Covered Entity Details

DSH440039L Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic (Active) - information as of 6/3/2025 11:59:17 AM

Main Details

Name

Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic

Subdivision Name

THE VANDERBILT CLINIC- CENTER FOR HUMAN NUTRITION

Type

Disproportionate Share Hospital

Rural

340B ID

DSH440039L

Medicare Provider Number

440039

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2013

Participating Start Date

4/1/2013

Participating Approval Date

1/22/2013

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Vanderbilt University Medical Center
James Edgar Newman, Vice President
(615) 293-3406

Primary Contact

DSH440039
Thomas Mark Sullivan, Chief Pharmacy Officer
(615) 343-9595

Addresses

Street Address

1211 21ST AVENUE
SUITE 514
NASHVILLE, TN 37212

Billing Address

VANDERBILT UNIVERSITY HOSPITAL AND CLINIC
726 MELROSE AVE
NASHVILLE, TN 37211-2151

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
TN	440039,44S039	1396882205,1558408633,1316974231,1932352283,1740203140,1700800877,1679971485,1285091330,1649637794
KY	01620046,54007604,54007745,54008081	1396882205,1558408633,1316974231,1932352283,1740203140,1700800877,1679971485,1285091330,1649637794
AL	200807,201320	1396882205,1558408633
AR	218693105	1396882205,1558408633
AZ	29498	1396882205,1558408633
CA	1396882205	1396882205,1558408633
CT	008076369	1396882205,1558408633
GA	003186677A	1396882205,1558408633
IL	352528741401	1396882205,1558408633
IN	300002314	1396882205,1558408633
LA	1790559	1396882205,1558408633
MI	1396882205	1396882205,1558408633
MO	1396882205	1396882205,1558408633
MS	00220498	1396882205,1558408633
NC	1396882205	1396882205,1558408633
NY	01926392	1396882205,1558408633
OH	0252306	1396882205,1558408633
PA	1032917280001,1032917280002	1396882205,1558408633
SC	441147,11611A	1396882205,1558408633
VA	1396882205	1396882205,1558408633
WV	1396882205	1396882205,1558408633
CO	95010773	1396882205,1558408633
DE	28741	1396882205,1558408633
IA	1912022	1396882205,1558408633
FL	120721800	1396882205,1558408633
KS	30004715880002	1396882205,1558408633
MD	45695200	1396882205,1558408633
MT	1396882205	1396882205,1558408633
NE	10028364900	1396882205,1558408633
UT	4239535	1396882205,1558408633
VT	0440039	1396882205,1558408633
WI	100230901	1396882205,1558408633
TX	404767201	1396882205,1558408633
WA	2260691	1396882205,1558408633

Shipping Addresses

Shipping Address 1

Vanderbilt Medical Group CLINIC PHARMACY
1211 MEDICAL CENTER DRIVE
TVC 1815
NASHVILLE, TN 37232

