| Addresses | Billing Address | Update | Recertification | HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | HENRY J. AUSTIN HEALTH CENTER, INC.
321 N. Warren St
Trenton, NJ 08618 | 2/13/2025 4:33 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/13/2025 4:33 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1008391 | 2/13/2025 4:33 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NJ | 2/13/2025 4:33 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1952032559 | 2/13/2025 4:33 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NJ | 2/13/2025 4:33 PM |
| Details | Last Recertification Date | Update | Recertification | 2/12/2024 7:43:50 AM | 2/13/2025 4:33:35 PM | 2/13/2025 4:33 PM |
| Contacts | Authorizing Official | Update | Change Request | Cherry, Merkle
Interim Chief Executive Officer
Henry J Austin Health Center
6094620140 | Davis II, Charles L.
Chief Executive Officer
Henry J. Austin Health Center, INC.,
6092785933 | 6/12/2024 11:39 AM |
| Contacts | Primary Contact | Update | Change Request | KALARIA, POONAM
340B Manager
Henry J Austin Health Center
6094375877 | Kemp, Taylor
340B Manager
Henry J. Austin Health Center, INC.,
6092785971 | 6/12/2024 11:39 AM |
| Addresses | Shipping Address | Delete | Recertification | HENRY J. AUSTIN HEALTH CENTER, INC.
317 Chambers St
TRENTON, NJ 08609 | | 2/12/2024 7:43 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/12/2024 7:43 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 0533955 | 2/12/2024 7:43 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NJ | 2/12/2024 7:43 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1326405622 | 2/12/2024 7:43 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NJ | 2/12/2024 7:43 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2023 3:05:33 PM | 2/12/2024 7:43:50 AM | 2/12/2024 7:43 AM |
| Details | Entity Name | Update | Recertification | HENRY J AUSTIN HEALTH CENTER INC | HENRY J. AUSTIN HEALTH CENTER INC | 2/12/2024 7:43 AM |
| Details | Entity Subname | Update | Recertification | CHAMBERS MANOR FAMILY PRACTICE | Henry J. Austin Health Center - Chambers | 2/12/2024 7:43 AM |
| Contacts | Authorizing Official | Update | Change Request | Alli, Kemi
Chief Executive Officer
Henry J. Austin Health Center
6092785909 | Cherry, Merkle
Interim Chief Executive Officer
Henry J Austin Health Center
6094620140 | 12/26/2023 10:36 AM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2022 7:02:16 AM | 2/13/2023 3:05:33 PM | 2/13/2023 3:05 PM |
| Contacts | Primary Contact | Update | Recertification | McCarthy, Caitlin
Director of Pharmacy Services
Henry J. Austin Health Center
6092706017 | KALARIA, POONAM
340B Manager
Henry J Austin Health Center
6094375877 | 2/14/2022 7:02 AM |
| Details | Last Recertification Date | Update | Recertification | 2/26/2021 1:25:16 PM | 2/14/2022 7:02:16 AM | 2/14/2022 7:02 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 12/14/2021 8:03 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 0054674 | 12/14/2021 8:03 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NJ | 12/14/2021 8:03 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1710161823 | 12/14/2021 8:03 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | NJ | 12/14/2021 8:03 PM |
| Addresses | Shipping Address | Delete | Recertification | HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | | 2/26/2021 1:25 PM |
| Addresses | Shipping Address | Insert | Recertification | | HENRY J. AUSTIN HEALTH CENTER, INC.
317 Chambers St
TRENTON, NJ 08609 | 2/26/2021 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2020 1:11:12 PM | 2/26/2021 1:25:16 PM | 2/26/2021 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2019 5:23:10 PM | 1/30/2020 1:11:12 PM | 1/30/2020 1:11 PM |
| Details | Last Recertification Date | Update | Recertification | 3/4/2018 8:58:30 PM | 1/30/2019 5:23:10 PM | 1/30/2019 5:23 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Alli, Kemi
Chief Executive and Medical Officer
Henry J. Austin Health Center
6092785909 | Alli, Kemi
Chief Executive Officer
Henry J. Austin Health Center
6092785909 | 7/16/2018 3:10 PM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2017 12:00:00 AM | 3/4/2018 8:58:30 PM | 3/4/2018 8:58 PM |
| Contacts | Authorizing Official | Update | | Alli, Kemi
Chief Executive and Medical Officer
6092785909 | Alli, Kemi
Chief Executive and Medical Officer
Henry J. Austin Health Center
6092785909 | 3/4/2018 8:53 PM |
| Contacts | Primary Contact | Update | | McCarthy, Caitlin
Director of Pharmacy Services
6092706017 | McCarthy, Caitlin
Director of Pharmacy Services
Henry J. Austin Health Center
6092706017 | 2/8/2018 12:39 PM |
| Contacts | Authorizing Official | Update | | Stokes, George C.
