| Contacts | Authorizing Official | Update | Change Request | Kongs, Michael
Assistant CFO & System Director & Controller
Stormont Vail Health inc.
7853545844-25844 | Mason, Stacie
Senior Vice President & Chief Financial Officer & Treasurer
Stormont Vail Healthcare, Inc.
7853545770 | 2/25/2025 6:48 AM |
| Addresses | Shipping Address | Insert | Change Request | | STORMONT VAIL MRI CENTER OF KANSAS
731 SW MULVANE
TOPEKA, KS 66606 | 12/19/2024 2:52 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1194782409 | 12/19/2024 2:52 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | NE | 12/19/2024 2:52 PM |
| Details | Entity Subname | Update | Change Request | Stormont Vail MRI Center of Kansas | STORMONT VAIL MRI CENTER OF KANSAS | 12/19/2024 2:52 PM |
| Details | Last Recertification Date | Update | Recertification | 8/14/2023 9:56:53 AM | 8/19/2024 2:17:15 PM | 8/19/2024 2:17 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Kongs, Michael
Controller
Stormont Vail Health inc.
7853545844-25844 | Kongs, Michael
Assistant CFO & System Director & Controller
Stormont Vail Health inc.
7853545844-25844 | 10/17/2023 1:47 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Brewer, Robert Alan
Pharmacy Supervisor - Finance and Medication Acquisition
Stormont-Vail Health
7853545498 | Brewer, Robert Alan
Pharmacy Manager - Finance and Medication Acquisition
Stormont-Vail Health
7853545498 | 10/17/2023 10:11 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 2:30:16 PM | 8/14/2023 9:56:53 AM | 8/14/2023 9:56 AM |
| Contacts | Primary Contact | Update | Group Change Request | Adams, Andrew J
Manager, Pharmacy Finance and Medication Acquisition
Stormont Vail Health inc.
7852700654 | Brewer, Robert Alan
Pharmacy Supervisor - Finance and Medication Acquisition
Stormont-Vail Health
7853545498 | 12/5/2022 12:06 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2021 1:23:50 PM | 9/7/2022 2:30:16 PM | 9/7/2022 2:30 PM |
| Medicaid Billing | Medicaid: Number | Delete | Group Change Request | 100099400A (KS) | | 4/11/2022 4:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Group Change Request | | False | 4/11/2022 4:17 PM |
| Medicaid Billing | Medicaid: Number | Insert | Group Change Request | | 30003913380001 | 4/11/2022 4:17 PM |
| Medicaid Billing | Medicaid: State | Insert | Group Change Request | | KS | 4/11/2022 4:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Group Change Request | | False | 9/15/2021 5:25 PM |
| Medicaid Billing | Medicaid: Number | Insert | Group Change Request | | 012691309 | 9/15/2021 5:25 PM |
| Medicaid Billing | Medicaid: State | Insert | Group Change Request | | MO | 9/15/2021 5:25 PM |
| Medicaid Billing | NPI: Number | Insert | Group Change Request | | 1194782409 | 9/15/2021 5:25 PM |
| Medicaid Billing | NPI: State | Insert | Group Change Request | | MO | 9/15/2021 5:25 PM |
| Addresses | Main Address | Update | Recertification |
731 SW Mulvane
Topeka, KS 66604 |
731 SW Mulvane
Topeka, KS 66606 | 9/10/2021 1:23 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2020 3:51:59 PM | 9/10/2021 1:23:50 PM | 9/10/2021 1:23 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Kongs, Michael
Controller
Stormont Vail Health inc.
7853546000-25844 | Kongs, Michael
Controller
Stormont Vail Health inc.
7853545844-25844 | 9/10/2021 12:38 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Adams, Andrew J
Pharmacy Manager, Finance
Stormont Vail Health inc.
7853546000 | Adams, Andrew J
Manager, Pharmacy Finance and Medication Acquisition
Stormont Vail Health inc.
7852700654 | 8/17/2021 11:38 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/15/2021 9:18 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 100099400A | 6/15/2021 9:18 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KS | 6/15/2021 9:18 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1194782409 | 6/15/2021 9:18 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | KS | 6/15/2021 9:18 AM |
| Contacts | Primary Contact | Update | Change Request | Awad, Dima
Admin Director Chief Pharmacy
Stormont Vail
7853546076 | Adams, Andrew J
Pharmacy Manager, Finance
Stormont Vail Health inc.
