Covered Entity Details

DSH500014 PROVIDENCE HEALTH & SERVICES - WASHINGTON (Active) - information as of 5/9/2025 12:13:03 AM

Main Details

Name

PROVIDENCE HEALTH & SERVICES - WASHINGTON

Subdivision Name

PROVIDENCE REGIONAL MEDICAL CENTER EVERETT COLBY CAMPUS

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500014

Medicare Provider Number

500014

Additional Details

Current Program Status

Active

Registration Date

1/7/2008

Participating Start Date

4/1/2005

Participating Approval Date

1/7/2008

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044

Primary Contact

Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530

Addresses

Street Address

1321 COLBY AVENUE
EVERETT, WA 98201

Billing Address

Providence St. Joseph Health
PO Box 31263
Salt Lake City, UT 84131

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #	12/10/2010
5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #	01/07/2008

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
OR		1700037801
AK		1700037801
CA		1700037801
ID		1700037801
WA		1700037801

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/14/2019	01/01/2020		01/01/2020
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	10/15/2019	01/01/2020	01/15/2025	01/20/2025
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/15/2019	01/01/2020		01/01/2020
Contract Detail	CREDENA HEALTH LLC	DBA CREDENA HEALTH PHARMACY EVERETT	1321 COLBY AVE	EVERETT	WA	98201-1665	10/14/2019	01/01/2020		01/01/2020
Contract Detail	CREDENA HEALTH LLC	DBA CREDENA HEALTH PHARMACY MONROE	19200 N KELSEY ST	MONROE	WA	98272-1431	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CREDENA HEALTH LLC	7376 SW DURHAM RD		PORTLAND	OR	97224	10/07/2022	01/01/2023		01/01/2023
Contract Detail	CREDENA HEALTH, LLC	6348 NE HALSEY ST	SUITE A	PORTLAND	OR	97213-4720	10/14/2019	01/01/2020		01/01/2020
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/14/2019	01/01/2020	11/07/2024	11/07/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/14/2019	01/01/2020	10/01/2022	01/04/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/15/2019	01/01/2020		01/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/15/2019	01/01/2020		01/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/15/2019	01/01/2020		01/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	10/15/2019	01/01/2020	01/15/2025	01/20/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12933	718 91ST AVE. NE	LAKE STEVENS	WA	98258-2420	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05598	6807 EVERGREEN WAY	EVERETT	WA	98203	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16403	1409 11TH AVE.	SEATTLE	WA	98122	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/14/2019	01/01/2020	10/01/2021	10/11/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH500014A	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROVIDENCE REGIONAL MEDICAL CENTER EVERETT PACIFIC CAMPUS	916 PACIFIC AVENUE	EVERETT	WA	Terminated
DSH500014D	Child	DSH	PROV REGL MED CENTER EVERETT	WOUND CLINIC	1330 ROCKEFELLER AVE	EVERETT	WA	Terminated
DSH500014E	Child	DSH	PROV REGL MED CENTER EVERETT	INTERVENTION CENTER	1509 CALIFORNIA ST	EVERETT	WA	Terminated
DSH500014F	Child	DSH	PROV REGL MED CENTER EVERETT	Breast Center	900 Pacific Avenue, Suite 120	Everett	WA	Terminated
DSH500014G	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Family Maternity Center / Labor and Delivery	900 Pacific Avenue	Everett	WA	Terminated
DSH500014H	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Anesthesia	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014J	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Recovery Room	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014K	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Operating Room	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014L	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Outpatient Therapy Services / Physical Therapy	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014M	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Chemical Dependency	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014N	Child	DSH	PROV REGL MED CENTER EVERETT	Pacific Campus / Maternal Fetal Medicine Clinic	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014P	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Post Partum and Post Operative	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014Q	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Radiation Oncology	1717 13th Street, Suite #2	Everett	WA	Active
DSH500014R	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PACIFIC CAMPUS / 2 NORTH MED SURG - 2 NORTH MED SURG - OUTPATIENT OBSERVATION BEDS	916 PACIFIC	EVERETT	WA	Terminated
DSH500014S	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Providence Regional Medical Center Everett Colby Campus - Anticoagulation Clinic	1330 Rockefeller Ave	Everett	WA	Active
DSH500014T	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12335	11603 STATE AVE G	MARYSVILLE	WA	Active
DSH500014U	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12346	12800 BOTHELL EVERETT HWY	EVERETT	WA	Active
DSH500014V	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12349	19200 N KELSEY ST	MONROE	WA	Active
