Covered Entity Details

DSH070002Q Saint Francis Hospital and Medical Center (Terminated) - information as of 5/11/2025 11:25:58 PM

Main Details

Name

Saint Francis Hospital and Medical Center

Subdivision Name

Surgicare

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070002Q

Medicare Provider Number

070002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

5/31/2012

Participating Start Date

7/1/2012

Participating Approval Date

6/21/2012

Last Recertification Date

9/1/2020

Termination Date
Termination Reason

10/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Saint Francis Hospital and Medical Center
Jennifer S Schneider, SVP and Chief Financial Officer
(860) 714-5360

Primary Contact

Saint Francis Hospital and Medical Center
James M Harris, Regional Director of Reimbursement
(860) 714-4396

Addresses

Street Address

500 Blue Hills Avenue
Hartford, CT 06112

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
CT	004024923,004041620	1407833486,1871713495
CA	1407833486,1871713495	1407833486,1871713495
KY	1407833486	1407833486
ME	1407833486,1871713495	1407833486,1871713495
MI	1407833486,1871713495	1407833486,1871713495
VT	0070002	1407833486,1871713495
RI	0070002,OP70002	1407833486,1871713495
VA	0700029	1407833486,1871713495
AK	154680105	1407833486,1871713495
DC	0102810	1407833486
DE	100048605	1407833486,1871713495
FL	092623000	1407833486,1871713495
GA	000651065X	1407833486,1871713495
IL	060646813002	1407833486,1871713495
IN	200109620A	1407833486,1871713495
MD	007755100	1407833486,1871713495
MA	110066556A,110066556B	1407833486,1871713495
MO	13913504	1407833486,1871713495
NH	3086219	1407833486,1871713495
NJ	5557801	1407833486,1871713495
OH	0104452	1407833486,1871713495
OK	100689090A	1407833486,1871713495
TX	142380801	1407833486,1871713495
PA	0007886430001	1407833486,1871713495

