| Details | Last Recertification Date | Update | Recertification | 8/29/2023 4:47:17 PM | 8/28/2024 1:11:09 PM | 8/28/2024 1:11 PM |
| Details | Last Recertification Date | Update | Recertification | 9/18/2022 12:33:28 PM | 8/29/2023 4:47:17 PM | 8/29/2023 4:47 PM |
| Contacts | Primary Contact | Update | PC Change Request | Kinter, Karen M
Vice President of Specialty Revenue Programs
Rochester Regional
5853683537 | Scardino, Robert Michael
340B Pharmacy System Manager
RRH
5853196750 | 7/20/2023 4:18 PM |
| Contacts | Authorizing Official | Update | Change Request | Thomas, Hugh
Executive Vice President, Chief Administrative Officer
Rochester Regional Health
5859224941 | Bishop, Shawn
Vice President, RRH Revenue & Reimbursement
Rochester Regional Health
5859220056 | 6/9/2023 6:54 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/18/2022 12:33 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 00354196 | 9/18/2022 12:33 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NY | 9/18/2022 12:33 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1568548782 | 9/18/2022 12:33 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NY | 9/18/2022 12:33 PM |
| Details | Last Recertification Date | Update | Recertification | | 9/18/2022 12:33:28 PM | 9/18/2022 12:33 PM |
| Contacts | Primary Contact | Update | PC Change Request | SOGOIAN, DAVID
DIRECTOR OF PHARMACY
Canton-Potsdam Hospital
3152615510 | Kinter, Karen M
Vice President of Specialty Revenue Programs
Rochester Regional
5853683537 | 8/31/2022 6:29 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Thomas, Hugh
Executive Vice President, Chief Administrative Officer
Unity Hospital
5859224941 | Thomas, Hugh
Executive Vice President, Chief Administrative Officer
Rochester Regional Health
5859224941 | 7/8/2022 12:36 PM |
| Contacts | Authorizing Official | Update | AO Change Request | McGregor, Donna M
System CFO
Canton-Potsdam Hospital
3152615451 | Thomas, Hugh
Executive Vice President, Chief Administrative Officer
Unity Hospital
5859224941 | 7/5/2022 1:22 PM |
| Details | State | Update | OPA Edit | Approved | Active | 10/6/2021 8:21 AM |
| Dates | Start Date | Update | OPA Edit | 1/1/2022 12:00:00 AM | 10/6/2021 12:00:00 AM | 10/6/2021 8:21 AM |
| Addresses | Billing Address | Insert | Reinstatement | | Canton-Potsdam Hospital
50 Leroy Street
Potsdam, NY 13676 | 10/6/2021 8:19 AM |
| Medicaid Billing | Medicaid: Number | Delete | Reinstatement | 330197 (NY) | | 10/6/2021 8:19 AM |
| Medicaid Billing | Medicaid: Number | Delete | Reinstatement | 00354196 (NY) | | 10/6/2021 8:19 AM |
| Medicaid Billing | NPI: Number | Delete | Reinstatement | 1568548782 (NY) | | 10/6/2021 8:19 AM |
| Contacts | Signed By | Update | Reinstatement | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
Canton-Potsdam Hospital
3152615100 | McGregor, Donna M
System CFO
Canton-Potsdam Hospital
3152615451 | 10/6/2021 8:19 AM |
| Details | Last Recertification Date | Update | Reinstatement | 9/8/2020 3:12:51 PM | | 10/6/2021 8:19 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/30/2021 12:00:00 AM | | 10/6/2021 8:19 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 10/25/2012 12:00:00 AM | 10/6/2021 8:19:43 AM | 10/6/2021 8:19 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 10/6/2021 8:19 AM |
