Covered Entity Details

DSH490009AS UNIVERSITY OF VIRGINIA MEDICAL CENTER (Active) - information as of 6/27/2025 3:30:01 AM

Main Details

Name

UNIVERSITY OF VIRGINIA MEDICAL CENTER

Subdivision Name

OB/GYN Clinic Northridge - 2015

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH490009AS

Medicare Provider Number

490009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/1/2012

Participating Start Date

1/1/2013

Participating Approval Date

10/9/2012

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

UVA Health System
Brian Wilmoth, Strategic Planning and Reimbursement Officer
(434) 243-9802

Primary Contact

UVA Health System
Jordan T DeAngelis, Director Pharmacy
(434) 982-1950

Addresses

Street Address

2955 Ivy Road
Charlottesville, VA 22903

Billing Address

UVA Health System
1215 Lee Street
Charlottesville, VA 22908

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
CA	1780630608	1780630608
CT	003067776	1780630608
DC	031927200	1780630608
FL	092849600	1780630608
KY	0166020800	1780630608
MD	005165900	1780630608
NC	4900009	1780630608
NY	01556041	1780630608
OH	0168796	1780630608
PA	1007498350011	1780630608
TN	0490009	1780630608
TX	072883401	1780630608
WA	3023017	1780630608
WV	0174018000	1780630608
VA	49-0009-0	1780630608