DSH500014W	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROVIDENCE HEALTH & SERVICES-WA - Nuclear Medicine - 1401.765000.12439	1717 13TH ST	EVERETT	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613534	Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613530	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1700037801 (AZ)		10/16/2024 2:06 PM
Addresses	Billing Address	Insert	Recertification		Providence St. Joseph Health PO Box 31263 Salt Lake City, UT 84131	9/4/2024 6:53 AM
Addresses	Shipping Address	Delete	Recertification	Providence Pacific Campus Pharmacy 916 Pacific Avenue Everett, WA 98201		9/4/2024 6:53 AM
Details	Last Recertification Date	Update	Recertification	9/7/2023 2:22:34 PM	9/4/2024 6:53:07 AM	9/4/2024 6:53 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 1:34:33 PM	9/7/2023 2:22:34 PM	9/7/2023 2:22 PM
Details	Last Recertification Date	Update	Recertification	9/3/2021 9:10:31 AM	9/1/2022 1:34:33 PM	9/1/2022 1:34 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 10:04:16 AM	9/3/2021 9:10:31 AM	9/3/2021 9:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3309606 (WA)		8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	511379 (AZ)		8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1006477 (AK)		8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1700037801 (CA)		8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1700037801 (ID)		8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	021915 (OR)		8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700037801	8/25/2020 10:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/25/2020 10:04 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1700037801 ( )		8/25/2020 10:04 AM
Details	Last Recertification Date	Update	Recertification	9/25/2019 1:47:14 PM	8/25/2020 10:04:16 AM	8/25/2020 10:04 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	183257105 (AR)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	45836060 (CO)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	091495900 (FL)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	N505733 (HI)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3523461619111001 (IL)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1700037801 (IA)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200867760A (KS)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1700878 (LA)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1700037801 (MI)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03228411 - out (NY)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	5010014 (NC)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1154 (ND)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3039787 (OH)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	12078B (SC)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1516736 (TN)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1700037801 (UT)		6/16/2020 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1700037801 (WY)		6/16/2020 3:10 PM
Addresses	Shipping Address	Delete	Change Request	Providence Medical Center Pharmacy 1321 Colby Avenue C Wing 1st Floor Everett, WA 98201		5/4/2020 3:38 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1700037801 (ME)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1700037801 (MN)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1700037801 (MO)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100261353-00 (NE)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0282855 (NJ)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100705340A (OK)		9/25/2019 1:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	200594400A (OK)		9/25/2019 1:47 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 4:44:47 PM	9/25/2019 1:47:14 PM	9/25/2019 1:47 PM
Contacts	Authorizing Official	Update	Change Request	Feeney, Sheri Chief Financial Officer Providence Western WA Region 2066282530	Combs, Scott CFO Providence Health & Services Washington 4252614044	5/9/2019 9:42 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 8:01:10 AM	8/22/2018 4:44:47 PM	8/22/2018 4:44 PM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	11/9/2017 8:01:10 AM	11/9/2017 8:01 AM
Contacts	Authorizing Official	Update		Feeney, Sheri Chief Financial Officer 2066282530	Feeney, Sheri Chief Financial Officer Providence Western WA Region 2066282530	9/26/2017 8:13 PM
Contacts	Primary Contact	Update		Werttemberger, Eric Director of Pharmacy 4252613534	Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613534	9/19/2017 3:51 PM
Contacts	Authorizing Official	Update		Hofheins, Todd CFO 4252614044	Feeney, Sheri Chief Financial Officer 2066282530	7/17/2017 8:30 PM
Contacts	Primary Contact	Insert			Werttemberger, Eric Director of Pharmacy 4252613534	6/12/2017 2:33 PM
Addresses	Main Address	Insert			1321 COLBY AVENUE EVERETT, WA 98201	6/8/2017 5:47 PM
Addresses	Shipping Address	Insert			Providence Medical Center Pharmacy 1321 Colby Avenue C Wing 1st Floor Everett, WA 98201	6/8/2017 5:47 PM
