Covered Entity Details

DSH160067V COVENANT MEDICAL CENTER (Terminated) - information as of 4/9/2025 4:43:14 AM

Main Details

Name

COVENANT MEDICAL CENTER

Subdivision Name

COVENANT CLINIC ARLINGTON

Type

Disproportionate Share Hospital

Rural

340B ID

DSH160067V

Medicare Provider Number

160067

Outpatient Facility Provider Number

163438

Additional Details

Current Program Status

Terminated

Registration Date

2/28/2011

Participating Start Date

4/1/2011

Participating Approval Date

3/17/2011

Last Recertification Date

8/12/2014

Termination Date
Termination Reason

7/1/2015
Loss of qualifying grant/support

Contacts

Authorizing Official

MercyOne NorthEast Iowa
Timothy Huber, Vice President of Finance
(319) 272-7607

Primary Contact

Covenant Medical Center
TRISH MEANS NEUROTH, Reimbursement Supervisor
(319) 272-7601

Addresses

Street Address

751 MAIN STREET
ARLINGTON, IA 50606

Billing Address

COVENANT CLINIC
PO BOX 6200
WATERLOO, IA 50704

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?
No

Shipping Addresses

Same as Street Address

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH160067A	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waverly Family Medicine	217 20TH STREET NW	WAVERLY	IA	Active
DSH160067AA	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Grand Crossing Allergy & Immunology	21 W Jefferson St	WATERLOO	IA	Active
DSH160067AB	Child	DSH	MercyOne Waterloo Medical Center	Mercy One Oelwein Family Medicine	129 8TH AVE SE	OELWEIN	IA	Active
DSH160067AC	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Weight Loss Center & Bariatric Surgery	515 College Street	CEDAR FALLS	IA	Active
DSH160067AD	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Internal Medicine	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067AE	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Reinbeck Family Medicine	501 MAIN STREET	REINBECK	IA	Active
DSH160067AF	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Pediatrics Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067AG	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Podiatry Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067AH	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Fairbank Family Medicine	105 S WALNUT ST	FAIRBANK	IA	Active
DSH160067AJ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Jesup Family Medicine	1094 220TH STREET	JESUP	IA	Active
DSH160067AK	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Outpatient Services, Pain Management	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067AL	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Tripoli Family Medicine	602 7TH AVE SW	TRIPOLI	IA	Active
DSH160067AM	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste CC	226 BLUE BELL RD	CEDAR FALLS	IA	Active
DSH160067AN	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Physical Medicine & Rehabilitation	3421 W 9TH STREET	WATERLOO	IA	Active
DSH160067AP	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Gladbrook Family Medicine	309 2ND STREET	GLADBROOK	IA	Terminated
DSH160067AQ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Neurosurgery	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067AR	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Kimball Family Medicine Ste 400	2055 KIMBALL DRIVE, STE 400	WATERLOO	IA	Active
DSH160067AS	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Behavioral Health Care	2802 ORCHARD DR	CEDAR FALLS	IA	Active
DSH160067AT	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls OB/GYN	226 Blue Bell Rd	Cedar Falls	IA	Terminated
DSH160067AU	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Gastroenterology Care	2710 St Francis Drive	Waterloo	IA	Active
DSH160067AV	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Heart Care	515 COLLEGE STREET SUITE 2000	CEDAR FALLS	IA	Active
DSH160067AW	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Orthopedics Care	516 S DIVISION ST	CEDAR FALLS	IA	Active
DSH160067AX	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls General Surgery	515 College St	Cedar Falls	IA	Active
DSH160067AY	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Family Medicine, Nephrology	516 Division Street	Cedar Falls	IA	Active
DSH160067AZ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Family Medicine Internal Medicine	516 S DIVISION ST.	CEDAR FALLS	IA	Active
DSH160067B	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Pediatrics Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067BA	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Specialists, Allergy-Immunology	516 Division Street	Cedar Falls	IA	Active
DSH160067BB	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls General Surgery, Otolaryngology	516 Division Street	Cedar Falls	IA	Active
DSH160067BC	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Behavioral Health Care	2750 SAINT FRANCIS DR	WATERLOO	IA	Active
DSH160067BD	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waverly Family Medicine, Psych	217 20TH NW ST	WAVERLY	IA	Active
DSH160067BE	Child	DSH	COVENANT MEDICAL CENTER	COVENANT Clinic Convenient Care	6301 UNIVERSITY AVE STE A3	CEDAR FALLS	IA	Terminated
DSH160067BF	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Maternal Fetal Medicine	432 King Drive	Waterloo	IA	Terminated