Shipping Addresses

Shipping Address 1

UVA Health System
1215 Lee Street
Charlottesville, VA 22908

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
DSH490009A	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	CONTINUUM HOME HEALTH CARE - 2893	2205 FONTAINE AVENUE	CHARLOTTESVILLE	VA	Active
DSH490009AA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Endocrine Clinic 2735	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009AB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pediatric Neurology UVPC- 2608	1221 Lee Street	Charlottesville	VA	Active
DSH490009AC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Family Medicine Crossroads - 2369	4916 Plank Road	North Garden	VA	Active
DSH490009AD	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Family Medicine Stoney Creek - 2186	2871 Rockfish Valley Hwy	Nellysford	VA	Active
DSH490009AE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Western Albemarle Fam Med - 2145	375 Four Leaf Lane	Charlottesville	VA	Active
DSH490009AF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVPC CARDIOLOGY - 2618	1221 Lee Street	Charlottesville	VA	Active
DSH490009AG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ID Travelers Clinic - 2639	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009AH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Infusion Procedural Center - 2790	1240 Lee Street	Charlottesville	VA	Active
DSH490009AJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Internal Medicine Orange - 2685	661 University Lane	Orange	VA	Active
DSH490009AK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Jefferson Area Board of Aging - 2855	674 Hillsdale Drive	Charlottesville	VA	Active
DSH490009AL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Kidney Center Clinic - 2626	1300 Jefferson Park Avenue	Charlottesville	VA	Active
DSH490009AM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Midlife Health - 2113	2955 Ivy Road	Charlottesville	VA	Active
DSH490009AN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Neurocognitive Assessment Lab - 2460	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009AP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Neurosurgery Clinic - 2662	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009AQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Nsgy at Fontaine - 2248	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009AR	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Heart Clinic - Fontaine - 2681	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009AS	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OB/GYN Clinic Northridge - 2015	2955 Ivy Road	Charlottesville	VA	Active
DSH490009AT	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	GYN clinic - PCC - 2606	1221 Lee Street	Charlottesville	VA	Active
DSH490009AU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Ophthalmology Cl - Northridge - 2088	2955 Ivy Road	Charlottesville	VA	Active
DSH490009AV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Ophthalmology Clinic - Old Med - 2629	1300 Jefferson Park Avenue	Charlottesville	VA	Active
DSH490009AW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Oral Surgery Clinic - 2633	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009AX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Orthopedics Clinic - Fontaine - 2631	545 Ray C. Hunt	Charlottesville	VA	Terminated
DSH490009AY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OCIR Orthopedics FL1 - 2743	2280 Ivy Road	Charlottesville	VA	Active
DSH490009AZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Otolaryngology Clinic - FONTAINE - 2634	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009B	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	LYNCHBURG DIALYSIS - 2511	103 CLIFTON STREET	LYNCHBURG	VA	Active
DSH490009BA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pain Management Center - 2286	545 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009BB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	PCC Family Medicine - 2640	1221 Lee Street	Charlottesville	VA	Active
DSH490009BC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Peds Clinic - Northridge - 2677	2955 Ivy Road	Charlottesville	VA	Active
DSH490009BD	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pediatric Clinic - Orange - 2398	661 University Lane	Orange	VA	Active
DSH490009BE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pediatric Specialty Clinic - Battle Building - 2636	1204 West Main Street	Charlottesville	VA	Active
DSH490009BF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Physical Medicine & Rehab - 2661	545 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009BG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Piedmont Nephrology - 2275	199 Spotnap Rd.	Charlottesville	VA	Terminated
DSH490009BH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Plastic Surgery - 2632	1300 Jefferson Park Ave.	Charlottesville	VA	Active
DSH490009BJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Psychiatric Medicine Clinic - 2356	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009BK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pulmonary Clinic - 2615	1221 Lee Street	Charlottesville	VA	Active
DSH490009BL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Rheumatology Clinic - 2624	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009BM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Surgery Clinic - 2642	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009BN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Teen/Young Adult - Battle Buliding - 2385	1204 West Main Street	Charlottesville	VA	Active
DSH490009BP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Radiation Oncology -Moser - 2381	2871 Ivy Road	Charlottesville	VA	Active
DSH490009BQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Radiation Oncology- ECCCC - 2285	1240 Lee Street	Charlottesville	VA	Active