| Dates | Registration Date | Update | Reinstatement | 10/15/2012 12:00:00 AM | 10/4/2021 4:42:56 PM | 10/6/2021 8:19 AM |
| Dates | Signed By Date | Update | Reinstatement | 10/15/2012 12:00:00 AM | 10/5/2021 2:46:52 PM | 10/6/2021 8:19 AM |
| Dates | Start Date | Update | Reinstatement | 10/27/2012 12:00:00 AM | 1/1/2022 12:00:00 AM | 10/6/2021 8:19 AM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2021 12:00:00 AM | | 10/6/2021 8:19 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 10/1/2021 12:00:00 AM | | 10/6/2021 8:19 AM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 10/6/2021 8:19 AM |
| Details | Comments Public | Insert | Reinstatement | | Participating from effective date: (10/27/2012) until terminated effective date: (10/1/2021), reinstatement effective date: 10/06/21 | 10/6/2021 6:44 AM |
| Details | State | Update | | To Be Terminated | Terminated | 10/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 9/30/2021 12:00:00 AM | 9/17/2021 7:41 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 9/17/2021 7:41 AM |
| Terminations | Termination Date | Update | Recertification | | 10/1/2021 12:00:00 AM | 9/17/2021 7:41 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 10/1/2021 12:00:00 AM | 9/17/2021 7:41 AM |
| Terminations | Termination Reason | Update | Recertification | | Failure to recertify | 9/17/2021 7:41 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/8/2020 3:12 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 330197 | 9/8/2020 3:12 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NY | 9/8/2020 3:12 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | NY | 9/8/2020 3:12 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2019 5:10:05 PM | 9/8/2020 3:12:51 PM | 9/8/2020 3:12 PM |
| Contacts | Authorizing Official | Update | AO Change Request | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
Canton-Potsdam Hospital
3152615100 | McGregor, Donna M
System CFO
Canton-Potsdam Hospital
3152615451 | 7/13/2020 7:34 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2018 10:20:17 AM | 9/3/2019 5:10:05 PM | 9/3/2019 5:10 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1568548782 | 5/9/2019 12:41 PM |
| Details | Last Recertification Date | Update | Recertification | 12/1/2017 9:52:03 AM | 8/23/2018 10:20:17 AM | 8/23/2018 10:20 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2016 12:00:00 AM | 12/1/2017 9:52:03 AM | 12/1/2017 9:52 AM |
| Contacts | Primary Contact | Update | Recertification | SOGOIAN, DAVID
DIRECTOR OF PHARMACY
3152615510 | SOGOIAN, DAVID
DIRECTOR OF PHARMACY
Canton-Potsdam Hospital
3152615510 | 12/1/2017 9:44 AM |
| Contacts | Authorizing Official | Update | | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
3152615100 | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
Canton-Potsdam Hospital
3152615100 | 10/16/2017 11:32 AM |
| Contacts | Signed By | Update | | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
3152615100 | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
Canton-Potsdam Hospital
3152615100 | 10/16/2017 11:32 AM |
| Contacts | Authorizing Official | Insert | | | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
3152615100 | 7/25/2017 7:36 AM |
| Contacts | Signed By | Insert | | | JACOBS, RICHARD D.
