Covered Entity Details

DSH390142S ALBERT EINSTEIN MEDICAL CENTER (Terminated) - information as of 5/14/2025 10:54:12 PM

Main Details

Name

ALBERT EINSTEIN MEDICAL CENTER

Subdivision Name

SHORT PROCEDURE UNIT ELKINS PARK

Type

Disproportionate Share Hospital

Rural

340B ID

DSH390142S

Medicare Provider Number

390142

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2012

Participating Start Date

1/1/2013

Participating Approval Date

10/25/2012

Last Recertification Date

8/31/2022

Termination Date
Termination Reason

10/1/2023
Site closure

Contacts

Authorizing Official

Jefferson Health
Walter Wyatt, VP-Finance
(215) 254-3254

Primary Contact

Albert Einstein Medical Center
Deborah Hauser, Director, Outpatient Pharmacy
(215) 456-6486

Addresses

Street Address

60 TOWNSHIP LINE ROAD
ELKINS PARK, PA 19027

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
NJ	4194802	1104989474,1174522114,1518000686,1881798320,1891010229,1902805245
NY	00382421	1104989474,1174522114,1518000686,1881798320,1891010229,1902805245
DE	200019421	1104989474,1174522114,1518000686,1881798320,1891010229,1902805245
PA	1007544140099,1007544140117,1007544140133,1007544140081,1007544140015,1007544140116,1007544140096,1007544140069	1104989474,1174522114,1518000686,1881798320,1891010229,1902805245