7853546000 | 6/15/2021 9:18 AM |
| Contacts | Authorizing Official | Update | Change Request | Langland, Robert Odin
Sr VP Finance
Stormont Vail
7853546148 | Kongs, Michael
Controller
Stormont Vail Health inc.
7853546000-25844 | 12/10/2020 3:41 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2019 7:58:27 AM | 8/21/2020 3:51:59 PM | 8/21/2020 3:51 PM |
| Contacts | Primary Contact | Update | Change Request | Merillat, Vicki
340B Pharmacy Buyer
Stormont Vail Health
7853546867 | Awad, Dima
Admin Director Chief Pharmacy
Stormont Vail
7853546076 | 2/10/2020 10:23 AM |
| Addresses | Billing Address | Insert | Recertification | | STORMONT-VAIL HEALTHCARE INC.
1500 SW 10th Ave
Topeka, KS 66604 | 8/29/2019 7:58 AM |
| Addresses | Shipping Address | Insert | Recertification | | STORMONT-VAIL HEALTHCARE INC.
1500 SW 10th Ave
Topeka, KS 66604 | 8/29/2019 7:58 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2018 3:18:10 PM | 8/29/2019 7:58:27 AM | 8/29/2019 7:58 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Merillat, Vicki
340B Pharmacy Buyer
Stormont Vail Health
7853546040 | Merillat, Vicki
340B Pharmacy Buyer
Stormont Vail Health
7853546867 | 4/9/2019 11:43 AM |
| Contacts | Primary Contact | Update | Change Request | Waite, Kevin
Director of Pharmacy
Stormont Vail Health
7853546076 | Merillat, Vicki
340B Pharmacy Buyer
Stormont Vail Health
7853546040 | 12/28/2018 2:24 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2016 12:00:00 AM | 8/20/2018 3:18:10 PM | 8/20/2018 3:18 PM |
| Terminations | Termination Reason | Update | | Failure to recertify | | 7/21/2018 12:21 PM |
| Details | State | Update | | Approved | Active | 4/1/2018 12:00 AM |
| Contacts | Signed By | Update | Reinstatement | Han, Kevin J.
VP CFO & Treasurer
7853546148 | Langland, Robert Odin
Sr VP Finance
Stormont Vail
7853546148 | 1/17/2018 12:13 PM |
| Dates | Participating Approval Date | Update | Reinstatement | | 1/17/2018 12:13:20 PM | 1/17/2018 12:13 PM |
| Details | State | Update | Reinstatement | Pending | Approved | 1/17/2018 12:13 PM |
| Dates | Signed By Date | Update | Reinstatement | 1/14/2013 12:00:00 AM | 1/15/2018 2:16:38 PM | 1/17/2018 12:13 PM |
| Dates | Start Date | Update | Reinstatement | | 4/1/2018 12:00:00 AM | 1/17/2018 12:13 PM |
| Terminations | Termination Reason | Update | Reinstatement | | Failure to recertify | 1/17/2018 12:13 PM |
| Details | Comments Public | Insert | Reinstatement | | Participating from effective date (4/1/2013). until terminated effective date (1/1/2018), reinstatement date effective date (04/01/2018) | 1/16/2018 2:19 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 1/1/2018 12:00:00 AM | | 1/15/2018 10:53 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 3/1/2013 12:00:00 AM | | 1/15/2018 10:53 AM |
| Details | State | Update | Reinstatement | Terminated | Pending | 1/15/2018 10:53 AM |
| Dates | Registration Date | Update | Reinstatement | 1/14/2013 12:00:00 AM | 1/15/2018 10:53:56 AM | 1/15/2018 10:53 AM |
| Dates | Start Date | Update | Reinstatement | 4/1/2013 12:00:00 AM | | 1/15/2018 10:53 AM |
| Terminations | Termination Date | Update | Reinstatement | 1/1/2018 12:00:00 AM | | 1/15/2018 10:53 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 1/1/2018 12:00:00 AM | | 1/15/2018 10:53 AM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 1/15/2018 10:53 AM |
| Details | State | Update | | To Be Terminated | Terminated | 1/1/2018 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 1/1/2018 12:00:00 AM | 12/7/2017 11:30 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 12/7/2017 11:30 AM |
| Terminations | Termination Date | Update | Recertification | | 1/1/2018 12:00:00 AM | 12/7/2017 11:30 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 1/1/2018 12:00:00 AM | 12/7/2017 11:30 AM |
| Terminations | Termination Reason | Update | Recertification | | Failure to recertify | 12/7/2017 11:30 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Han, Kevin J.