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
DSH440039AA	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT SURGERY CENTER	225 BEDFORD WAY	FRANKLIN	TN	Active
DSH440039AB	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT SLEEP DISORDER CLINIC	2555 WEST END AVENUE	NASHVILLE	TN	Active
DSH440039AC	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT DAYANI CENTER FOR HEALTH AND WELLNESS	1500 MEDICAL CENTER DRIVE	NASHVILLE	TN	Active
DSH440039AE	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT PSYCHIATRIC HOSPITAL	1601 23RD AVE SOUTH, SUITE #1050	NASHVILLE	TN	Active
DSH440039AF	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT INGRAM CANCER CENTER AT SPRING HILL / INGRAM CANCER CENTER	1003 RESERVE BLVD, SUITE #240	SPRING HILL	TN	Active
DSH440039AG	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT OSHER CENTER FOR INTERATIVE MEDICINE / CENTER FOR INTEGRATIVE MEDICINE	3401 WEST END AVENUE, SUITE # 380	NASHVILLE	TN	Active
DSH440039AH	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Cancer Clinic / Hereditary Cancer Clinic	1500 21st Ave, Suite 2500	Nashville	TN	Active
DSH440039AJ	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Hereditary Cancer Program	1500 21st Ave, Suite 2810	Nashville	TN	Active
DSH440039AK	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Transplant Services - Transplant	1500 21st Avenue South	Nashville	TN	Active
DSH440039AL	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Vanderbilt Internal Medicine Clinics - Vanderbilt Internal Medicine HMG	1500 21st Ave. South	Nashville	TN	Active
DSH440039AM	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Vanderbilt Internal Medicine Clinic - Adult Primary Care Center	719 Thompson Lane	Nashville	TN	Active
DSH440039AN	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT HEALTH BREAST CENTER - Women's Breast Health	324 COOL SPRINGS BLVD	FRANKLIN	TN	Active
DSH440039AP	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Oral Surgery - Oral Surgery	420 24th Ave S.	Nashville	TN	Active
DSH440039AQ	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Neurology OHO - Neurology Clinic	719 Thompson Lane	Nashville	TN	Active
DSH440039AR	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Dermatology OHO - Derm Clinic	719 Thompson Lane	Nashville	TN	Active
DSH440039AS	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Internal Medicine OHO - Internal Medicine Clinic	719 Thompson Lane	Nashville	TN	Active
DSH440039AT	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Cardiology OHO - Cardiology	719 Thompson Lane	Nashville	TN	Active
DSH440039AU	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Peds University Pediatrics OHO - University Peds	719 Thompson Lane	Nashville	TN	Active
DSH440039AV	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Orthopaedics Spine OHO - Ortho Spine	719 Thompson Lane	Nashville	TN	Active
DSH440039AW	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Oncology Breast Surgery OHO - Breast Center	719 Thompson Lane	Nashville	TN	Active
DSH440039AX	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	OBGYN OHO - OBGYN Clinic	719 Thompson Lane	Nashville	TN	Active
DSH440039AY	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Surgical Weight Loss OHO - Surgical Weight Loss	719 Thompson Lane	Nashville	TN	Active
DSH440039AZ	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Interventional Pain OHO - Pain Center	719 Thompson Lane	Nashville	TN	Active
DSH440039BA	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VPEC OHO - Perioperative Services	719 Thompson Lane	Nashville	TN	Active
DSH440039BB	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	CWI Ultrasound OHO - Center for Womens Imaging Ultrasound	719 Thompson Lane	Nashville	TN	Active
DSH440039BC	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VUMC Psychiatric Hospital - Partial Hospitalization Program	1601 23rd Ave S	Nashville	TN	Active
DSH440039BD	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	MCJCHV Murfreesboro - MCJCHV Murfreesboro	2102 W Northfield Blvd	Murfreesboro	TN	Active
DSH440039BE	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT HEALTH HENDERSONVILLE - orthopedics	129 N ANDERSON LN	HENDERSONVILLE	TN	Active
DSH440039BF	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT ORAL HEALTH - Oral Health	2111 BELCOURT AVE	NASHVILLE	TN	Active
DSH440039BG	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT HEALTH BELLE MEADE - Oncology	6002 HIGHWAY 100	NASHVILLE	TN	Active
DSH440039BH	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Vanderbilt Lung Institute - Pulmonary	719 Thompson Lane	Nashville	TN	Active
DSH440039BJ	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Behavioral Health Belcourt - Psychiatry	2111 Belcourt Ave	Nashville	TN	Active
DSH440039BK	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Vanderbilt Endoscopy - Endoscopy	719 Thompson Lane	Nashville	TN	Active
DSH440039BL	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Vanderbilt Transplant Clinic VAV - Transplant	1500 21ST AVE S	Nashville	TN	Active
DSH440039BM	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT SLEEP DISORDERS CENTER - Sleep Disorders Clinic	650 BAKERS BRIDGE AVE	FRANKLIN	TN	Active
DSH440039BN	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Therapeutics Infusion Village at Vanderbilt - Infusion Clinic	1500 21ST AVENUE	Nashville	TN	Active
DSH440039BP	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT HEALTH PLEASANT VIEW - Vanderbilt Ingram Cancer Center (VICC)	6536 HIGHWAY 41A	PLEASANT VIEW	TN	Active
DSH440039BQ	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VICC Cancer Center Lebanon - Cancer	1616 W MAIN ST	LEBANON	TN	Active
DSH440039BR	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	Colorectal Surgery MAB - Surgery	1211 21ST AVENUE	Nashville	TN	Active
DSH440039BS	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	VANDERBILT MEDICAL LABORATORIES - M - Pathology	445 GREAT CIRCLE RD	NASHVILLE	TN	Approved
DSH440039G	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC - ONE HUNDRED OAKS	719 THOMPSON LANE	NASHVILLE	TN	Active
DSH440039H	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC - FRANKLIN ONCOLOGY	324 COOL SPRINGS BLVD.	FRANKLIN	TN	Active
DSH440039J	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC - COOL SPRINGS RHEUMATOLOGY	2001 MALLORY LANE	FRANKLIN	TN	Active
DSH440039K	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- THE VANDERBILT EYE INSTITUTE	2311 PIERCE AVENUE	NASHVILLE	TN	Active
DSH440039L	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- CENTER FOR HUMAN NUTRITION	1211 21ST AVENUE	NASHVILLE	TN	Active
DSH440039M	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- INFECTIOUS DISEASE CLINIC	1211 21ST AVENUE	NASHVILLE	TN	Active
DSH440039N	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- NUTRITION CLINIC	1211 21ST AVENUE	NASHVILLE	TN	Active
DSH440039P	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- PEDIATRIC REHABILITATION CLINIC	719 THOMPSON LANE	NASHVILLE	TN	Active
DSH440039Q	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT OUTPATIENT SURGERY CENTER (FEL)	410 24TH AVENUE	NASHVILLE	TN	Active
DSH440039R	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	NORTHCREST VICC CANCER CLINIC	500 NORTHCREST DRIVE, SUITE 521	SPRINGFIELD	TN	Terminated
DSH440039S	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	GREEN HILLS MEDICINE CLINIC	3810 BEDFORD AVENUE	NASHVILLE	TN	Active
DSH440039T	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- NEUROSURGERY CLINIC	1500 21ST AVENUE	NASHVILLE	TN	Active
DSH440039U	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- PSYCHIATRIC CLINIC AT VAV	1500 21ST AVENUE	NASHVILLE	TN	Active
DSH440039W	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- ORTHODONTIC AND DENTAL CLINIC	1500 21ST AVENUE	NASHVILLE	TN	Terminated
DSH440039X	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- IBD CLINIC	719 Thompson Lane	NASHVILLE	TN	Active
DSH440039Y	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- PSYCHIATRY CLINIC AT VAV	1500 21ST AVE	NASHVILLE	TN	Active