DSH490009BR	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Transplant Clinic-Davis Wing - 2648	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009BS	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UMA Clinic-JMA - 2622	1222 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009BT	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Ultrasound Radiology - 2276	337 Crispell Drive	Charlottesville	VA	Active
DSH490009BU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OCIR Orthopedics FL 2 - 2341	2280 Ivy Road	Charlottesville	VA	Active
DSH490009BV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UPC - 2627	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009BW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Urology Clinic - 2644	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009BX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Specialty Care - Augusta - 2287	57 Beam Lane	Fishersville	VA	Active
DSH490009BY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Spine Center Fontaine- 2223	415 Ray C. Hunt Drive	Charlottesville	VA	Terminated
DSH490009BZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pelvic Med and Recon Surgery - 2263	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009C	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	AMHERST DIALYSIS - 2024	143 AMBRIAR PLAZA	AMHERST	VA	Active
DSH490009CA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Work Med - 2787	1910 Arlington Blvd	Charlottesville	VA	Active
DSH490009CB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Vein Clinic - 2498	2955 Ivy Road	Charlottesville	VA	Active
DSH490009CC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pediatric Clinic - Battle Building - 2637	1204 West Main Street	Charlottesville	VA	Active
DSH490009CD	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB MATERNAL FETAL CL - 2736	1204 West Main Street	Charlottesville	VA	Active
DSH490009CE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	EEG/Epilepsy Surgery - 2203	1221 Lee Street	Charlottesville	VA	Active
DSH490009CF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Heart Center Clinic PCC - 2618	1221 Lee Street	Charlottesville	VA	Terminated
DSH490009CG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Repro-Endo-Northridge - 2796	2955 Ivy Rd.	Charlottesville	VA	Terminated
DSH490009CH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Rheumatology Pantops - 2536	650 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009CJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Farmville Dialysis - 2073	937 S. Main Street	Farmville	VA	Active
DSH490009CK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Zion Crossroads Hub - 2574	1015 Spring Creek Parkway	Zions Crossroads	VA	Active
DSH490009CL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ZCSC PRIMARY CARE - 2574	1015 Spring Creek Parkway	Zions Crossroads	VA	Terminated
DSH490009CM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Zion Crossroads Multispecialty Care - 2574	1015 Spring Creek Parkway	Zions Crossroads	VA	Terminated
DSH490009CN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ZCSC DERMATOLOGY - 2574	1015 Spring Creek Parkway	Zions Crossroads	VA	Terminated
DSH490009CP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Rehab Engineering - 2081	1105 West Main Street	Charlottesville	VA	Terminated
DSH490009CQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center-Multispecialty - 2448	1240 Lee Street	Charlottesville	VA	Active
DSH490009CR	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ECCC Multispecialty - 2676	1240 Lee Street	Charlottesville	VA	Active
DSH490009CS	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	EC West Clinc - 2676	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009CT	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	EC Surgery Oncology Clinic - 2676	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009CU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Sleep Disorders Center - 2366	1222 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009CV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Sleep Disorder Center Pantops - 2366	1222 Jefferson Park Ave	Charlottesville	VA	Terminated
DSH490009CW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	EC Pallative Care Clinic - 2676	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009CX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Neuropsychology Fontaine - 2460	500 Ray C. Hunt Drive	Charlottesville	VA	Terminated
DSH490009CY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Teen Health and Young Adult - 2385	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009CZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	General Peds Clinic - 2637	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009D	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Outpatient Surgery Center - 2660	1204 West Main Street	CHARLOTTESVILLE	VA	Active
DSH490009DA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OB-Fetal Care Ctr-Battle Bldg - 2736	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009DB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Dental Peds - 2321	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009DC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Child Dev/Rehab Center - 2321	1204 West Main Street	Charlottesville	VA	Active
DSH490009DD	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Peds Specalty Clinic - 2636	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009DE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Specialty Care Pinnacle Dr - 2425	9 Pinnacle Drive	Fishersville	VA	Active
DSH490009DF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Audiology Contract Service - 2614	415 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009DG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB PEDS CARD CL FL 6 - 2211	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009DH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB Audiology -2614	1204 West Main Street	Charlottesville	VA	Active
DSH490009DJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Prosthetics & Orthotics - 2649	2216 Ivy Road	Charlottesville	VA	Terminated