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
DSH070002A	Child	DSH	Saint Francis Hospital and Medical Center	Gengras Clinic	114 Woodland Street	Hartford	CT	Active
DSH070002B	Child	DSH	Saint Francis Hospital and Medical Center	St. Francis Hospital Dental Clinic	1000 Asylum Avenue	Hartford	CT	Terminated
DSH070002C	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis/Mount Sinai Regional Cancer Center	114 Woodland Street	Hartford	CT	Active
DSH070002D	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Radiology and Imaging	114 Woodland Street	Hartford	CT	Terminated
DSH070002E	Child	DSH	Saint Francis Hospital and Medical Center	Bariatric Nutrition Services	114 Woodland Street	Hartford	CT	Terminated
DSH070002F	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Dental Clinic (at Woodland)	114 Woodland Street	Hartford	CT	Terminated
DSH070002G	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Radiology and Imaging at Burgdorf/Fleet Health Center	131 Coventry Street	Hartford	CT	Terminated
DSH070002H	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Pediatrics Service Burgdorf/Fleet Health Center	131 Coventry Street	Hartford	CT	Active
DSH070002J	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Medicine Service Burgdorf/Fleet Health Center	131 Coventry Street	Hartford	CT	Active
DSH070002K	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Obstetrics and Gynecology Service Burgdorf/Fleet Health Center	131 Coventry Street	Hartford	CT	Active
DSH070002L	Child	DSH	Saint Francis Hospital and Medical Center	Burgdorf Dental Clinic	131 Coventry Street	Hartford	CT	Terminated
DSH070002M	Child	DSH	Saint Francis Hospital and Medical Center	Mobile MRI at Avon Health Center	35 Nod Road	Avon	CT	Terminated
DSH070002N	Child	DSH	Saint Francis Hospital and Medical Center	Center for Advanced Wound Care Healing	114 Woodland street	Hartford	CT	Active
DSH070002P	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Hospital Radiology and Imaging at Mt. Sinai Campus	500 Blue Hills Avenue	Hartford	CT	Terminated
DSH070002Q	Child	DSH	Saint Francis Hospital and Medical Center	Surgicare	500 Blue Hills Avenue	Hartford	CT	Terminated
DSH070002R	Child	DSH	Saint Francis Hospital and Medical Center	Saint Francis Care Radiology Suite	7 Elm Street	Enfield	CT	Terminated
DSH070002S	Child	DSH	Saint Francis Hospital and Medical Center	Diagnostic Imaging Breast Health Center	114 Woodland Street	Hartford	CT	Terminated
DSH070002T	Child	DSH	Saint Francis Hospital and Medical Center	Child Advocacy Center	1000 Asylum Avenue	Hartford	CT	Terminated
DSH070002U	Child	DSH	Saint Francis Hospital and Medical Center	Diabetes Care	114 Woodland Street	Hartford	CT	Terminated
DSH070002V	Child	DSH	Saint Francis Hospital and Medical Center	Mandell SFH MS Center	500 Blue Hills Avenue	Hartford	CT	Active
DSH070002W	Child	DSH	Saint Francis Hospital and Medical Center	Glastonbury Infusion Center - Oncology	31 Sycamore Street	Glastonbury	CT	Active
DSH070002X	Child	DSH	Saint Francis Hospital and Medical Center	Gengras Medical Clinic - Medicine	114 Woodland Street	Hartford	CT	Active
DSH070002Y	Child	DSH	Saint Francis Hospital and Medical Center	Gengras Surgical Clinic - Surgery	114 Woodland street	Hartford	CT	Active
DSH070002Z	Child	DSH	Saint Francis Hospital and Medical Center	Center for Diabetes and Metabolic Care - Diabetes and Endocrinology Center	1075 Asylum Avenue	Hartford	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/30/2021 12:00:00 AM	8/31/2021 1:08 PM
Details	State	Update	Recertification	Active	To Be Terminated	8/31/2021 1:08 PM
Terminations	Termination Date	Update	Recertification		10/1/2021 12:00:00 AM	8/31/2021 1:08 PM
Terminations	Termination Effective Date	Update	Recertification		6/30/2021 12:00:00 AM	8/31/2021 1:08 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	8/31/2021 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		004041620	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0070002	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0070002	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP70002	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0700029	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		154680105	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0102810	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100048605	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		092623000	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000651065X	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		060646813002	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200109620A	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		007755100	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110066556A	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110066556B	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		13913504	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3086219	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		5557801	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0104452	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100689090A	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		142380801	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0007886430001	9/1/2020 9:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407833486	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871713495	9/1/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/1/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1871713495 ( )		9/1/2020 9:11 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 8:11:30 PM	9/1/2020 9:11:41 AM	9/1/2020 9:11 AM
