Covered Entity Details

DSH330047G ST. MARYS HEALTHCARE (Terminated) - information as of 4/25/2025 12:01:56 AM

Main Details

Name

ST. MARYS HEALTHCARE

Subdivision Name

Memorial Campus

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330047G

Medicare Provider Number

330047

Outpatient Facility Provider Number

330047

Additional Details

Current Program Status

Terminated

Registration Date

2/28/2012

Participating Start Date

3/7/2012

Participating Approval Date

3/7/2012

Last Recertification Date

8/24/2020

Termination Date
Termination Reason

4/1/2021
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

St. Mary's Healthcare
Rick Henze, Vice President of Finance/CFO
(518) 841-7435

Primary Contact

St. Mary's Healthcare
Keith Waters, Sr. Director of Finance
(518) 770-7583

Addresses

Street Address

4988 State Highway 30
Amsterdam, NY 12010

Billing Address
Same as Street Address

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	00351639	1811977796,1164497103

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
DSH330047A	Child	DSH	ST. MARYS HEALTHCARE	Health Center at Johnstown	700 South Perry Street	Johnstown	NY	Active
DSH330047AA	Child	DSH	ST. MARYS HEALTHCARE	Diabetes Medical Services	4950 State Highway 30	Amsterdam	NY	Terminated
DSH330047AB	Child	DSH	ST. MARYS HEALTHCARE	Pediatric Medical Services	4988 State Highway 30	Amsterdam	NY	Terminated
DSH330047AC	Child	DSH	ST. MARYS HEALTHCARE	PROS PERSONALIZED RECOVERY	4988 STATE HIGHWAY 30	AMSTERDAM	NY	Terminated
DSH330047AD	Child	DSH	ST. MARYS HEALTHCARE	FULTON CO PROS PERSONALIZED RECOVER	73N MAIN ST	GLOVERSVILLE	NY	Terminated
DSH330047AE	Child	DSH	ST. MARYS HEALTHCARE	St. Mary's Ear, Nose & Throat	380 Guy Park Ave	Amsterdam	NY	Active
DSH330047AF	Child	DSH	ST. MARYS HEALTHCARE	Urology Center-Department 59100 - Urology	4950 State Highway 30	Amsterdam	NY	Active
DSH330047AG	Child	DSH	ST. MARYS HEALTHCARE	ALCOHOL CLINIC - MONTGOMERY COUNTY - ADDICTIONS	4988 STATE HIGHWAY 30	AMSTERDAM	NY	Active
DSH330047AH	Child	DSH	ST. MARYS HEALTHCARE	ACT PROGRAM - MENTAL HEALTH	446B GUY PARK AVENUE	AMSTERDAM	NY	Active
DSH330047AJ	Child	DSH	ST. MARYS HEALTHCARE	CANCER MEDICINE CENTER RADIATION ON - Radiation Oncology	4950 STATE HIGHWAY 30	AMSTERDAM	NY	Active
DSH330047AK	Child	DSH	ST. MARYS HEALTHCARE	CARONDELET PAVILION HEALTH CENTER - Prenatal	380 GUY PARK AVE	AMSTERDAM	NY	Terminated
DSH330047AL	Child	DSH	ST. MARYS HEALTHCARE	GLOVERSVILLE HEALTH CENTER - Gloversville Urgent Care	84 E STATE ST	GLOVERSVILLE	NY	Active
DSH330047AM	Child	DSH	ST. MARYS HEALTHCARE	CANCER MEDICINE CENTER - Infusion Clinic	4950 STATE HIGHWAY 30	AMSTERDAM	NY	Active
DSH330047AN	Child	DSH	ST. MARYS HEALTHCARE	CANAJOHARIE HEALTH CENTER - Pediatric Pulmonology	48 ERIE BLVD	CANAJOHARIE	NY	Terminated
DSH330047AP	Child	DSH	ST. MARYS HEALTHCARE	Johnstown OB/GYN - OB\GYN	700 South Perry Street	Johnstown	NY	Terminated
DSH330047AQ	Child	DSH	ST. MARYS HEALTHCARE	AMSTERDAM PODIATRY CENTER - Podiatry	446A GUY PARK AVE	AMSTERDAM	NY	Active
DSH330047AR	Child	DSH	ST. MARYS HEALTHCARE	MENTAL HEALTH ADULT CLINIC - BEHAVIORAL HEALTH	4988 STATE HWY 30	AMSTERDAM	NY	Active
DSH330047AS	Child	DSH	ST. MARYS HEALTHCARE	Neuro Clinic - Headache Clinic	4950 State Highway 30	Amsterdam	NY	Active
