/14/2025 8:36 AM
Dates	Signed By Date	Insert	New Registration			4/14/2025 8:36 AM
Dates	Start Date	Insert	New Registration			4/14/2025 8:36 AM
Terminations	Termination Comments	Insert	New Registration			4/14/2025 8:36 AM
Terminations	Termination Date	Insert	New Registration			4/14/2025 8:36 AM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2025 8:36 AM
Terminations	Termination Reason	Insert	New Registration			4/14/2025 8:36 AM