Contacts	Authorizing Official	Update	AO Change Request	Bittner, David Senior Vice President Finance & CFO Saing Francis Hospital and Medical Center 8607141950	Schneider, Jennifer S SVP and Chief Financial Officer Saint Francis Hospital and Medical Center 8607145360	12/23/2019 11:09 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 9:31:18 AM	8/21/2019 8:11:30 PM	8/21/2019 8:11 PM
Contacts	Primary Contact	Update	Change Request	Harris, James Regional Director of Reimbursement Saint Francis Hospital and Medical Center 8607144396	Harris, James M Regional Director of Reimbursement Saint Francis Hospital and Medical Center 8607144396	8/6/2019 8:21 AM
Contacts	Authorizing Official	Update	Profile Change Request	Bittner, David Senior Vice President Finance & CFO Saing Francis Hospital and Medical Center 8607144609	Bittner, David Senior Vice President Finance & CFO Saing Francis Hospital and Medical Center 8607141950	7/12/2019 2:44 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 6:47:02 AM	8/28/2018 9:31:18 AM	8/28/2018 9:31 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/16/2017 6:47:02 AM	11/16/2017 6:47 AM
Contacts	Authorizing Official	Update		Bittner, David Senior Vice President Finance & CFO 8607144609	Bittner, David Senior Vice President Finance & CFO Saing Francis Hospital and Medical Center 8607144609	10/23/2017 12:27 PM
Contacts	Primary Contact	Update	Profile Change Request	Harris, James Director of Reimbursement and Budget Saint Francis Hospital and Medical Center 8607144396	Harris, James Regional Director of Reimbursement Saint Francis Hospital and Medical Center 8607144396	10/19/2017 12:20 PM
Contacts	Primary Contact	Update		Harris, James Director of Reimbursement and Budget 8607144396	Harris, James Director of Reimbursement and Budget Saint Francis Hospital and Medical Center 8607144396	10/19/2017 12:14 PM
Contacts	Signed By	Insert			Giamalis, John Chief Financial Officer 8607144812	6/20/2017 9:32 AM
Contacts	Primary Contact	Insert			Harris, James Director of Reimbursement and Budget 8607144396	6/20/2017 9:32 AM
Contacts	Authorizing Official	Insert			Bittner, David Senior Vice President Finance & CFO 8607144609	6/20/2017 9:32 AM
Addresses	Main Address	Insert			500 Blue Hills Avenue Hartford, CT 06112	5/3/2017 11:58 AM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 3:27 PM
Medicaid Billing	Medicaid: Number	Update		04024923	004024923	3/4/2016 2:54 PM
Details	Last Recertification Date	Update		8/18/2014 12:00:00 AM	8/14/2015 12:00:00 AM	8/14/2015 9:23 AM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	8/18/2014 12:00:00 AM	8/18/2014 2:18 PM
Details	Last Recertification Date	Update			9/13/2013 12:00:00 AM	9/13/2013 11:06 AM
Details	340B ID	Update		IS-DSH070002Q	DSH070002Q	6/21/2012 9:48 AM
Dates	Participating Approval Date	Update			6/21/2012 12:00:00 AM	6/21/2012 9:48 AM
Details	State	Update		Pending	Active	6/21/2012 9:48 AM
Dates	Start Date	Update			7/1/2012 12:00:00 AM	6/21/2012 9:48 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DSH070002Q	6/7/2012 9:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/31/2012 12:02 PM
Medicaid Billing	Medicaid: Number	Insert			04024923	5/31/2012 12:02 PM
Medicaid Billing	Medicaid: State	Insert			CT	5/31/2012 12:02 PM
Medicaid Billing	NPI: Number	Insert			1871713495	5/31/2012 12:02 PM
Details	Last Recertification Date	Insert				5/31/2012 12:02 PM
Details	Grant Number	Insert				5/31/2012 12:02 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	5/31/2012 12:02 PM
Details	Is Authorizing Official EHB Data	Insert				5/31/2012 12:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				5/31/2012 12:02 PM
Details	Medicare Provider Number	Insert			070002	5/31/2012 12:02 PM
Details	Entity Name	Insert			Saint Francis Hospital and Medical Center	5/31/2012 12:02 PM
Details	Program Code	Insert			DSH	5/31/2012 12:02 PM
Details	Entity Subname	Insert			Surgicare	5/31/2012 12:02 PM
Dates	Participating Approval Date	Insert				5/31/2012 12:02 PM
Details	State	Insert			Pending	5/31/2012 12:02 PM
Dates	Registration Date	Insert			5/31/2012 12:00:00 AM	5/31/2012 12:02 PM
Dates	Signed By Date	Insert			5/31/2012 12:00:00 AM	5/31/2012 12:02 PM
Dates	Start Date	Insert				5/31/2012 12:02 PM
Terminations	Termination Comments	Insert				5/31/2012 12:02 PM
Terminations	Termination Date	Insert				5/31/2012 12:02 PM
Terminations	Termination Effective Date	Insert				5/31/2012 12:02 PM
Terminations	Termination Reason	Insert				5/31/2012 12:02 PM