Addresses	Shipping Address	Insert			Providence Pacific Campus Pharmacy 916 Pacific Avenue Everett, WA 98201	6/8/2017 5:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			511379	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			AZ	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1006477	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			AK	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			183257105	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			AR	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			CA	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			45836060	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			CO	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			091495900	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			FL	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			N505733	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			HI	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			ID	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			3523461619111001	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			IL	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			IA	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			200867760A	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			KS	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700878	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			LA	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			ME	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			MI	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			MN	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			MO	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			100261353-00	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			NE	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			0282855	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			NJ	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			03228411 - out	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			NY	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			5010014	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			NC	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1154	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			ND	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			3039787	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			OH	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			100705340A	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			OK	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			200594400A	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			OK	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			12078B	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			SC	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1516736	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			TN	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			UT	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			WY	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: Number	Insert			021915	6/8/2017 5:46 PM
Medicaid Billing	Medicaid: State	Insert			OR	6/8/2017 5:46 PM
Medicaid Billing	NPI: Number	Insert			1700037801	6/8/2017 5:46 PM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/11/2016 12:00:00 AM	8/11/2016 6:41 PM
Contacts	Authorizing Official	Insert			Hofheins, Todd CFO 4252614044	5/11/2016 11:15 AM
Medicaid Billing	Medicaid: Number	Update		1700037801	3309606	3/11/2016 1:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/14/2015 12:36 PM
Medicaid Billing	Medicaid: Number	Insert			1700037801	9/14/2015 12:36 PM
Medicaid Billing	Medicaid: State	Insert			WA	9/14/2015 12:36 PM
Details	Last Recertification Date	Update		8/18/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 1:25 PM
Details	Entity Name	Update		PROVIDENCE HEALTH & SERVICES – WASHINGTON	PROVIDENCE HEALTH & SERVICES - WASHINGTON	11/14/2014 10:56 AM
Details	Last Recertification Date	Update		9/4/2013 12:00:00 AM	8/18/2014 12:00:00 AM	8/18/2014 2:58 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/4/2013 12:00:00 AM	9/4/2013 7:00 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/17/2012 9:02 AM
Details	Entity Subname	Update		PROVIDENCE REGIONAL MEDICAL CENTER EVERETT	PROVIDENCE REGIONAL MEDICAL CENTER EVERETT COLBY CAMPUS	3/26/2012 10:25 AM
Details	Comments Public	Insert			5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #	12/10/2010 1:47 PM
Details	Last Recertification Date	Insert				1/7/2008 5:07 PM
Details	Grant Number	Insert				1/7/2008 5:07 PM
Details	340B ID	Insert			DSH500014	1/7/2008 5:07 PM
Details	Is Authorizing Official EHB Data	Insert				1/7/2008 5:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/7/2008 5:07 PM
Details	Medicare Provider Number	Insert			500014	1/7/2008 5:07 PM
Details	Entity Name	Insert			PROVIDENCE HEALTH & SERVICES – WASHINGTON	1/7/2008 5:07 PM
Details	Program Code	Insert			DSH	1/7/2008 5:07 PM
Details	Entity Subname	Insert			PROVIDENCE REGIONAL MEDICAL CENTER EVERETT	1/7/2008 5:07 PM
Dates	Participating Approval Date	Insert			1/7/2008 12:00:00 AM	1/7/2008 5:07 PM
Details	State	Insert			Active	1/7/2008 5:07 PM
Dates	Registration Date	Insert			1/7/2008 12:00:00 AM	1/7/2008 5:07 PM
Dates	Signed By Date	Insert			2/21/2005 12:00:00 AM	1/7/2008 5:07 PM
Dates	Start Date	Insert			4/1/2005 12:00:00 AM	1/7/2008 5:07 PM
Terminations	Termination Comments	Insert				1/7/2008 5:07 PM
Terminations	Termination Date	Insert				1/7/2008 5:07 PM
Terminations	Termination Effective Date	Insert				1/7/2008 5:07 PM
Terminations	Termination Reason	Insert				1/7/2008 5:07 PM
Details	Comments Public	Insert			5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #	1/7/2008 5:07 PM