CHIEF EXECUTIVE OFFICER
6099893599 | Alli, Kemi
Chief Executive and Medical Officer
6092785909 | 2/13/2017 10:53 AM |
| Contacts | Primary Contact | Update | | Primero, Elidoro
Chief Financial Officer
6092786012 | McCarthy, Caitlin
Director of Pharmacy Services
6092706017 | 2/13/2017 10:53 AM |
| Addresses | Main Address | Insert | | |
317 Chambers St
Trenton, NJ 08609-2603 | 2/13/2017 9:57 AM |
| Details | Last Recertification Date | Update | | 2/29/2016 12:00:00 AM | 2/13/2017 12:00:00 AM | 2/13/2017 9:57 AM |
| Contacts | Primary Contact | Update | | Cryan, James
Director of Finance
6092786013 | Primero, Elidoro
Chief Financial Officer
6092786012 | 2/29/2016 10:52 PM |
| Details | Last Recertification Date | Update | | 3/11/2015 12:00:00 AM | 2/29/2016 12:00:00 AM | 2/29/2016 10:52 PM |
| Contacts | Authorizing Official | Update | | MUSHOCK, RICHARD M.
CHIEF FINANCE OFFICER
6092785938 | Stokes, George C.
CHIEF EXECUTIVE OFFICER
6099893599 | 2/29/2016 4:47 PM |
| Details | Last Recertification Date | Update | | 3/17/2014 12:00:00 AM | 3/11/2015 12:00:00 AM | 3/11/2015 10:04 AM |
| Addresses | Shipping Address | Update | |
HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | 7/3/2014 4:20 PM |
| Addresses | Shipping Address | Insert | | |
HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | 7/3/2014 4:20 PM |
| Contacts | Primary Contact | Update | | Higgins, Corinne
CHIEF FINANCE OFFICER
6092785938 | Cryan, James
Director of Finance
6092786013 | 4/30/2014 10:39 AM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/17/2014 12:00:00 AM | 3/17/2014 3:46 PM |
| Details | Entity Name | Update | | HENRY J. AUSTIN HEALTH CENTER, INC. | HENRY J AUSTIN HEALTH CENTER INC | 3/17/2014 3:46 PM |
| Details | Entity Subname | Update | | CHAMBERS MANOR | CHAMBERS MANOR FAMILY PRACTICE | 3/17/2014 3:46 PM |
| Contacts | Primary Contact | Update | | MUSHOCK, RICHARD M.
CHIEF FINANCE OFFICER
6092785938 | Higgins, Corinne
CHIEF FINANCE OFFICER
6092785938 | 3/18/2013 11:02 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/18/2013 11:02 AM |
| Contacts | Authorizing Official | Insert | | | MUSHOCK, RICHARD M.
CHIEF FINANCE OFFICER
6092785938 | 1/12/2010 9:33 AM |
| Contacts | Primary Contact | Insert | | | MUSHOCK, RICHARD M.
CHIEF FINANCE OFFICER
6092785938 | 1/12/2010 9:33 AM |
| Addresses | Billing Address | Insert | | | HENRY J. AUSTIN HEALTH CENTER, INC.
321 NORTH WARREN STREET
TRENTON, NJ 08618 | 5/25/2006 10:58 AM |
| Details | Last Recertification Date | Insert | | | | 5/25/2006 10:58 AM |
| Details | Grant Number | Insert | | | H80CS00531 | 5/25/2006 10:58 AM |
| Details | 340B ID | Insert | | | CH02007D | 5/25/2006 10:58 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 5/25/2006 10:58 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 5/25/2006 10:58 AM |
| Details | Medicare Provider Number | Insert | | | | 5/25/2006 10:58 AM |
| Details | Entity Name | Insert | | | HENRY J. AUSTIN HEALTH CENTER, INC. | 5/25/2006 10:58 AM |
| Details | Program Code | Insert | | | CH | 5/25/2006 10:58 AM |
| Details | Entity Subname | Insert | | | CHAMBERS MANOR | 5/25/2006 10:58 AM |
| Dates | Participating Approval Date | Insert | | | 2/14/2006 12:00:00 AM | 5/25/2006 10:58 AM |
| Details | State | Insert | | | Active | 5/25/2006 10:58 AM |
| Dates | Registration Date | Insert | | | 2/10/2006 12:00:00 AM | 5/25/2006 10:58 AM |
| Dates | Signed By Date | Insert | | | 1/13/2006 12:00:00 AM | 5/25/2006 10:58 AM |
| Dates | Start Date | Insert | | | 4/1/2006 12:00:00 AM | 5/25/2006 10:58 AM |
| Terminations | Termination Comments | Insert | | | | 5/25/2006 10:58 AM |
| Terminations | Termination Date | Insert | | | | 5/25/2006 10:58 AM |
| Terminations | Termination Effective Date | Insert | | | | 5/25/2006 10:58 AM |
| Terminations | Termination Reason | Insert | | | | 5/25/2006 10:58 AM |