VP CFO & Treasurer
7853546148 | Langland, Robert Odin
Sr VP Finance
Stormont Vail
7853546148 | 12/4/2017 5:48 PM |
| Contacts | Primary Contact | Update | | Waite, Kevin
Director of Pharmacy
7853546076 | Waite, Kevin
Director of Pharmacy
Stormont Vail Health
7853546076 | 10/18/2017 9:58 AM |
| Addresses | Main Address | Insert | | |
731 SW Mulvane
Topeka, KS 66604 | 11/2/2016 2:31 PM |
| Contacts | Authorizing Official | Insert | | | Han, Kevin J.
VP CFO & Treasurer
7853546148 | 11/2/2016 2:31 PM |
| Contacts | Signed By | Insert | | | Han, Kevin J.
VP CFO & Treasurer
7853546148 | 11/2/2016 2:31 PM |
| Contacts | Primary Contact | Insert | | | Waite, Kevin
Director of Pharmacy
7853546076 | 11/2/2016 2:31 PM |
| Details | Last Recertification Date | Update | | 8/14/2015 12:00:00 AM | 8/29/2016 12:00:00 AM | 8/29/2016 12:01 PM |
| Details | Entity Subname | Update | | Stormont-Vail MRI Center of Kansas | Stormont Vail MRI Center of Kansas | 8/29/2016 12:01 PM |
| Details | Last Recertification Date | Update | | 8/27/2014 12:00:00 AM | 8/14/2015 12:00:00 AM | 8/14/2015 4:23 PM |
| Details | Last Recertification Date | Update | | 8/26/2013 10:15:15 AM | 8/27/2014 12:00:00 AM | 8/27/2014 12:48 PM |
| Details | Last Recertification Date | Update | | | 8/26/2013 10:15:15 AM | 8/26/2013 10:15 AM |
| Details | 340B ID | Update | | ISDR-DSH170086F | DSH170086F | 3/1/2013 5:38 PM |
| Dates | Participating Approval Date | Update | | | 3/1/2013 12:00:00 AM | 3/1/2013 5:38 PM |
| Details | State | Update | | Pending | Active | 3/1/2013 5:38 PM |
| Dates | Start Date | Update | | | 4/1/2013 12:00:00 AM | 3/1/2013 5:38 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | ISDR-DSH170086F | 1/28/2013 5:06 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2013 10:21 AM |
| Details | Grant Number | Insert | | | | 1/14/2013 10:21 AM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 1/14/2013 10:21 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/14/2013 10:21 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2013 10:21 AM |
| Details | Medicare Provider Number | Insert | | | 170086 | 1/14/2013 10:21 AM |
| Details | Entity Name | Insert | | | STORMONT-VAIL HEALTHCARE INC. | 1/14/2013 10:21 AM |
| Details | Program Code | Insert | | | DSH | 1/14/2013 10:21 AM |
| Details | Entity Subname | Insert | | | Stormont-Vail MRI Center of Kansas | 1/14/2013 10:21 AM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2013 10:21 AM |
| Details | State | Insert | | | Pending | 1/14/2013 10:21 AM |
| Dates | Registration Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 10:21 AM |
| Dates | Signed By Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 10:21 AM |
| Dates | Start Date | Insert | | | | 1/14/2013 10:21 AM |
| Terminations | Termination Comments | Insert | | | | 1/14/2013 10:21 AM |
| Terminations | Termination Date | Insert | | | | 1/14/2013 10:21 AM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2013 10:21 AM |
| Terminations | Termination Reason | Insert | | | | 1/14/2013 10:21 AM |