| Details | Last Recertification Date | Update | Recertification | 2/26/2024 2:43:49 PM | 2/18/2025 5:28:06 PM | 2/18/2025 5:28 PM |
| Contacts | Authorizing Official | Update | Group Change Request | Brodine, Warren J
Chief Executive Officer
Eisner Health
2137461037-3305 | Gutierrez-McCarthy, Monica
CEO
Eisner Health
2133423325 | 4/15/2024 10:09 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2023 1:34:35 PM | 2/26/2024 2:43:49 PM | 2/26/2024 2:43 PM |
| Details | Last Recertification Date | Update | Recertification | 2/25/2022 6:44:49 AM | 2/9/2023 1:34:35 PM | 2/9/2023 1:34 PM |
| Addresses | Shipping Address | Delete | Recertification | Eisner Health
1500 S Olive St
Los Angeles, CA 90015 | | 2/25/2022 6:44 AM |
| Addresses | Shipping Address | Insert | Recertification | | Eisner Health
1500 S Olive St RM#101
Los Angeles, CA 90015 | 2/25/2022 6:44 AM |
| Contacts | Primary Contact | Update | Recertification | Alton, Nicole
Director, Pharmacy Services
Eisner Health
2133423333 | Tavares-Kuhn, Nicole Marie
Director, Pharmacy Services
Eisner Health
2135880467 | 2/25/2022 6:44 AM |
| Details | Last Recertification Date | Update | Recertification | 2/22/2021 2:15:37 PM | 2/25/2022 6:44:49 AM | 2/25/2022 6:44 AM |
| Addresses | Shipping Address | Delete | Change Request | USC-Family Medical Center at California Hospital
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015-3048 | | 4/20/2021 11:19 AM |
| Addresses | Shipping Address | Delete | Change Request | EISNER PEDIATRIC & FAMILY MEDICAL CENTER
1500 S OLIVE ST.,
LOS ANGELES, CA 90015-3023 | | 4/20/2021 11:19 AM |
| Addresses | Shipping Address | Insert | Change Request | | Eisner Health
1500 S Olive St
Los Angeles, CA 90015 | 4/20/2021 11:19 AM |
| Addresses | Shipping Address | Insert | Change Request | | Eisner Health Family Medicine at California Hospital
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015 | 4/20/2021 11:19 AM |
| Addresses | Main Address | Update | Change Request |
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015-3048 |
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015 | 4/20/2021 11:19 AM |
| Addresses | Billing Address | Update | Change Request | PEDIATRIC & FAMILY MEDICAL CENTER
1530 S OLIVE ST.,
LOS ANGELES, CA 90015-3023 | Eisner Health
1530 S Olive St.,
Los Angeles, CA 90015 | 4/20/2021 11:19 AM |
| Details | Entity Name | Update | Change Request | PEDIATRIC & FAMILY MEDICAL CENTER | Eisner Health Family Medicine Center at California Hospital | 4/20/2021 11:19 AM |
| Details | Entity Subname | Update | Change Request | USC-Eisner Family Medicine Center at California Hospital | Eisner Health Family Medicine Center at California Hospital | 4/20/2021 11:19 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1386934875 ( ) | | 2/22/2021 2:15 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1326370073 ( ) | | 2/22/2021 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1326370073 | 2/22/2021 2:15 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 2/22/2021 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1386934875 | 2/22/2021 2:15 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 2/22/2021 2:15 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2020 10:26:56 AM | 2/22/2021 2:15:37 PM | 2/22/2021 2:15 PM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2019 6:20:36 PM | 1/31/2020 10:26:56 AM | 1/31/2020 10:26 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2018 8:26:50 PM | 2/15/2019 6:20:36 PM | 2/15/2019 6:20 PM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2017 12:00:00 AM | 2/13/2018 8:26:50 PM | 2/13/2018 8:26 PM |
| Contacts | Authorizing Official | Update | Change Request | de Leon, Chona
Chief Operating Officer
2137475542-3326 | Brodine, Warren J
Chief Executive Officer
Eisner Health
2137461037-3305 | 1/24/2018 3:14 PM |
| Contacts | Primary Contact | Update | | Alton, Nicole
Director, Pharmacy Services
2133423333 | Alton, Nicole
Director, Pharmacy Services
Eisner Health
2133423333 | 1/12/2018 11:15 AM |
| Contacts | Primary Contact | Update | | ALTON, NICOLE
DIRECTOR OF PHARMACY SERVICES
2137461037-3333 | Alton, Nicole
Director, Pharmacy Services
2133423333 | 4/6/2017 7:37 AM |
| Contacts | Authorizing Official | Update | | de Leon, Chona
Chief Operating Officer
2137461037-3326 | de Leon, Chona
Chief Operating Officer
2137475542-3326 | 4/6/2017 7:37 AM |
| Contacts | Signed By | Insert | | | COAN, CARL E.
