| Details | Last Recertification Date | Update | Recertification | 2/9/2024 2:09:56 PM | 2/14/2025 5:30:52 PM | 2/14/2025 5:30 PM |
| Details | Last Recertification Date | Update | Recertification | 2/23/2023 6:47:59 AM | 2/9/2024 2:09:56 PM | 2/9/2024 2:09 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2022 1:35:47 PM | 2/23/2023 6:47:59 AM | 2/23/2023 6:47 AM |
| Contacts | Primary Contact | Update | PC Change Request | Nallapaneni, Hari
CMO
CareSTL Health
3143675820 | Jones, Renee L
Chief Information Officer
CareSTL Health
3143675820-2311 | 2/22/2023 4:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2021 5:01:31 PM | 2/7/2022 1:35:47 PM | 2/7/2022 1:35 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1467494062 | 2/2/2021 5:01 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MO | 2/2/2021 5:01 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1467494062 ( ) | | 2/2/2021 5:01 PM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2020 11:19:12 AM | 2/2/2021 5:01:31 PM | 2/2/2021 5:01 PM |
| Contacts | Primary Contact | Update | Change Request | Nallapaneni, Hari
Chief Medical Officer
CareSTL Health
3143675820 | Nallapaneni, Hari
CMO
CareSTL Health
3143675820 | 1/27/2021 8:48 AM |
| Contacts | Primary Contact | Update | Recertification | Etuk, Leslie McCrary
Chief Medical Officer
CareSTL Health
3143894566-7031 | Nallapaneni, Hari
Chief Medical Officer
CareSTL Health
3143675820 | 2/5/2020 11:19 AM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2019 12:54:12 PM | 2/5/2020 11:19:12 AM | 2/5/2020 11:19 AM |
| Addresses | Billing Address | Update | Recertification | MYRTLE HILLIARD DAVIS COMP HEALTH CENTER
5471 DR MARTIN LUTHER KING DR
ST. LOUIS, MO 63112-4265 | CareSTL Health
5471 Dr Martin Luther King Drive
Saint Louis, MO 63112-4265 | 2/5/2019 12:54 PM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2018 10:33:14 AM | 2/5/2019 12:54:12 PM | 2/5/2019 12:54 PM |
| Details | Entity Name | Update | Recertification | MYRTLE HILLIARD DAVIS COMPREHENSIVE HEALTH CENTERS, INC. | CareSTL Health | 2/5/2019 12:54 PM |
| Details | Entity Subname | Update | Recertification | FLORENCE HILL HEALTH CENTER | CareSTL Health #2 | 2/5/2019 12:54 PM |
| Contacts | Primary Contact | Update | Recertification | Etuk, Leslie McCrary
Chief Medical Officer
Myrtle Hilliard Davis Comprehensive Health Centers, Inc
3143894566-7031 | Etuk, Leslie McCrary
Chief Medical Officer
CareSTL Health
3143894566-7031 | 2/1/2019 2:55 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Clabon, Angela R
CEO
Myrtle Hilliard Davis Comprehensive Health Centers, Inc
3143675820-2227 | Clabon, Angela R
CEO
CareSTL Health
3143675820-2227 | 1/29/2019 11:16 AM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2017 12:00:00 AM | 2/9/2018 10:33:14 AM | 2/9/2018 10:33 AM |
| Contacts | Primary Contact | Update | Recertification | Etuk, Leslie McCrary
Chief Medical Officer
3143894566-7031 | Etuk, Leslie McCrary
Chief Medical Officer
Myrtle Hilliard Davis Comprehensive Health Centers, Inc
3143894566-7031 | 2/9/2018 10:32 AM |
| Contacts | Authorizing Official | Update | | Clabon, Angela
CEO
3143675820-2227 | Clabon, Angela R
CEO
Myrtle Hilliard Davis Comprehensive Health Centers, Inc
3143675820-2227 | 2/9/2018 10:24 AM |
| Contacts | Primary Contact | Update | | Munimuddappa, Manohara
Chief Medical Officer
3143675820-2280 | Etuk, Leslie McCrary
Chief Medical Officer
3143894566-7031 | 2/14/2017 11:19 AM |
| Contacts | Authorizing Official | Update | | WHITE, CORLISS