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
DSH390142A	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	ALBERT EINSTEIN CANCER CENTER @ CENTER ONE	9880 Bustleton Avenue	Philadelphia	PA	Active
DSH390142AA	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Observation MA5B - Observation	60 Township Line Road	Elkins Park	PA	Terminated
DSH390142AB	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Observation MA2C - Observation	60 Township Line Road	Elkins Park	PA	Terminated
DSH390142AC	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Center For Wound Healing - Wound Healing	1200 West Tabor Road	Philadelphia	PA	Active
DSH390142AD	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Rheumatology Outpatient - Rheumatology Outpatient	5401 Old York Road	Philadelphia	PA	Active
DSH390142AE	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Outpatient Gastroenterology - Outpatient Gastroenterology	5401 Old York Road	Philadelphia	PA	Active
DSH390142AF	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Albert Einstein Medical Center-Neurology - Neurology	5401 Old York Road	Philadelphia	PA	Active
DSH390142AG	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Albert Einstein Medical Center-Pulmonary - Pulmonary	5401 Old York Road	Philadelphia	PA	Active
DSH390142AH	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Endocrinology - EP - Endocrinology	50 East Township Line Road	Elkins Park	PA	Active
DSH390142B	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	PSYCH EMERGENCY GERMANTOWN	ONE PENN BOULEVARD	PHILADELPHIA	PA	Terminated
DSH390142D	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	AMBULATORY SURGERY CENTER ONE	9880 Bustleton Avenue	Philadelphia	PA	Active
DSH390142E	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	ANESTHESIOLOGY ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142F	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	ECHO/STRESS LAB ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142G	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	EMERGENCY DEPARTMENT ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142H	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	GAIT ANALYSIS LAB ELKINS PARK	60 Township Line Road	Elkins Park	PA	Active
DSH390142J	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	MOTOR CONTROL LAB ELKINS PARK	60 Township Line Road	Elkins Park	PA	Active
DSH390142K	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	OPERATING ROOM ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142L	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RADIOLOGY CENTER ONE	9880 Bustleton Avenue	Philadelphia	PA	Active
DSH390142M	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RADIOLOGY CT SCAN ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142N	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RADIOLOGY DIAGNOSTIC ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142P	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RADIOLOGY MRI ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142Q	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RECOVERY ROOM ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142R	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	RESPIRATORY THERAPY/EKG ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142S	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	SHORT PROCEDURE UNIT ELKINS PARK	60 TOWNSHIP LINE ROAD	ELKINS PARK	PA	Terminated
DSH390142T	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Center One-EMG/Diagnostics	9880 Bustleton Avenue	Philadelphia	PA	Active
DSH390142U	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Anesthesia Pain Center	1200 W Tabor Road	Philadelphia	PA	Active
DSH390142V	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Hepatology/Liver	5401 Old York Road	Philadelphia	PA	Active
DSH390142W	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Kidney Acquisition/Transplant	5401 Old York Road	Philadelphia	PA	Active
DSH390142X	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Gastroenterology Procedures	1200 West Tabor Road	Philadelphia	PA	Active
DSH390142Y	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Observation MA2P - Observation	60 Township Line Road	Elkins Park	PA	Terminated
DSH390142Z	Child	DSH	ALBERT EINSTEIN MEDICAL CENTER	Observation MA5A - Observation	60 Township Line Road	Elkins Park	PA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Wyatt, Walter VP-Finance Albert Einstein Medical Center 2152543254	Wyatt, Walter VP-Finance Jefferson Health 2152543254	1/30/2025 1:33 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/30/2023 12:00:00 AM	8/1/2023 2:52 PM
Details	State	Update	Termination Request	Active	To Be Terminated	8/1/2023 2:52 PM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	8/1/2023 2:52 PM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2023 12:00:00 AM	8/1/2023 2:52 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	8/1/2023 2:52 PM
Contacts	Primary Contact	Update	Group Change Request	Hauser, Deborah Director, Pharmacy Services Einstein Healthcare Network 2154566486	Hauser, Deborah Director, Outpatient Pharmacy Albert Einstein Medical Center 2154566486	7/26/2023 12:48 PM
Contacts	Authorizing Official	Update	Change Request	Wyatt, Walter VP, Finance Albert Einstein Medical Center 2152543254	Wyatt, Walter VP-Finance Albert Einstein Medical Center 2152543254	11/17/2022 2:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2022 12:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007544140116	8/31/2022 12:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/31/2022 12:14 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 11:21:37 AM	8/31/2022 12:14:02 PM	8/31/2022 12:14 PM
Contacts	Authorizing Official	Update	Change Request	BLANEY, GERARD CHIEF FINANCIAL OFFICER Einstein Healthcare Network 2154566020	Wyatt, Walter VP, Finance Albert Einstein Medical Center 2152543254	6/13/2022 6:53 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 2:09:55 PM	8/30/2021 11:21:37 AM	8/30/2021 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/6/2021 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007544140133	8/6/2021 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	8/6/2021 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 2:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007544140117	8/27/2020 2:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104989474	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174522114	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518000686	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881798320	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1891010229	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1902805245	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104989474	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174522114	