Covered Entity Details

CAH471301-09 GIFFORD MEDICAL CENTER (Active) - information as of 5/27/2025 2:39:20 PM

Main Details

Name

GIFFORD MEDICAL CENTER

Subdivision Name

LEVESQUE MEDICAL OFFICES - ORTHOPEDIC CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH471301-09

Medicare Provider Number

471301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

6/8/2011

Participating Start Date

7/1/2011

Participating Approval Date

6/14/2011

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Gifford Health Care, Inc.
Michael Costa, CEO
(802) 728-2211

Primary Contact

Gifford Health Care, Inc.
Dawn M Cogger, 340B Coordinator
(802) 728-2108

Addresses

Street Address

44 SOUTH MAIN STREET
RANDOLPH, VT 05060

Billing Address

LEVESQUE MEDICAL OFFICES - ORTHOPEDIC CLINIC
P.O. BOX 2000
RANDOLPH, VT 05060

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
Contract Detail	DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA	12 CENTERRA PKWY STE 10		LEBANON	NH	03766	10/12/2020	01/01/2021			01/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH471301-01	Child	CAH	GIFFORD MEDICAL CENTER	ROCHESTER HEALTH CENTER	235 SOUTH MAIN ST	ROCHESTER	VT	Terminated
CAH471301-02	Child	CAH	GIFFORD MEDICAL CENTER	BETHEL HEALTH CENTER	1823 VT RTE 107	RANDOLPH	VT	Terminated
CAH471301-03	Child	CAH	GIFFORD MEDICAL CENTER	KINGWOOD HEALTH CENTER - NEURO CLINIC	1422 ROUTE 66	RANDOLPH	VT	Terminated
CAH471301-04	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - PODIATRY CLINIC	44 SOUTH MAIN STREET	RANDOLPH	VT	Active
CAH471301-05	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - NEURO CLINIC	44 SOUTH MAIN STREET	RANDOLPH	VT	Terminated
CAH471301-06	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - PEDI & INTERNAL CLINIC	44 SOUTH MAIN STREET	RANDOLPH	VT	Terminated
CAH471301-07	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - GEN SURGERY CLINIC (SURGICAL)	44 SOUTH MAIN STREET	RANDOLPH	VT	Active
CAH471301-08	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - GEN SURGERY CLINIC (UROLOGY)	44 SOUTH MAIN STREET	RANDOLPH	VT	Active
CAH471301-09	Child	CAH	GIFFORD MEDICAL CENTER	LEVESQUE MEDICAL OFFICES - ORTHOPEDIC CLINIC	44 SOUTH MAIN STREET	RANDOLPH	VT	Active
CAH471301-10	Child	CAH	GIFFORD MEDICAL CENTER	SHARON HEALTH CENTER	12 SHIPPEE LANE	SHARON	VT	Active
CAH471301-11	Child	CAH	GIFFORD MEDICAL CENTER	TWIN RIVER HEALTH CENTER - GENERAL SURGERY CLINIC (UROLOGY)	108 NORTH MAIN ST	WHITE RIVER JUNCTION	VT	Terminated
CAH471301-12	Child	CAH	GIFFORD MEDICAL CENTER	GIFFORD HEALTH CENTER AT BERLIN - NEURO CLINIC	82 EAST VIEW LANE	BARRE	VT	Terminated
CAH471301-13	Child	CAH	GIFFORD MEDICAL CENTER	GIFFORD HEALTH CENTER AT BERLIN - OB/GYN CLINIC	82 EAST VIEW LANE	BARRE	VT	Terminated
CAH471301-14	Child	CAH	GIFFORD MEDICAL CENTER	GIFFORD HEALTH CENTER AT BERLIN - SPECIALTY CLINICS	82 EAST VIEW LANE	BARRE	VT	Active
CAH471301-15	Child	CAH	GIFFORD MEDICAL CENTER	GIFFORD HEALTH CENTER AT BERLIN - PED & INTERNAL CLINIC	82 EAST VIEW LANE	BARRE	VT	Terminated
CAH471301-16	Child	CAH	GIFFORD MEDICAL CENTER	GIFFORD HEALTH CENTER AT BERLIN - ORTHOPEDIC CLINIC	82 EAST VIEW LANE	BARRE	VT	Terminated
CAH471301-17	Child	CAH	GIFFORD MEDICAL CENTER	CHELSEA HEALTH CENTER	356 VT RTE 110	CHELSEA	VT	Terminated
CAH471301-18	Child	CAH	GIFFORD MEDICAL CENTER	MENIG EXTENDED CARE	44 SOUTH MAIN STREET	RANDOLPH	VT	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Costa, Michael CEO Gifford Medical Center 8027282211	Costa, Michael CEO Gifford Health Care, Inc. 8027282211	2/9/2025 12:21 PM
Contacts	Primary Contact	Update	Profile Change Request	Cogger, Dawn M 340B Coordinator Gifford Health Care 8027282108	Cogger, Dawn M 340B Coordinator Gifford Health Care, Inc. 8027282108	2/4/2025 2:47 PM
Contacts	Authorizing Official	Update	Change Request	Bennett, Daniel CEO Gifford Health Care 8027282304	Costa, Michael CEO Gifford Medical Center 8027282211	10/10/2024 8:13 AM
