Covered Entity Details

DSH330194G MAIMONIDES MEDICAL CENTER (Active) - information as of 4/25/2025 12:00:42 AM

Main Details

Name

MAIMONIDES MEDICAL CENTER

Subdivision Name

9TH AVENUE WOMEN'S PRIMARY CARE CENTER

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330194G

Medicare Provider Number

330194

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

6/11/2009

Participating Start Date

7/1/2009

Participating Approval Date

6/15/2009

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

Maimonides Medical Center
John Marshall, EVP MedAffair/Chair MedOfficer
(718) 283-8313

Primary Contact

Maimonides Medical Center
Yevgenia Bukher, Assistant Director, Pharmacy
(718) 283-7232

Addresses

Street Address

4422 9TH AVENUE
BROOKLYN, NY 11220

Billing Address

Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY 11219

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	00243641,02998736	1093777492,1083623144
NJ	4157206	1093777492

Shipping Addresses

Shipping Address 1

9TH AVENUE WOMEN'S PRIMARY CARE CENTER
4422 9TH AVENUE
Brooklyn, NY 11220

Shipping Address 2

Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY 11219

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
Contract Detail	MMC PHARMACY INC	948 48TH ST		BROOKLYN	NY	11219-2918	10/09/2023	01/01/2024	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330194A	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES REHABILITATION SERVICES	883 65TH STREET	BROOKLYN	NY	Active
DSH330194B	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES SLEEP DISORDER CLINIC	6405 7TH AVENUE	BROOKLYN	NY	Active
DSH330194C	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES AMBULATORY CARE CENTER	1301 57TH STREET	BROOKLYN	NY	Active
DSH330194D	Child	DSH	MAIMONIDES MEDICAL CENTER	FORT HAMILTON CLINIC TREATMENT PROGRAM	8710 FIFTH AVENUE	BROOKLYN	NY	Terminated
DSH330194E	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES ADULT/PEDIATRIC DENTAL CLINIC	4303-4305 13TH AVENUE	BROOKLYN	NY	Active
DSH330194F	Child	DSH	MAIMONIDES MEDICAL CENTER	MAPLETON CLINIC TREATMENT CENTER	1083 MCDONALD AVENUE	BROOKLYN	NY	Terminated
DSH330194G	Child	DSH	MAIMONIDES MEDICAL CENTER	9TH AVENUE WOMEN'S PRIMARY CARE CENTER	4422 9TH AVENUE	BROOKLYN	NY	Active
DSH330194H	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES FAMILY HEALTH CENTER	1401 NEWKIRK AVENUE	BROOKLYN	NY	Active
DSH330194J	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES PRIMARY HEALTH SERVICES	6323 SEVENTH AVENUE	BROOKLYN	NY	Active
DSH330194K	Child	DSH	MAIMONIDES MEDICAL CENTER	BENSONHURST CLINIC TREATMENT CENTER	8620 18TH AVENUE	BROOKLYN	NY	Terminated
DSH330194L	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES ADULT PRIMARY CARE CENTER	1250 57TH STREET	BROOKLYN	NY	Active
DSH330194M	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CANCER CENTER	6300 8TH AVENUE	BROOKLYN	NY	Active
DSH330194N	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Breast Center	745 64th Street	Brooklyn	NY	Active
DSH330194P	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CARDIOLOGY OUTPATIENT C	421 OCEAN PKWY	BROOKLYN	NY	Active
DSH330194Q	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CARDIOLOGY OUTPATIENT CENTER	850 49TH ST	BROOKLYN	NY	Active
DSH330194R	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Cardiology	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194S	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Pediatric Specialties	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194T	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Pediatric Cardiology	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194U	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Cardiothoracic Surgery - Cardiothoracic Surgery	4813 9th Avenue - Seventh Floor	Brooklyn	NY	Active
DSH330194V	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Rheumatology - Rheumatology	4813 9TH Ave - Seventh Floor	Brooklyn	NY	Active
DSH330194W	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Health Bay Ridge Emergency Department - Emergency Department	9036 7th Avenue	Brooklyn	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Marshall, John P Chief Medical Officer Maimonides Medical Center 7182836028	Marshall, John EVP MedAffair/Chair MedOfficer Maimonides Medical Center 7182838313	4/10/2025 10:44 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 10:32:30 AM	8/30/2024 5:14:37 AM	8/30/2024 5:14 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 1:56:39 PM	8/21/2023 10:32:30 AM	8/21/2023 10:32 AM
Contacts	Primary Contact	Update	PC Change Request	Limoncelli, Vito Associate Director Maimonides Medical Center 7182836146	Bukher, Yevgenia Assistant Director, Pharmacy Maimonides Medical Center 7182837232	7/13/2023 11:05 AM
Contacts	Authorizing Official	Update	AO Change Request	Doyle, Declan SVP, Operations and Clinical Programs Maimonides Medical Center 7182837106	Marshall, John P Chief Medical Officer Maimonides Medical Center 7182836028	7/13/2023 7:17 AM
Contacts	Primary Contact	Update	PC Change Request	Caruso, Patricia Ann Director of Pharmacy Maimonides Medical Center 7182837207	Limoncelli, Vito Associate Director Maimonides Medical Center 7182836146	4/3/2023 6:53 AM