CEO
2137461037-3330 | 2/14/2017 7:20 AM |
| Addresses | Main Address | Insert | | |
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015-3048 | 2/14/2017 7:20 AM |
| Details | Last Recertification Date | Update | | 3/7/2016 12:00:00 AM | 2/14/2017 12:00:00 AM | 2/14/2017 7:20 AM |
| Contacts | Primary Contact | Insert | | | ALTON, NICOLE
DIRECTOR OF PHARMACY SERVICES
2137461037-3333 | 10/13/2016 1:09 PM |
| Contacts | Authorizing Official | Insert | | | de Leon, Chona
Chief Operating Officer
2137461037-3326 | 10/13/2016 1:09 PM |
| Addresses | Billing Address | Insert | | | PEDIATRIC & FAMILY MEDICAL CENTER
1530 S OLIVE ST.,
LOS ANGELES, CA 90015-3023 | 10/13/2016 1:09 PM |
| Addresses | Shipping Address | Insert | | | EISNER PEDIATRIC & FAMILY MEDICAL CENTER
1500 S OLIVE ST.,
LOS ANGELES, CA 90015-3023 | 10/13/2016 1:09 PM |
| Addresses | Shipping Address | Insert | | | USC-Family Medical Center at California Hospital
1400 S. Grand Ave. STE 101
Los Angeles, CA 90015-3048 | 10/13/2016 1:09 PM |
| Details | Last Recertification Date | Update | | 3/4/2015 12:00:00 AM | 3/7/2016 12:00:00 AM | 3/7/2016 9:06 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 9/1/2015 3:35 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1326370073 | 9/1/2015 3:35 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 9/1/2015 3:35 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1326370073 | 9/1/2015 3:35 PM |
| Medicaid Billing | Medicaid: Number | Update | | 1326370073 | 1386934875 | 3/4/2015 12:12 PM |
| Medicaid Billing | NPI: Number | Update | | 1326370073 | 1386934875 | 3/4/2015 12:12 PM |
| Details | Last Recertification Date | Update | | 3/14/2014 12:00:00 AM | 3/4/2015 12:00:00 AM | 3/4/2015 12:12 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/14/2014 12:00:00 AM | 3/14/2014 6:10 AM |
| Details | Entity Name | Update | | EISNER PEDIATRIC & FAMILY MEDICAL CENTER | PEDIATRIC & FAMILY MEDICAL CENTER | 3/14/2014 6:10 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 5/9/2013 7:32 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1326370073 | 5/9/2013 7:32 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 5/9/2013 7:32 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1326370073 | 5/9/2013 7:32 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/11/2013 12:45 PM |
| Details | Entity Subname | Update | | USC/EPFMC FAMILY PRACTICE CENTER | USC-Eisner Family Medicine Center at California Hospital | 9/30/2011 3:07 PM |
| Dates | Participating Approval Date | Update | | | 9/26/2011 12:00:00 AM | 9/26/2011 5:51 PM |
| Details | State | Update | | Pending | Active | 9/26/2011 5:51 PM |
| Dates | Start Date | Update | | | 10/1/2011 12:00:00 AM | 9/26/2011 5:51 PM |
| Details | 340B ID | Update | | ONLINE_REG | CH092134F | 9/8/2011 11:10 AM |
| Details | Last Recertification Date | Insert | | | | 7/18/2011 3:27 PM |
| Details | Grant Number | Insert | | | H80CS04223 | 7/18/2011 3:27 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 7/18/2011 3:27 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/18/2011 3:27 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/18/2011 3:27 PM |
| Details | Medicare Provider Number | Insert | | | | 7/18/2011 3:27 PM |
| Details | Entity Name | Insert | | | EISNER PEDIATRIC & FAMILY MEDICAL CENTER | 7/18/2011 3:27 PM |
| Details | Program Code | Insert | | | CH | 7/18/2011 3:27 PM |
| Details | Entity Subname | Insert | | | USC/EPFMC FAMILY PRACTICE CENTER | 7/18/2011 3:27 PM |
| Dates | Participating Approval Date | Insert | | | | 7/18/2011 3:27 PM |
| Details | State | Insert | | | Pending | 7/18/2011 3:27 PM |
| Dates | Registration Date | Insert | | | 7/18/2011 12:00:00 AM | 7/18/2011 3:27 PM |
| Dates | Signed By Date | Insert | | | 7/18/2011 12:00:00 AM | 7/18/2011 3:27 PM |
| Dates | Start Date | Insert | | | | 7/18/2011 3:27 PM |
| Terminations | Termination Comments | Insert | | | | 7/18/2011 3:27 PM |
| Terminations | Termination Date | Insert | | | | 7/18/2011 3:27 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/18/2011 3:27 PM |
| Terminations | Termination Reason | Insert | | | | 7/18/2011 3:27 PM |