DSH330047AT	Child	DSH	ST. MARYS HEALTHCARE	Mental Health Day Treatment - Childrens Day Treatment Program	234 Lincoln Ave	Gloversville	NY	Active
DSH330047B	Child	DSH	ST. MARYS HEALTHCARE	Gastroenterology Health Center	425 Guy Park Avenue	Amsterdam	NY	Active
DSH330047C	Child	DSH	ST. MARYS HEALTHCARE	Methadone Maintenance Treatment Program	4988 State Highway 30	Amsterdam	NY	Active
DSH330047D	Child	DSH	ST. MARYS HEALTHCARE	Health Center at Northville	331 Bridge Street	Northville	NY	Active
DSH330047E	Child	DSH	ST. MARYS HEALTHCARE	Urology Health Center	425 Guy Park Avenue	Amsterdam	NY	Terminated
DSH330047F	Child	DSH	ST. MARYS HEALTHCARE	Health Center at Carondelet Pavilion	380 Guy Park Avenue	Amsterdam	NY	Terminated
DSH330047G	Child	DSH	ST. MARYS HEALTHCARE	Memorial Campus	4988 State Highway 30	Amsterdam	NY	Terminated
DSH330047H	Child	DSH	ST. MARYS HEALTHCARE	Health Center at Canajoharie	48 Erie Boulevard	Canajoharie	NY	Active
DSH330047K	Child	DSH	ST. MARYS HEALTHCARE	Health Center at Gloversville	84 East State Street	Gloversville	NY	Active
DSH330047L	Child	DSH	ST. MARYS HEALTHCARE	Urgent Care Center at Memorial	4950 State Highway 30	Amsterdam	NY	Active
DSH330047M	Child	DSH	ST. MARYS HEALTHCARE	Amsterdam Family Health Center	4950 State Highway 30	Amsterdam	NY	Active
DSH330047Q	Child	DSH	ST. MARYS HEALTHCARE	Cancer Medicine Center	4950 State Highway 30	Amsterdam	NY	Active
DSH330047R	Child	DSH	ST. MARYS HEALTHCARE	Urology Health Center	425 Guy Park Avenue	Amsterdam	NY	Active
DSH330047T	Child	DSH	ST. MARYS HEALTHCARE	Fulton County Mental Health Clinic	73 North Main St	Gloversville	NY	Terminated
DSH330047U	Child	DSH	ST. MARYS HEALTHCARE	Fulton County Addictions Clinic	73 North Main Street	Gloversville	NY	Terminated
DSH330047V	Child	DSH	ST. MARYS HEALTHCARE	Amsterdam OB/GYN Health Center	425 Guy Park Ave, Suite 102	Amsterdam	NY	Active
DSH330047W	Child	DSH	ST. MARYS HEALTHCARE	Broadalbin Health Center	3768 State Highway 30	Broadalbin	NY	Terminated
DSH330047X	Child	DSH	ST. MARYS HEALTHCARE	St. Johnsville Urgent Care	7 Timmerman Avenue	St. Johnville	NY	Active
DSH330047Y	Child	DSH	ST. MARYS HEALTHCARE	Johnstown Pediatrics	700 South Perry Street	Johnstown	NY	Active
DSH330047Z	Child	DSH	ST. MARYS HEALTHCARE	Children's Mental Health Clinic	4988 State Highway 30	Amsterdam	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/30/2020 12:00:00 AM	1/8/2021 6:55 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/8/2021 6:55 AM
Terminations	Termination Date	Update	Termination Request		4/1/2021 12:00:00 AM	1/8/2021 6:55 AM
Terminations	Termination Effective Date	Update	Termination Request		6/30/2020 12:00:00 AM	1/8/2021 6:55 AM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	1/8/2021 6:55 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	8/24/2020 8:15 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	8/24/2020 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 2:14:46 PM	8/24/2020 8:15:59 AM	8/24/2020 8:15 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1811977796	10/22/2019 10:49 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1164497103	10/22/2019 10:49 AM