DSH490009DK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	C.T. Scan - 2282	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009DL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Nuclear Medicine - 2284	1240 Lee Street	Charlottesville	VA	Active
DSH490009DM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Mobile Mammography - 2465	1215 Lee Street	Charlottesville	VA	Active
DSH490009DN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Northridge Mammography - 2446	2955 Ivy Raod	Charlottesville	VA	Active
DSH490009DP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Radiology Orange - 2521	661 University Lane	Orange	VA	Active
DSH490009DQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Radiology Fontaine - 2189	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009DR	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	PET - 2087	1240 Lee Street	Charlottesville	VA	Active
DSH490009DS	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Rad Diagnostic F545 C-ARM - 2827	545 Ray C Hunt Drive	Charlottesville	VA	Active
DSH490009DT	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Med ECG Card REH NR - 2681	2955 Ivy Road	Charlottesville	VA	Terminated
DSH490009DU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cardiac Rehab & Outreach - 2720	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009DV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Medical Nutritional Therapy - 2552	2955 Ivy Road	Charlottesville	VA	Terminated
DSH490009DW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Gamma Knife PCC - 2317	1221 Lee Street	Charlottesville	VA	Active
DSH490009DX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Gamma Knife E & M PCC - 2317	1221 Lee Street	Charlottesville	VA	Terminated
DSH490009DY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pulmonary Function Testing Ctr - 2273	1204 West Main Street	Charlottesville	VA	Active
DSH490009DZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Breast Center Mammography - 2147	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009EA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Physical Therapy - 2272	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009EB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Occupational Therapy - 2270	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009EC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Speech Pathology - 2243	415 Ray C. Hunt Drive	Charlottesville	VA	Terminated
DSH490009ED	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB PEDS ECHO - 2211	1204 West Main Street	Charlottesville	VA	Active
DSH490009EE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVPC EMG - 2205	1221 Lee Street	Charlottesville	VA	Active
DSH490009EF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F415 EMG HAND - 2205	415 Ray C. Hunt Drive	Charlottesville	VA	Terminated
DSH490009EG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVPC ECHO LAB - 2200	1221 Lee Street	Charlottesville	VA	Active
DSH490009EH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB ECHO LAB - 2200	1204 West Main Street	Charlottesville	VA	Active
DSH490009EJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Vascular Lab - 2127	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009EK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ZCSC HEART AND VASC LB - 2574	1015 Spring Creek Parkway	Zion Crossroads	VA	Terminated
DSH490009EL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Zion Crossroads Specialty Care EMG services - 2574	1015 Spring Creek Parkway	Zion Crossroads	VA	Terminated
DSH490009EM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Emily Couric Cancer Center Psych - 2676	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009EN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Prim and Spec Care Pantops - 2427	650 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009EP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Staunton Dialysis - 2782	81 Orchard Hills Circle	Staunton	VA	Active
DSH490009EQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Appomattox Dialysis - 2432	7787 Richmond Highway	Appomattox	VA	Active
DSH490009ER	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ERC Radiology - 2474	1240 Lee Street	Charlottesville	VA	Active
DSH490009ES	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F500 STRESS LAB - 2379 - F500 STRESS LAB - 2379	500 Ray C Hunt Drive	Charlottesville	VA	Terminated
DSH490009ET	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F500 Echo Lab - 2200 - F500 Echo Lab - 2200	500 Ray C Hunt Drive	Charlottesville	VA	Active
DSH490009EU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVBB RAD DIAGNOSTIC - 2672 - UVBB RAD DIAGNOSTIC - 2672	1204 West Main Street	Charlottesville	VA	Active
DSH490009EV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	NRDG OBGYN UROGYN - 2263 - NRDG OBGYN UROGYN - 2263	2955 Ivy Rd.	Charlottesville	VA	Terminated
DSH490009EW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ECCC RAD DIAGNOSTIC - 2283	1240 West Main Street	Charlottesville	VA	Active
DSH490009EX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Emily Couric Pallative Care Clinic - 2467 - Pallative Care	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009EY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Peds Respiratory Medicine - 2636 - Respiratory services	1221 Lee Street	Charlottesville	VA	Active
DSH490009EZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Digestive Health Clinic - 2061 - Digestive Health	1221 Lee Street	Charlottesville	VA	Active
DSH490009F	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Altavista Dialysis - 2135	701 5th Street	Alta Vista	VA	Active
DSH490009FA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F500 Stress - 2200 - Stress Test	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009FB	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F500 Stress - 2380 - Stress Test	500 Ray C. Hunt Drive	Charlottesville	VA	Active
DSH490009FC	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Emily Couric Stress Lab - 2380 - Stress Lab	1240 Lee Street	Charlottesville	VA	Active