Contacts	Authorizing Official	Update	AO Change Request	GIBBS, KENNETH D. CEO Maimonides Medical Center 7182836575	Doyle, Declan SVP, Operations and Clinical Programs Maimonides Medical Center 7182837106	3/23/2023 4:32 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 2:34:23 PM	9/12/2022 1:56:39 PM	9/12/2022 1:56 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 1:18:10 PM	9/8/2021 2:34:23 PM	9/8/2021 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 1:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4157206	9/2/2020 1:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/2/2020 1:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1093777492	9/2/2020 1:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/2/2020 1:18 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/2/2020 1:18 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/2/2020 1:18 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 2:59:55 PM	9/2/2020 1:18:10 PM	9/2/2020 1:18 PM
Details	Last Recertification Date	Update	Recertification	9/4/2018 1:48:27 PM	9/9/2019 2:59:55 PM	9/9/2019 2:59 PM
Addresses	Billing Address	Insert	Change Request		Maimonides Medical Center 4802 Tenth Avenue Brooklyn, NY 11219	4/18/2019 9:48 AM
Addresses	Shipping Address	Insert	Change Request		9TH AVENUE WOMEN'S PRIMARY CARE CENTER 4422 9TH AVENUE Brooklyn, NY 11220	4/18/2019 9:48 AM
Addresses	Shipping Address	Insert	Change Request		Maimonides Medical Center 4802 Tenth Avenue Brooklyn, NY 11219	4/18/2019 9:48 AM
Contacts	Primary Contact	Update	Change Request	CASSERA, FRED DIRECTOR OF PHARMACY Maimonides Medical Center 7182837205	Caruso, Patricia Ann Director of Pharmacy Maimonides Medical Center 7182837207	4/18/2019 9:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2018 1:48 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00243641	9/4/2018 1:48 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/4/2018 1:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1083623144	9/4/2018 1:48 PM
Details	Last Recertification Date	Update	Recertification	11/20/2017 1:52:33 PM	9/4/2018 1:48:27 PM	9/4/2018 1:48 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/20/2017 1:52:33 PM	11/20/2017 1:52 PM
Contacts	Authorizing Official	Update		GIBBS, KENNETH D. CEO 7182836575	GIBBS, KENNETH D. CEO Maimonides Medical Center 7182836575	11/17/2017 3:35 PM
Contacts	Primary Contact	Update		CASSERA, FRED DIRECTOR OF PHARMACY 7182837205	CASSERA, FRED DIRECTOR OF PHARMACY Maimonides Medical Center 7182837205	9/26/2017 1:37 PM
Contacts	Primary Contact	Update		GUNN, ELAINE ASSOCIATE VICE PRESIDENT AMBULATORY HEALTH SERVICES NETWORK 7182837427	CASSERA, FRED DIRECTOR OF PHARMACY 7182837205	1/10/2017 11:54 AM
Contacts	Authorizing Official	Update		NALDI, ROBERT EXECUTIVE VP/CFO 7182833900	GIBBS, KENNETH D. CEO 7182836575	1/10/2017 11:54 AM
Addresses	Main Address	Insert			4422 9TH AVENUE BROOKLYN, NY 11220	8/10/2016 2:24 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 2:24 PM
Medicaid Billing	NPI: Number	Insert			1093777492	1/22/2016 4:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/14/2015 2:46 PM
Medicaid Billing	Medicaid: Number	Insert			02998736	12/14/2015 2:46 PM
Medicaid Billing	Medicaid: State	Insert			NY	12/14/2015 2:46 PM
Details	Last Recertification Date	Update		8/14/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 1:27 PM
Details	Last Recertification Date	Update		8/27/2013 8:16:36 AM	8/14/2014 12:00:00 AM	8/14/2014 2:48 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/27/2013 8:16:36 AM	8/27/2013 8:16 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/1/2012 7:46 AM
Contacts	Authorizing Official	Insert			NALDI, ROBERT EXECUTIVE VP/CFO 7182833900	9/21/2009 9:48 AM
Contacts	Primary Contact	Insert			GUNN, ELAINE ASSOCIATE VICE PRESIDENT AMBULATORY HEALTH SERVICES NETWORK 7182837427	6/15/2009 8:26 PM
Details	Last Recertification Date	Insert				6/15/2009 8:26 PM
Details	Grant Number	Insert				6/15/2009 8:26 PM
Details	340B ID	Insert			DSH330194G	6/15/2009 8:26 PM
Details	Is Authorizing Official EHB Data	Insert				6/15/2009 8:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/15/2009 8:26 PM
Details	Medicare Provider Number	Insert			330194	6/15/2009 8:26 PM
Details	Entity Name	Insert			MAIMONIDES MEDICAL CENTER	6/15/2009 8:26 PM
Details	Program Code	Insert			DSH	6/15/2009 8:26 PM
Details	Entity Subname	Insert			9TH AVENUE WOMEN'S PRIMARY CARE CENTER	6/15/2009 8:26 PM
Dates	Participating Approval Date	Insert			6/15/2009 12:00:00 AM	6/15/2009 8:26 PM
Details	State	Insert			Active	6/15/2009 8:26 PM
Dates	Registration Date	Insert			6/11/2009 12:00:00 AM	6/15/2009 8:26 PM
Dates	Signed By Date	Insert			5/21/2009 12:00:00 AM	6/15/2009 8:26 PM
Dates	Start Date	Insert			7/1/2009 12:00:00 AM	6/15/2009 8:26 PM
Terminations	Termination Comments	Insert				6/15/2009 8:26 PM
Terminations	Termination Date	Insert				6/15/2009 8:26 PM
Terminations	Termination Effective Date	Insert				6/15/2009 8:26 PM
Terminations	Termination Reason	Insert				6/15/2009 8:26 PM