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518000686	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881798320	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1891010229	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1902805245	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104989474	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174522114	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518000686	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881798320	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1891010229	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1902805245	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104989474	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174522114	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518000686	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881798320	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1891010229	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1902805245	8/27/2020 2:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1104989474 ( )		8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1174522114 ( )		8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1902805245 ( )		8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1881798320 ( )		8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1891010229 ( )		8/27/2020 2:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1518000686 ( )		8/27/2020 2:09 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 8:08:37 AM	8/27/2020 2:09:55 PM	8/27/2020 2:09 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 11:14:13 AM	8/29/2019 8:08:37 AM	8/29/2019 8:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4194802	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00382421	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200019421	4/4/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	4/4/2019 3:39 PM
Details	Last Recertification Date	Update	Recertification	11/17/2017 9:35:54 AM	8/30/2018 11:14:13 AM	8/30/2018 11:14 AM
Contacts	Authorizing Official	Update	Profile Change Request	BLANEY, GERARD VICE PRESIDENT FINANCE Einstein Healthcare Network 2154566020	BLANEY, GERARD CHIEF FINANCIAL OFFICER Einstein Healthcare Network 2154566020	8/30/2018 10:19 AM
Contacts	Signed By	Update	Profile Change Request	BLANEY, GERARD VICE PRESIDENT FINANCE Einstein Healthcare Network 2154566020	BLANEY, GERARD CHIEF FINANCIAL OFFICER Einstein Healthcare Network 2154566020	8/30/2018 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/17/2017 9:35 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007544140096	11/17/2017 9:35 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	11/17/2017 9:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/17/2017 9:35 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007544140069	11/17/2017 9:35 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	11/17/2017 9:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1881798320	11/17/2017 9:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891010229	11/17/2017 9:35 AM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/17/2017 9:35:54 AM	11/17/2017 9:35 AM
Contacts	Authorizing Official	Update		BLANEY, GERARD VICE PRESIDENT FINANCE 2154566020	BLANEY, GERARD VICE PRESIDENT FINANCE Einstein Healthcare Network 2154566020	10/20/2017 12:58 PM
Contacts	Signed By	Update		BLANEY, GERARD VICE PRESIDENT FINANCE 2154566020	BLANEY, GERARD VICE PRESIDENT FINANCE Einstein Healthcare Network 2154566020	10/20/2017 12:58 PM
Contacts	Primary Contact	Update		Hauser, Deborah Director, Pharmacy Services 2154566486	Hauser, Deborah Director, Pharmacy Services Einstein Healthcare Network 2154566486	10/9/2017 3:20 PM
Contacts	Primary Contact	Insert			Hauser, Deborah Director, Pharmacy Services 2154566486	7/25/2017 8:40 AM
Contacts	Authorizing Official	Insert			BLANEY, GERARD VICE PRESIDENT FINANCE 2154566020	7/25/2017 8:40 AM
Contacts	Signed By	Insert			BLANEY, GERARD VICE PRESIDENT FINANCE 2154566020	7/25/2017 8:40 AM
Addresses	Main Address	Insert			60 TOWNSHIP LINE ROAD ELKINS PARK, PA 19027	4/20/2017 5:41 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 2:29 PM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/14/2015 12:00:00 AM	8/14/2015 9:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/19/2014 11:48 AM
Medicaid Billing	Medicaid: Number	Insert			1007544140081	8/19/2014 11:48 AM
Medicaid Billing	Medicaid: State	Insert			PA	8/19/2014 11:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/19/2014 11:48 AM
Medicaid Billing	Medicaid: Number	Insert			1007544140015	8/19/2014 11:48 AM
Medicaid Billing	Medicaid: State	Insert			PA	8/19/2014 11:48 AM
Medicaid Billing	NPI: Number	Insert			1104989474	8/19/2014 11:48 AM
Medicaid Billing	NPI: Number	Insert			1174522114	8/19/2014 11:48 AM
Medicaid Billing	NPI: Number	Insert			1902805245	8/19/2014 11:48 AM
Details	Last Recertification Date	Update		8/29/2013 9:42:41 AM	8/19/2014 12:00:00 AM	8/19/2014 11:48 AM
Details	Last Recertification Date	Update			8/29/2013 9:42:41 AM	8/29/2013 9:42 AM
Details	340B ID	Update		IS-AP-DSH390142S	DSH390142S	10/25/2012 4:29 PM
Dates	Participating Approval Date	Update			10/25/2012 12:00:00 AM	10/25/2012 4:29 PM
Details	State	Update		Pending	Active	10/25/2012 4:29 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	10/25/2012 4:29 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-AP-DSH390142S	10/19/2012 10:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/11/2012 3:31 PM
Medicaid Billing	Medicaid: Number	Insert			1007544140099	10/11/2012 3:31 PM
Medicaid Billing	Medicaid: State	Insert			PA	10/11/2012 3:31 PM
Medicaid Billing	NPI: Number	Insert			1518000686	10/11/2012 3:31 PM
Details	Last Recertification Date	Insert				10/11/2012 3:31 PM
Details	Grant Number	Insert				10/11/2012 3:31 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/11/2012 3:31 PM
Details	Is Authorizing Official EHB Data	Insert				10/11/2012 3:31 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/11/2012 3:31 PM
Details	Medicare Provider Number	Insert			390142	10/11/2012 3:31 PM
Details	Entity Name	Insert			ALBERT EINSTEIN MEDICAL CENTER	10/11/2012 3:31 PM
Details	Program Code	Insert			DSH	10/11/2012 3:31 PM
Details	Entity Subname	Insert			SHORT PROCEDURE UNIT ELKINS PARK	10/11/2012 3:31 PM
Dates	Participating Approval Date	Insert				10/11/2012 3:31 PM
Details	State	Insert			Pending	10/11/2012 3:31 PM
Dates	Registration Date	Insert			10/11/2012 12:00:00 AM	10/11/2012 3:31 PM
Dates	Signed By Date	Insert			10/11/2012 12:00:00 AM	10/11/2012 3:31 PM
Dates	Start Date	Insert				10/11/2012 3:31 PM
Terminations	Termination Comments	Insert				10/11/2012 3:31 PM
Terminations	Termination Date	Insert				10/11/2012 3:31 PM
Terminations	Termination Effective Date	Insert				10/11/2012 3:31 PM
Terminations	Termination Reason	Insert				10/11/2012 3:31 PM