DSH490009FD	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Emily Couric Stress Lab - Stress Test	1240 Lee Street	Charlottesville	VA	Terminated
DSH490009FE	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Culpeper Dialysis - 2841 - Dialysis Center	610 Laurel Street	Culpeper	VA	Active
DSH490009FF	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	ECCC Apheresis - 2294 - Apheresis	1240 Lee Street	Charolottesville	VA	Active
DSH490009FG	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	JPA SAME DAY Clinic - 2420	1222 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009FH	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pediatric Therapy - 2714 - Speech, OT and PT	1204 West Main Street	Charlottesville	VA	Active
DSH490009FJ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVWC TXP ECHO - 2200 - ECHO	1300 Jefferson Park Avenue	Charlottesville	VA	Active
DSH490009FK	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVML GI Motility - 2293 - Endoscopy	500 Monroe Lane	Charlottesville	VA	Active
DSH490009FL	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OCIR Center Pre/Post-OP - 2599 - Operating Room	2280 Ivy Road	Charlottesville	VA	Active
DSH490009FM	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVML Endoscopy Center- 2475 - Endoscopy	500 Monroe Lane	Charlottesville	VA	Active
DSH490009FN	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Lynchburg Home Dialysis - 2017 - Home Program Dialysis	103 Clifton Street	Lynchburg	VA	Active
DSH490009FP	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OCIR Center Anesthesiology - 2374 - Anesthesiology	2280 Ivy Road	Charlottesville	VA	Active
DSH490009FQ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	OCIR Center OR - 2487 - OR	2280 Ivy Road	Charlottesville	VA	Active
DSH490009FR	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Kidney Center Home Dialysis - 2363 - Home Program Dialysis	1300 Jefferson Park Avenue	Charlottesville	VA	Active
DSH490009FS	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pulmonary Clinic - 2615 - Pulmonary	1222 Jefferson Park Avenue	Charlottesville	VA	Active
DSH490009FT	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	RECTOR & VISITORS OF THE UNIVERSITY - F545 PETC	545 RAY C HUNT DR	CHARLOTTESVILLE	VA	Active
DSH490009FU	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F525 Pre Anesthesia Center - 2374 - Anesthesiology	545 Ray C. Hunt Drive, First Floor	Charlottesville	VA	Active
DSH490009FV	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	UVA Health Emp. Prim Care - 2775 - Clinic	1300 Jefferson Park Avenue, 3rd floor	Charlottesville	VA	Active
DSH490009FW	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center West Infusion - 2941 - Cancer Center	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009FX	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center Pantops Infusion - 2939 - Cancer Center	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009FY	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center Augusta Infusion - 2938 - Cancer Center	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009FZ	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center East Infusion - 2935 - Cancer Center	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009G	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Orange Dialysis - 2067	661 University Lane	Orange	VA	Active
DSH490009GA	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Cancer Center East Clinic - 2934 - Cancer Center	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009H	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Augusta Dialysis - 2822	2602 W Main Street	Waynesboro	VA	Active
DSH490009I	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Page Dialysis - 2213	235 Medical Center Drive	Stanley	VA	Active
DSH490009J	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Zion Dialysis Center - 2865	75 Circle Pointe Drive	Gordonsville	VA	Active
DSH490009K	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Kidney Center - 2226	1300 Jefferson Park Ave 5th Floor	Charlottesville	VA	Active
DSH490009L	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Augusta Oncology - 2471	57 Beam Lane	Fishersville	VA	Active
DSH490009M	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Pantops Oncology - 2295	590 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009N	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Adult Neuro Fontaine - 2512	500 Ray C. Hunt Drive	Charlottesville	VA	Terminated
DSH490009P	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Adult Neurology - 2607	1221 Lee Street	Charlottesville	VA	Active
DSH490009Q	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Adult Psych-Northridge - 2603	2955 Ivy Road	Charlottesville	VA	Active
DSH490009R	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Allergy Clinic - 2265	2955 Ivy Road	Charlottesville	VA	Active
DSH490009S	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Behavioral Medicine Clinic - 2602	1300 Jefferson Park Ave	Charlottesville	VA	Active
DSH490009T	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Breast Clinic - 2641	652 Peter Jefferson Parkway	Charlottesville	VA	Active
DSH490009U	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Child & Family Psychiatric Med - 2667	310 Old Ivy Way	Charlottesville	VA	Active
DSH490009V	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Colonnades - 2651	100 Colonnades Hill Drive	Charlottesville	VA	Active
DSH490009W	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Peds Dental Clinic-Battle Building - 2611	1204 West Main Street	Charlottesville	VA	Terminated
DSH490009X	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Dentistry Clinic - 2635	1222 Jefferson Park Avenue	Charlottesville	VA	Terminated
DSH490009Y	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	Dermatology Clnic-PCC - 2601	1221 Lee Street	Charlottesville	VA	Active
DSH490009Z	Child	DSH	UNIVERSITY OF VIRGINIA MEDICAL CENTER	F415 DIABETES ED & MGT - 2735	415 Ray C. Hunt Drive	Charlottesville	VA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 10:38:31 AM	8/12/2024 9:23:38 AM	8/12/2024 9:23 AM