Contacts	Primary Contact	Update	Change Request	Waters, Keith Senior Director of Finance St. Mary's Healthcare 5187707583	Waters, Keith Sr. Director of Finance St. Mary's Healthcare 5187707583	10/17/2019 12:02 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 4:51:39 PM	8/21/2019 2:14:46 PM	8/21/2019 2:14 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 2:31:33 PM	8/23/2018 4:51:39 PM	8/23/2018 4:51 PM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/10/2017 2:31:33 PM	11/10/2017 2:31 PM
Contacts	Primary Contact	Update	Recertification	Waters, Keith Senior Director of Finance 5187707583	Waters, Keith Senior Director of Finance St. Mary's Healthcare 5187707583	11/10/2017 2:31 PM
Contacts	Authorizing Official	Update		Henze, Rick Vice President of Finance/CFO 5188417435	Henze, Rick Vice President of Finance/CFO St. Mary's Healthcare 5188417435	9/29/2017 8:33 AM
Contacts	Authorizing Official	Update		Henze, Rick Vice President of Finance/CFO 5188417435	Henze, Rick Vice President of Finance/CFO 5188417435	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Henze, Rick Vice President of Finance/CFO 5188417435	7/28/2017 6:41 PM
Contacts	Primary Contact	Insert			Waters, Keith Senior Director of Finance 5187707583	7/28/2017 6:41 PM
Addresses	Main Address	Insert			4988 State Highway 30 Amsterdam, NY 12010	7/28/2017 6:41 PM
Contacts	Signed By	Insert			Sagan, John Vice President of Finance/CFO 5188417435	7/28/2017 6:41 PM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/26/2016 12:00:00 AM	8/26/2016 10:39 AM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 8:46 AM
Details	Last Recertification Date	Update		8/19/2013 9:18:08 PM	8/11/2014 12:00:00 AM	8/11/2014 9:56 AM
Details	Last Recertification Date	Update			8/19/2013 9:18:08 PM	8/19/2013 9:18 PM
Details	Entity Name	Update		ST. MARYS HEATLHCARE	ST. MARYS HEALTHCARE	7/23/2012 2:17 PM
Details	340B ID	Update		IS-JH-DSH330047G	DSH330047G	3/7/2012 5:54 PM
Dates	Participating Approval Date	Update			3/7/2012 12:00:00 AM	3/7/2012 5:54 PM
Details	State	Update		Pending	Active	3/7/2012 5:54 PM
Dates	Start Date	Update			3/7/2012 12:00:00 AM	3/7/2012 5:54 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-JH-DSH330047G	3/5/2012 9:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/28/2012 11:38 AM
Medicaid Billing	Medicaid: Number	Insert			00351639	2/28/2012 11:38 AM
Medicaid Billing	Medicaid: State	Insert			NY	2/28/2012 11:38 AM
Details	Last Recertification Date	Insert				2/28/2012 11:38 AM
Details	Grant Number	Insert				2/28/2012 11:38 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	2/28/2012 11:38 AM
Details	Is Authorizing Official EHB Data	Insert				2/28/2012 11:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert				2/28/2012 11:38 AM
Details	Medicare Provider Number	Insert			330047	2/28/2012 11:38 AM
Details	Entity Name	Insert			ST. MARYS HEATLHCARE	2/28/2012 11:38 AM
Details	Program Code	Insert			DSH	2/28/2012 11:38 AM
Details	Entity Subname	Insert			Memorial Campus	2/28/2012 11:38 AM
Dates	Participating Approval Date	Insert				2/28/2012 11:38 AM
Details	State	Insert			Pending	2/28/2012 11:38 AM
Dates	Registration Date	Insert			2/28/2012 12:00:00 AM	2/28/2012 11:38 AM
Dates	Signed By Date	Insert			2/28/2012 12:00:00 AM	2/28/2012 11:38 AM
Dates	Start Date	Insert				2/28/2012 11:38 AM
Terminations	Termination Comments	Insert				2/28/2012 11:38 AM
Terminations	Termination Date	Insert				2/28/2012 11:38 AM
Terminations	Termination Effective Date	Insert				2/28/2012 11:38 AM
Terminations	Termination Reason	Insert				2/28/2012 11:38 AM