DSH160067BG	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Orthopedics Care	516 S Division St	Cedar Falls	IA	Terminated
DSH160067BH	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Urology Care	3410 KIMBALL AVE.	WATERLOO	IA	Active
DSH160067BJ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Orthopedics Care, Radiology	2710 St Francis Dr	Waterloo	IA	Terminated
DSH160067BK	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Internal Medicine, Infectious Disease	2710 St Francis Dr	Waterloo	IA	Active
DSH160067BL	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Pain Management	2710 ST FRANCIS DR	WATERLOO	IA	Active
DSH160067BM	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Neurology	2710 St Francis Dr	Waterloo	IA	Terminated
DSH160067BN	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Neurosurgery	2710 St Francis Dr	Waterloo	IA	Terminated
DSH160067BP	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Internal Medicine	2710 St Francis Dr	Waterloo	IA	Active
DSH160067BQ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste OPT, Arrowhead Occupational Health & Wellness	226 BLue Bell Rd	Cedar Falls	IA	Active
DSH160067BR	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste OPT, Chiropractic Care	226 Blue Bell Rd	Cedar Falls	IA	Terminated
DSH160067BS	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste OPT, Arrowhead Outpatient Physical Therapy	226 Blue Bell Rd	Cedar Falls	IA	Active
DSH160067BT	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste OPT, Arrowhead Radiology	226 Blue Bell Rd	Cedar Falls	IA	Active
DSH160067BU	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste CC, Arrowhead Lab	226 Blue Bell Rd	Cedar Falls	IA	Active
DSH160067BV	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste CC, Arrowhead Psychiatry	226 Blue Bell RD	Cedar Falls	IA	Active
DSH160067BW	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste CC, Arrowhead Surgery	226 Blue Bell Rd	Cedar Falls	IA	Terminated
DSH160067BX	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waverly Family Medicine, Nephrology	217 20th St NW	Waverly	IA	Active
DSH160067BY	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Kimball Outpatient Physical & Occupational	2204 Kimball Ave	Waterloo	IA	Active
DSH160067C	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo General Surgery	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067CA	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Cancer Center	200 East Ridgeway Ave	Waterloo	IA	Active
DSH160067CB	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Parkersburg Family Medicine	1306 HWY 57 UNIT A	PARKERSBURG	IA	Active
DSH160067CC	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Heart Care	129 8th Ave SE	Oelwein	IA	Active
DSH160067CD	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Internal Medicine, Nephrology	129 8th Ave SE	Oelwein	IA	Active
DSH160067CE	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Sleep Lab	2710 St Francis Drive	Waterloo	IA	Active
DSH160067CF	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Traer Physical Therapy	549 Second Street	Traer	IA	Active
DSH160067CG	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Internal Medicine	2710 St Francis Dr	Waterloo	IA	Terminated
DSH160067CH	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Grand Crossing Family Medicine	21 W Jefferson St	Waterloo	IA	Terminated
DSH160067CJ	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Kimball Family Medicine Ste 330	2055 Kimball Avenue	Waterloo	IA	Terminated
DSH160067CK	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Allison Family Medicine	502 Locust St	Allison	IA	Terminated
DSH160067CL	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Independence Family Medicine	2004 ENTERPRISE CT	INDEPENDENCE	IA	Active
DSH160067CM	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Oelwein Urgent Care & Occupational Medicine	129 8th Avenue SE	OELWEIN	IA	Active
DSH160067CN	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo OB/GYN - MercyOne Waterloo OB/GYN	3421 W 9th St, Ste G4500	Waterloo	IA	Active
DSH160067CP	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Northeast Iowa Family Medicine & Residency - Family Medicine	2055 Kimball Ave	Waterloo	IA	Active
DSH160067D	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Gynecology Care	226 BLUEBELL STREET	CEDAR FALLS	IA	Active
DSH160067E	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Neurology	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067F	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Wound Care	3421 W 9th St	WATERLOO	IA	Terminated
DSH160067G	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Traer Family Medicine	200 WALNUT STREET	TRAER	IA	Active
DSH160067H	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Urgent Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067J	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road Ste CC, Arrowhead Podiatry	226 BLUE BELL RD, Suite CC	CEDAR FALLS	IA	Active
DSH160067K	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Evansdale Family Medicine	3562 LAFAYETTE RD	EVANSDALE	IA	Active
DSH160067L	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Orthopedics Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067M	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Vascular Surgery	2710 ST FRANCIS DRIVE	WATERLOO	IA	Terminated