Contacts	Primary Contact	Update	Group Change Request	Griggs, Danielle Pharmacy Director, Business Services UVA Health System 4342975582	DeAngelis, Jordan T Director Pharmacy UVA Health System 4349821950	3/14/2024 7:25 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 9:16:56 AM	8/15/2023 10:38:31 AM	8/15/2023 10:38 AM
Addresses	Billing Address	Insert	Change Request		UVA Health System 1215 Lee Street Charlottesville, VA 22908	9/28/2022 11:11 AM
Addresses	Shipping Address	Insert	Change Request		UVA Health System 1215 Lee Street Charlottesville, VA 22908	9/28/2022 11:11 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 10:02:36 AM	8/24/2022 9:16:56 AM	8/24/2022 9:16 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 8:31:44 AM	8/16/2021 10:02:36 AM	8/16/2021 10:02 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DC	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	1/19/2021 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	1/19/2021 2:56 PM
Medicaid Billing	NPI: State	Update	Recertification		VA	8/20/2020 8:31 AM
Contacts	Primary Contact	Update	Recertification	Saenz, Rafael Administrator, Pharmacy Services UVA Health System 4344657091	Griggs, Danielle Pharmacy Director, Business Services UVA Health System 4342975582	8/20/2020 8:31 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 8:15:37 AM	8/20/2020 8:31:44 AM	8/20/2020 8:31 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 9:27:03 AM	8/19/2019 8:15:37 AM	8/19/2019 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1780630608	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003067776	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		031927200	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092849600	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0166020800	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		005165900	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4900009	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01556041	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0168796	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007498350011	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0490009	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		072883401	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3023017	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0174018000	3/15/2019 11:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/15/2019 11:03 AM
Details	Last Recertification Date	Update	Recertification	11/3/2017 8:55:20 AM	8/15/2018 9:27:03 AM	8/15/2018 9:27 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1780630608	6/26/2018 3:57 PM
Details	Entity Subname	Update	Change Request	University Physicians for Women at Northridge - 2015	OB/GYN Clinic Northridge - 2015	6/26/2018 3:57 PM
Details	Last Recertification Date	Update	Recertification	10/24/2017 8:51:27 AM	11/3/2017 8:55:20 AM	11/3/2017 8:55 AM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	10/24/2017 8:51:27 AM	10/24/2017 8:51 AM
Contacts	Primary Contact	Insert	Change Request		Saenz, Rafael Administrator, Pharmacy Services UVA Health System 4344657091	10/23/2017 1:38 PM
Contacts	Authorizing Official	Update	AO Change Request	FITZGERALD, LARRY CFO 4349245426	Wilmoth, Brian Strategic Planning and Reimbursement Officer UVA Health System 4342439802	9/21/2017 8:36 PM
Contacts	Authorizing Official	Update		Wilmoth, Brian Strategic Planning and Reimbursement Officer UVA Health System 4342439802	FITZGERALD, LARRY CFO 4349245426	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			FITZGERALD, LARRY CFO 4349245426	7/3/2017 3:55 PM
Contacts	Signed By	Insert			FITZGERALD, LARRY CFO 4349245426	7/3/2017 3:55 PM
Addresses	Main Address	Insert			2955 Ivy Road Charlottesville, VA 22903	7/3/2017 3:55 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 11:03 AM
Details	Last Recertification Date	Update		8/6/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 8:45 AM
Details	Entity Subname	Update		OB/GYN clinic - Northridge - 2015	University Physicians for Women at Northridge - 2015	11/14/2014 1:10 PM
Details	Last Recertification Date	Update		8/19/2013 8:50:10 AM	8/6/2014 12:00:00 AM	8/6/2014 9:13 AM
Details	Last Recertification Date	Update			8/19/2013 8:50:10 AM	8/19/2013 8:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/2/2013 7:38 AM
Medicaid Billing	Medicaid: Number	Insert			49-0009-0	7/2/2013 7:38 AM
Medicaid Billing	Medicaid: State	Insert			VA	7/2/2013 7:38 AM
Details	340B ID	Update		IS-DR-DSH490009AS	DSH490009AS	10/9/2012 9:57 AM
Dates	Participating Approval Date	Update			10/9/2012 12:00:00 AM	10/9/2012 9:57 AM
Details	State	Update		Pending	Active	10/9/2012 9:57 AM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	10/9/2012 9:57 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DR-DSH490009AS	10/3/2012 3:50 PM
Details	Last Recertification Date	Insert				10/1/2012 1:03 PM
Details	Grant Number	Insert				10/1/2012 1:03 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/1/2012 1:03 PM
Details	Is Authorizing Official EHB Data	Insert				10/1/2012 1:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/1/2012 1:03 PM
Details	Medicare Provider Number	Insert			490009	10/1/2012 1:03 PM
Details	Entity Name	Insert			UNIVERSITY OF VIRGINIA MEDICAL CENTER	10/1/2012 1:03 PM
Details	Program Code	Insert			DSH	10/1/2012 1:03 PM
Details	Entity Subname	Insert			OB/GYN clinic - Northridge - 2015	10/1/2012 1:03 PM
Dates	Participating Approval Date	Insert				10/1/2012 1:03 PM
Details	State	Insert			Pending	10/1/2012 1:03 PM
Dates	Registration Date	Insert			10/1/2012 12:00:00 AM	10/1/2012 1:03 PM
Dates	Signed By Date	Insert			10/1/2012 12:00:00 AM	10/1/2012 1:03 PM
Dates	Start Date	Insert				10/1/2012 1:03 PM
Terminations	Termination Comments	Insert				10/1/2012 1:03 PM
Terminations	Termination Date	Insert				10/1/2012 1:03 PM
Terminations	Termination Effective Date	Insert				10/1/2012 1:03 PM
Terminations	Termination Reason	Insert				10/1/2012 1:03 PM