| Details | Last Recertification Date | Update | Recertification | 8/30/2023 10:34:47 AM | 9/5/2024 11:54:26 AM | 9/5/2024 11:54 AM |
| Details | Entity Subname | Update | Recertification | ROSCOE HEALTH CENTER | UHS PRIM CARE ROSCOE-FAMILY PRACTICE | 9/5/2024 11:54 AM |
| Contacts | Primary Contact | Update | Recertification | Waldron, William G
Director of Pharmacy
United Health Services Hospitals, Inc
6077631835 | Decaro, Ryan C.
Pharmacy Business Manager
United Health Services Hospitals, Inc
6077631838 | 8/30/2023 10:34 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 12:37:35 PM | 8/30/2023 10:34:47 AM | 8/30/2023 10:34 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 10:32:17 AM | 9/8/2022 12:37:35 PM | 9/8/2022 12:37 PM |
| Addresses | Shipping Address | Insert | Recertification | | Delaware Valley Hospital
1 Titus Place
Walton, NY 13856 | 9/9/2021 10:32 AM |
| Addresses | Billing Address | Update | Recertification | DELAWARE VALLEY HOSPITAL
2 TITUS PLACE
WALTON, NY 13856 | DELAWARE VALLEY HOSPITAL
1 TITUS PLACE
WALTON, NY 13856 | 9/9/2021 10:32 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2020 1:09:11 PM | 9/9/2021 10:32:17 AM | 9/9/2021 10:32 AM |
| Contacts | Authorizing Official | Update | Change Request | Summers, Paul K
President/CEO
Delaware Valley Hospital. Inc.
6078652160 | Rider, LuCinda M
Chief Financial Officer
Delaware Valley Hospital, Inc.
6078652190 | 1/28/2021 8:10 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | NY | 9/10/2020 1:09 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2019 1:29:19 PM | 9/10/2020 1:09:11 PM | 9/10/2020 1:09 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2018 11:25:18 AM | 9/3/2019 1:29:19 PM | 9/3/2019 1:29 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Summers, Paul
Chief Executive Officer
Delaware Valley Hospital, Inc.
6078652160 | Summers, Paul K
President/CEO
Delaware Valley Hospital. Inc.
6078652160 | 7/1/2019 7:52 AM |
| Contacts | Primary Contact | Update | Change Request | Waldron, William
Associate Director of Pharmacy
United Health Services Hospitals, Inc
6077631835 | Waldron, William G
Director of Pharmacy
United Health Services Hospitals, Inc
6077631835 | 5/22/2019 4:23 PM |
| Details | Last Recertification Date | Update | Recertification | 11/22/2017 11:52:27 AM | 8/29/2018 11:25:18 AM | 8/29/2018 11:25 AM |
| Details | Last Recertification Date | Update | Recertification | 8/12/2016 12:00:00 AM | 11/22/2017 11:52:27 AM | 11/22/2017 11:52 AM |
| Contacts | Authorizing Official | Update | | Summers, Paul
Chief Executive Officer
6078652160 | Summers, Paul
Chief Executive Officer
Delaware Valley Hospital, Inc.
6078652160 | 10/20/2017 9:37 AM |
| Contacts | Primary Contact | Update | | Waldron, William
Associate Director of Pharmacy
6077631835 | Waldron, William
Associate Director of Pharmacy
United Health Services Hospitals, Inc
6077631835 | 9/20/2017 8:51 AM |
| Contacts | Primary Contact | Update | | JAMES, JASON
PHARMACIST
6078652187 | Waldron, William
Associate Director of Pharmacy
6077631835 | 8/3/2017 10:40 AM |
| Contacts | Authorizing Official | Insert | | | Summers, Paul
Chief Executive Officer
6078652160 | 8/3/2017 10:40 AM |
| Addresses | Main Address | Insert | | |
1982 OLD RT 17
ROSCOE, NY 12776 | 8/12/2016 12:13 PM |
| Details | Last Recertification Date | Update | | 8/19/2015 12:00:00 AM | 8/12/2016 12:00:00 AM | 8/12/2016 12:13 PM |
| Details | Last Recertification Date | Update | | 8/15/2014 12:00:00 AM | 8/19/2015 12:00:00 AM | 8/19/2015 8:58 AM |
| Details | Last Recertification Date | Update | | 8/27/2013 12:00:00 AM | 8/15/2014 12:00:00 AM | 8/15/2014 1:41 PM |
| Medicaid Billing | NPI: Number | Update | | 1144312646 | 1417940719 | 8/27/2013 7:33 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/27/2013 12:00:00 AM | 8/27/2013 7:33 AM |
| Addresses | Billing Address | Insert | | | DELAWARE VALLEY HOSPITAL
2 TITUS PLACE
WALTON, NY 13856 | 8/5/2013 7:33 AM |
| Contacts | Primary Contact | Insert | | | JAMES, JASON
PHARMACIST
6078652187 | 6/1/2012 7:42 AM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 6/1/2012 7:42 AM |
| Details | Entity Name | Update | | DELAWARE VALLEY HOSPITAL | DELAWARE VALLEY HOSPITAL INC. | 1/31/2012 9:19 AM |
| Details | Entity Subname | Update | | UHS PRIMARY CARE ROSCOE | ROSCOE HEALTH CENTER | 1/31/2012 9:19 AM |
| Details | Comments Public | Insert | | | 1/31/12 - Updated subdiv name (was UHS PRIMARY CARE ROSCOE) | 1/31/2012 9:19 AM |
| Details | Last Recertification Date | Insert | | | | 11/22/2010 2:26 PM |
| Details | Grant Number | Insert | | | | 11/22/2010 2:26 PM |
| Details | 340B ID | Insert | | | CAH331312-01 | 11/22/2010 2:26 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 11/22/2010 2:26 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 11/22/2010 2:26 PM |
| Details | Medicare Provider Number | Insert | | | 331312 | 11/22/2010 2:26 PM |
| Details | Entity Name | Insert | | | DELAWARE VALLEY HOSPITAL | 11/22/2010 2:26 PM |
| Details | Program Code | Insert | | | CAH | 11/22/2010 2:26 PM |
| Details | Entity Subname | Insert | | | UHS PRIMARY CARE ROSCOE | 11/22/2010 2:26 PM |
| Dates | Participating Approval Date | Insert | | | 11/17/2010 12:00:00 AM | 11/22/2010 2:26 PM |
| Details | State | Insert | | | Active | 11/22/2010 2:26 PM |
| Dates | Registration Date | Insert | | | 11/16/2010 12:00:00 AM | 11/22/2010 2:26 PM |
| Dates | Signed By Date | Insert | | | 9/24/2010 12:00:00 AM | 11/22/2010 2:26 PM |
| Dates | Start Date | Insert | | | 1/1/2011 12:00:00 AM | 11/22/2010 2:26 PM |
| Terminations | Termination Comments | Insert | | | | 11/22/2010 2:26 PM |
| Terminations | Termination Date | Insert | | | | 11/22/2010 2:26 PM |
| Terminations | Termination Effective Date | Insert | | | | 11/22/2010 2:26 PM |
| Terminations | Termination Reason | Insert | | | | 11/22/2010 2:26 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1144312646 | 11/16/2010 3:37 PM |