Details	Last Recertification Date	Update	Recertification	8/29/2023 9:16:07 AM	8/14/2024 9:47:54 AM	8/14/2024 9:47 AM
Contacts	Primary Contact	Update	Profile Change Request	Cogger, Dawn M 340B Coordinator Gifford Health Care 8027282337	Cogger, Dawn M 340B Coordinator Gifford Health Care 8027282108	9/6/2023 11:03 AM
Addresses	Billing Address	Insert	Recertification		LEVESQUE MEDICAL OFFICES - ORTHOPEDIC CLINIC P.O. BOX 2000 RANDOLPH, VT 05060	8/29/2023 9:16 AM
Details	Last Recertification Date	Update	Recertification	9/19/2022 8:28:55 AM	8/29/2023 9:16:07 AM	8/29/2023 9:16 AM
Contacts	Primary Contact	Update	Change Request	DiStefano, Rachel A Specialist Gifford 8027282203	Cogger, Dawn M 340B Coordinator Gifford Health Care 8027282337	8/1/2023 5:22 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 9:23:49 AM	9/19/2022 8:28:55 AM	9/19/2022 8:28 AM
Details	Last Recertification Date	Update	Recertification	8/18/2020 10:19:12 AM	8/16/2021 9:23:49 AM	8/16/2021 9:23 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 1:19:47 PM	8/18/2020 10:19:12 AM	8/18/2020 10:19 AM
Contacts	Authorizing Official	Update	AO Change Request	Hebert, Jeff CFO Gifford Medical Center 8027282356	Bennett, Daniel CEO Gifford Health Care 8027282304	1/23/2020 10:57 AM
Contacts	Primary Contact	Update	Recertification	Ertel, Jennifer Project Manager Gifford Medical Center 8027282339	DiStefano, Rachel A Specialist Gifford 8027282203	8/21/2019 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 9:54:37 AM	8/21/2019 1:19:47 PM	8/21/2019 1:19 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 10:02:34 AM	8/17/2018 9:54:37 AM	8/17/2018 9:54 AM
Details	Last Recertification Date	Update	Recertification	10/24/2017 4:44:47 PM	11/8/2017 10:02:34 AM	11/8/2017 10:02 AM
Contacts	Primary Contact	Insert	Recertification		Ertel, Jennifer Project Manager Gifford Medical Center 8027282339	10/24/2017 4:44 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	10/24/2017 4:44:47 PM	10/24/2017 4:44 PM
Contacts	Authorizing Official	Update		Hebert, Jeff CFO 8027282356	Hebert, Jeff CFO Gifford Medical Center 8027282356	10/24/2017 4:26 PM
Contacts	Authorizing Official	Insert			Hebert, Jeff CFO 8027282356	7/12/2017 4:16 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 9:39 AM
Addresses	Main Address	Insert			44 SOUTH MAIN STREET RANDOLPH, VT 05060	8/29/2016 9:39 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 12:34 PM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 12:54 PM
Addresses	Billing Address	Update		, VT	GIFFORD MEDICAL CENTER PO BOX 2000 RANDOLPH, VT 05060	8/30/2013 3:36 PM
Addresses	Billing Address	Insert			, VT	8/30/2013 3:36 PM
Details	Last Recertification Date	Update			8/30/2013 12:00:00 AM	8/30/2013 3:36 PM
Details	Last Recertification Date	Insert				6/14/2011 10:56 AM
Details	Grant Number	Insert				6/14/2011 10:56 AM
Details	340B ID	Insert			CAH471301-09	6/14/2011 10:56 AM
Details	Is Authorizing Official EHB Data	Insert				6/14/2011 10:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert				6/14/2011 10:56 AM
Details	Medicare Provider Number	Insert			471301	6/14/2011 10:56 AM
Details	Entity Name	Insert			GIFFORD MEDICAL CENTER	6/14/2011 10:56 AM
Details	Program Code	Insert			CAH	6/14/2011 10:56 AM
Details	Entity Subname	Insert			LEVESQUE MEDICAL OFFICES - ORTHOPEDIC CLINIC	6/14/2011 10:56 AM
Dates	Participating Approval Date	Insert			6/14/2011 12:00:00 AM	6/14/2011 10:56 AM
Details	State	Insert			Active	6/14/2011 10:56 AM
Dates	Registration Date	Insert			6/8/2011 12:00:00 AM	6/14/2011 10:56 AM
Dates	Signed By Date	Insert			4/21/2011 12:00:00 AM	6/14/2011 10:56 AM
Dates	Start Date	Insert			7/1/2011 12:00:00 AM	6/14/2011 10:56 AM
Terminations	Termination Comments	Insert				6/14/2011 10:56 AM
Terminations	Termination Date	Insert				6/14/2011 10:56 AM
Terminations	Termination Effective Date	Insert				6/14/2011 10:56 AM
Terminations	Termination Reason	Insert				6/14/2011 10:56 AM