INTERIM CEO
3143675820-2279 | Clabon, Angela
CEO
3143675820-2227 | 2/14/2017 11:19 AM |
| Addresses | Main Address | Insert | | |
5541 Riverview Blvd
Saint Louis, MO 63120-2443 | 2/14/2017 11:11 AM |
| Details | Last Recertification Date | Update | | 2/22/2016 12:00:00 AM | 2/14/2017 12:00:00 AM | 2/14/2017 11:11 AM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 2/22/2016 9:46 AM |
| Details | Last Recertification Date | Update | | 3/2/2015 12:00:00 AM | 2/22/2016 12:00:00 AM | 2/22/2016 9:46 AM |
| Details | Last Recertification Date | Update | | 3/13/2014 12:00:00 AM | 3/2/2015 12:00:00 AM | 3/2/2015 10:26 AM |
| Contacts | Primary Contact | Update | | TURNER, KEVIN
MEDICAL DIRECTOR
3143675820-2280 | Munimuddappa, Manohara
Chief Medical Officer
3143675820-2280 | 4/30/2014 10:39 AM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/13/2014 12:00:00 AM | 3/13/2014 3:19 PM |
| Details | Entity Name | Update | | MYRTLE HILLIARD DAVIS COMP HEALTH CENTER | MYRTLE HILLIARD DAVIS COMPREHENSIVE HEALTH CENTERS, INC. | 3/13/2014 3:19 PM |
| Contacts | Primary Contact | Update | | TURNER, KEVIN
MEDICAL DIRECTOR
3143675820-280 | TURNER, KEVIN
MEDICAL DIRECTOR
3143675820-2280 | 2/28/2013 12:34 PM |
| Contacts | Authorizing Official | Update | | GRIFFIN, ARCHIE
CEO
3143675820-226 | WHITE, CORLISS
INTERIM CEO
3143675820-2279 | 2/28/2013 12:34 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1467494062 | 2/28/2013 12:33 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/28/2013 12:33 PM |
| Contacts | Authorizing Official | Insert | | | GRIFFIN, ARCHIE
CEO
3143675820-226 | 9/23/2010 11:47 AM |
| Contacts | Primary Contact | Insert | | | TURNER, KEVIN
MEDICAL DIRECTOR
3143675820-280 | 9/20/2010 6:39 PM |
| Addresses | Billing Address | Insert | | | MYRTLE HILLIARD DAVIS COMP HEALTH CENTER
5471 DR MARTIN LUTHER KING DR
ST. LOUIS, MO 63112-4265 | 9/20/2010 6:38 PM |
| Details | Last Recertification Date | Insert | | | | 9/20/2010 6:38 PM |
| Details | Grant Number | Insert | | | H80CS00749 | 9/20/2010 6:38 PM |
| Details | 340B ID | Insert | | | CH07037A | 9/20/2010 6:38 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/20/2010 6:38 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/20/2010 6:38 PM |
| Details | Medicare Provider Number | Insert | | | | 9/20/2010 6:38 PM |
| Details | Entity Name | Insert | | | MYRTLE HILLIARD DAVIS COMP HEALTH CENTER | 9/20/2010 6:38 PM |
| Details | Program Code | Insert | | | CH | 9/20/2010 6:38 PM |
| Details | Entity Subname | Insert | | | FLORENCE HILL HEALTH CENTER | 9/20/2010 6:38 PM |
| Dates | Participating Approval Date | Insert | | | 12/6/2005 12:00:00 AM | 9/20/2010 6:38 PM |
| Details | State | Insert | | | Active | 9/20/2010 6:38 PM |
| Dates | Registration Date | Insert | | | 12/5/2005 12:00:00 AM | 9/20/2010 6:38 PM |
| Dates | Signed By Date | Insert | | | 11/21/2005 12:00:00 AM | 9/20/2010 6:38 PM |
| Dates | Start Date | Insert | | | 12/6/2005 12:00:00 AM | 9/20/2010 6:38 PM |
| Terminations | Termination Comments | Insert | | | | 9/20/2010 6:38 PM |
| Terminations | Termination Date | Insert | | | | 9/20/2010 6:38 PM |
| Terminations | Termination Effective Date | Insert | | | | 9/20/2010 6:38 PM |
| Terminations | Termination Reason | Insert | | | | 9/20/2010 6:38 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 12/5/2005 2:22 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 601291107 | 12/5/2005 2:22 PM |
| Medicaid Billing | Medicaid: State | Insert | | | MO | 12/5/2005 2:22 PM |