DSH160067N	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Family Medicine	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067P	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls Family Medicine Suite 100	516 S DIVISION STREET	CEDAR FALLS	IA	Active
DSH160067Q	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Dysart Family Medicine	501 CLARK ST	DYSART	IA	Active
DSH160067R	Child	DSH	MercyOne Waterloo Medical Center	MercyOne La Porte City Family Medicine	601 HIGHWAY 218 NORTH	LAPORTE CITY	IA	Active
DSH160067S	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Hematology/Oncology	200 E RIDGEWAY AVENUE	WATERLOO	IA	Active
DSH160067T	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Bluebell Road, Ste OPT, Convenient Care	226 BLUE BELL RD	CEDAR FALLS	IA	Active
DSH160067U	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Cedar Falls, Gastroenterology Family Medicine	516 S DIVISION STREET	CEDAR FALLS	IA	Active
DSH160067V	Child	DSH	COVENANT MEDICAL CENTER	COVENANT CLINIC ARLINGTON	751 MAIN STREET	ARLINGTON	IA	Terminated
DSH160067W	Child	DSH	MercyOne Waterloo Medical Center	COVENANT CLINIC SHELL ROCK	309 S CHERRY STREET	SHELL ROCK	IA	Terminated
DSH160067X	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Heart Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067Y	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo Pulmonary Care	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active
DSH160067Z	Child	DSH	MercyOne Waterloo Medical Center	MercyOne Waterloo ENT	2710 ST FRANCIS DRIVE	WATERLOO	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Huber, Timothy Controller MercyOne NorthEast Iowa 3192727607	Huber, Timothy Vice President of Finance MercyOne NorthEast Iowa 3192727607	10/4/2021 9:19 AM
Contacts	Authorizing Official	Update	Change Request	Davenport, Douglas Chief Financial Officer MercyOne Northeast Iowa 3192727359	Huber, Timothy Controller MercyOne NorthEast Iowa 3192727607	1/28/2020 11:32 AM
Contacts	Authorizing Official	Update	Profile Change Request	Davenport, Douglas Chief Financial Officer Wheaton Iowa 3192727359	Davenport, Douglas Chief Financial Officer MercyOne Northeast Iowa 3192727359	4/11/2019 9:37 AM
Contacts	Authorizing Official	Update	Change Request	Huber, Timothy VP Finance Covenant Medical Center 3192727607	Davenport, Douglas Chief Financial Officer Wheaton Iowa 3192727359	11/19/2018 9:43 AM
Contacts	Primary Contact	Update	Recertification	NEUROTH, TRISH MEANS Reimbursement Supervisor 3192727601	NEUROTH, TRISH MEANS Reimbursement Supervisor Covenant Medical Center 3192727601	11/27/2017 10:47 AM
Contacts	Authorizing Official	Update		Huber, Timothy VP Finance 3192727607	Huber, Timothy VP Finance Covenant Medical Center 3192727607	10/16/2017 5:25 PM
Contacts	Authorizing Official	Update		PANICUCCI, MICHELE SENIOR VP/CFO 3192727359	Huber, Timothy VP Finance 3192727607	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			PANICUCCI, MICHELE SENIOR VP/CFO 3192727359	7/21/2017 7:13 PM
Contacts	Primary Contact	Insert			NEUROTH, TRISH MEANS Reimbursement Supervisor 3192727601	7/21/2017 7:13 PM
Addresses	Main Address	Insert			751 MAIN STREET ARLINGTON, IA 50606	4/9/2015 3:04 PM
Addresses	Billing Address	Insert			COVENANT CLINIC PO BOX 6200 WATERLOO, IA 50704	4/9/2015 3:04 PM
Dates	Last Date That 340B Drugs Purchased	Update			4/1/2015 12:00:00 AM	4/9/2015 3:04 PM
Details	State	Update		Active	Terminated	4/9/2015 3:04 PM
Terminations	Termination Comments	Update			This facility is a rural health clinic, and we have never used the 340B program for this facility. We are requesting this 340B number be terminated for non-use. The above termination reason do not apply to this facility.	4/9/2015 3:04 PM
Terminations	Termination Date	Update			7/1/2015 12:00:00 AM	4/9/2015 3:04 PM
Terminations	Termination Effective Date	Update			4/1/2015 12:00:00 AM	4/9/2015 3:04 PM
Terminations	Termination Reason	Update			Loss of qualifying grant/support	4/9/2015 3:04 PM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	8/12/2014 12:00:00 AM	8/12/2014 9:01 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 12:00:00 AM	9/10/2013 9:41 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	4/30/2012 12:26 PM
Details	Last Recertification Date	Insert				4/1/2011 10:54 AM
Details	Grant Number	Insert				4/1/2011 10:54 AM
Details	340B ID	Insert			DSH160067V	4/1/2011 10:54 AM
Details	Is Authorizing Official EHB Data	Insert				4/1/2011 10:54 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/1/2011 10:54 AM
Details	Medicare Provider Number	Insert			160067	4/1/2011 10:54 AM
Details	Entity Name	Insert			COVENANT MEDICAL CENTER	4/1/2011 10:54 AM
Details	Program Code	Insert			DSH	4/1/2011 10:54 AM
Details	Entity Subname	Insert			COVENANT CLINIC ARLINGTON	4/1/2011 10:54 AM
Dates	Participating Approval Date	Insert			3/17/2011 12:00:00 AM	4/1/2011 10:54 AM
Details	State	Insert			Active	4/1/2011 10:54 AM
Dates	Registration Date	Insert			2/28/2011 12:00:00 AM	4/1/2011 10:54 AM
Dates	Signed By Date	Insert			1/24/2011 12:00:00 AM	4/1/2011 10:54 AM
Dates	Start Date	Insert			4/1/2011 12:00:00 AM	4/1/2011 10:54 AM
Terminations	Termination Comments	Insert				4/1/2011 10:54 AM
Terminations	Termination Date	Insert				4/1/2011 10:54 AM
Terminations	Termination Effective Date	Insert				4/1/2011 10:54 AM
Terminations	Termination Reason	Insert				4/1/2011 10:54 AM