VP FOR FINANCE AND CFO
3152615100 | 7/25/2017 7:36 AM |
| Contacts | Primary Contact | Update | | BOIALLIS, CHRISTOPHER
DIRECTOR OF PHARMACY
3152615510 | SOGOIAN, DAVID
DIRECTOR OF PHARMACY
3152615510 | 7/25/2017 7:36 AM |
| Addresses | Main Address | Insert | | |
6119 US HIGHWAY 11
CANTON, NY 13617 | 7/24/2017 7:02 PM |
| Addresses | Billing Address | Insert | | | Canton-Potsdam Hospital
50 Leroy Street
Potsdam, NY 13676 | 7/24/2017 7:02 PM |
| Addresses | Shipping Address | Insert | | | Canton-Potsdam Hospital
50 Leroy Street
Potsdam, NY 13676 | 7/24/2017 7:02 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 5/5/2017 10:21 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 00354196 | 5/5/2017 10:21 AM |
| Medicaid Billing | Medicaid: State | Insert | | | NY | 5/5/2017 10:21 AM |
| Details | Entity Subname | Update | | CPH St. Lawrence Orthopedic and Sports Medicine Clinic | ORTHOPEDICS AND SPORTS MEDICINE | 1/30/2017 8:55 AM |
| Contacts | Primary Contact | Insert | | | BOIALLIS, CHRISTOPHER
DIRECTOR OF PHARMACY
3152615510 | 8/18/2016 3:09 PM |
| Details | Last Recertification Date | Update | | 9/2/2015 12:00:00 AM | 8/18/2016 12:00:00 AM | 8/18/2016 2:51 PM |
| Details | Last Recertification Date | Update | | 9/3/2014 12:00:00 AM | 9/2/2015 12:00:00 AM | 9/2/2015 10:44 AM |
| Details | Last Recertification Date | Update | | 9/11/2013 10:02:05 AM | 9/3/2014 12:00:00 AM | 9/3/2014 1:32 PM |
| Details | Last Recertification Date | Update | | | 9/11/2013 10:02:05 AM | 9/11/2013 10:02 AM |
| Details | Comments Public | Insert | | | 11/2/2012 – Participation start date changed from 1/1/2013 to 10/27/2012 to reflect post-Sandy public health emergency determination for the State of New York [T.Lew] | 11/5/2012 10:54 AM |
| Dates | Start Date | Update | | 1/1/2013 12:00:00 AM | 10/27/2012 12:00:00 AM | 11/2/2012 4:59 PM |
| Details | 340B ID | Update | | IS-JH-DSH330197L | DSH330197L | 10/25/2012 12:07 PM |
| Dates | Participating Approval Date | Update | | | 10/25/2012 12:00:00 AM | 10/25/2012 12:07 PM |
| Details | State | Update | | Pending | Active | 10/25/2012 12:07 PM |
| Dates | Start Date | Update | | | 1/1/2013 12:00:00 AM | 10/25/2012 12:07 PM |
| Details | 340B ID | Update | | IS-JH-DSH330197Q | IS-JH-DSH330197L | 10/24/2012 2:52 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | IS-JH-DSH330197Q | 10/24/2012 2:47 PM |
| Details | Last Recertification Date | Insert | | | | 10/15/2012 1:44 PM |
| Details | Grant Number | Insert | | | | 10/15/2012 1:44 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 10/15/2012 1:44 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/15/2012 1:44 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/15/2012 1:44 PM |
| Details | Medicare Provider Number | Insert | | | 330197 | 10/15/2012 1:44 PM |
| Details | Entity Name | Insert | | | CANTON-POTSDAM HOSPITAL | 10/15/2012 1:44 PM |
| Details | Program Code | Insert | | | DSH | 10/15/2012 1:44 PM |
| Details | Entity Subname | Insert | | | CPH St. Lawrence Orthopedic and Sports Medicine Clinic | 10/15/2012 1:44 PM |
| Dates | Participating Approval Date | Insert | | | | 10/15/2012 1:44 PM |
| Details | State | Insert | | | Pending | 10/15/2012 1:44 PM |
| Dates | Registration Date | Insert | | | 10/15/2012 12:00:00 AM | 10/15/2012 1:44 PM |
| Dates | Signed By Date | Insert | | | 10/15/2012 12:00:00 AM | 10/15/2012 1:44 PM |
| Dates | Start Date | Insert | | | | 10/15/2012 1:44 PM |
| Terminations | Termination Comments | Insert | | | | 10/15/2012 1:44 PM |
| Terminations | Termination Date | Insert | | | | 10/15/2012 1:44 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/15/2012 1:44 PM |
| Terminations | Termination Reason | Insert | | | | 10/15/2012 1:44 PM |