DSH440039Z	Child	DSH	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- PSYCHIATRY CLINIC AT VPH	1601 23RD AVE	NASHVILLE	TN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30004715880002	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		45695200	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10028364900	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4239535	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440039	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100230901	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		404767201	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2260691	4/15/2025 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		KS	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		KS	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	4/15/2025 1:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/15/2025 1:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	4/15/2025 1:22 PM
Contacts	Primary Contact	Update	Recertification	HAYMAN, JIMMY N. Chief Pharmacy Officer Vanderbilt University Medical Center 6153220716-6153220716	Sullivan, Thomas Mark Chief Pharmacy Officer DSH440039 6153439595	8/20/2024 12:43 PM
Details	Last Recertification Date	Update	Recertification	8/18/2023 10:49:27 AM	8/20/2024 12:43:56 PM	8/20/2024 12:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/5/2024 12:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		120721800	4/5/2024 12:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/5/2024 12:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	4/5/2024 12:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/5/2024 12:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	4/5/2024 12:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/5/2024 12:12 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 12:21:05 PM	8/18/2023 10:49:27 AM	8/18/2023 10:49 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	404767201 (TX)		12/27/2022 12:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396882205 (TX)		12/27/2022 12:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1558408633 (TX)		12/27/2022 12:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003126994 (CT)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	020595000 (FL)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	024102200 (FL)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	N/A (NV)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200745200A (OK)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200745200C (OK)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4411487 (CO)		11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95010773	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		54007604	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		54007745	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		54008081	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		28741	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1912022	11/28/2022 10:42 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1396882205 (FL)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1558408633 (FL)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1396882205 (NV)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1558408633 (NV)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1396882205 (OK)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1558408633 (OK)		11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	11/28/2022 10:42 AM
Medicaid Billing	NPI: State	Insert	Change Request		DE	11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	11/28/2022 10:42 AM
Medicaid Billing	NPI: State	Insert	Change Request		DE	11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	11/28/2022 10:42 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	11/28/2022 10:42 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	11/28/2022 10:42 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	11/28/2022 10:42 AM
Details	Last Recertification Date	Update	Recertification	8/26/2021 9:04:08 AM	8/26/2022 12:21:05 PM	8/26/2022 12:21 PM
Contacts	Authorizing Official	Update	Change Request	Moore, Cecelia Britt Chief Financial Officer Vanderbilt University Medical Center 6153220084	Newman, James Edgar Vice President Vanderbilt University Medical Center 6152933406	3/31/2022 6:57 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 5:18:27 PM	8/26/2021 9:04:08 AM	8/26/2021 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/17/2021 5:49 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4411487	3/17/2021 5:49 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/17/2021 5:49 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	3/17/2021 5:49 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	3/17/2021 5:49 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	3/17/2021 5:49 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	3/17/2021 5:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		44S039	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01620046	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200807	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		201320	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		218693105	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		29498	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008076369	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003126994	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		020595000	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		024102200	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003186677A	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		352528741401	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300002314	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1790559	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00220498	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		N/A	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01926392	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0252306	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200745200A	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200745200C	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1032917280001	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1032917280002	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		441147	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11611A	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		404767201	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316974231	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1932352283	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740203140	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700800877	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1679971485	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285091330	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649637794	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316974231	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1932352283	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740203140	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700800877	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1679971485	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285091330	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649637794	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396882205	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	12/22/2020 12:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558408633	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	12/22/2020 12:18 PM
Medicaid Billing	NPI: State	Update	Recertification		TN	9/1/2020 5:18 PM
Details	Last Recertification Date	Update	Recertification	9/12/2019 4:17:11 PM	9/1/2020 5:18:27 PM	9/1/2020 5:18 PM
Contacts	Primary Contact	Update	Change Request	HAYMAN, JIMMY Chief Pharmacy Officer Vanderbilt University Medical Center 6158755031	HAYMAN, JIMMY N. Chief Pharmacy Officer Vanderbilt University Medical Center 6153220716-6153220716	1/7/2020 3:18 PM
Contacts	Authorizing Official	Update	Change Request	Moore, Cecelia B Associate Vice Chancellor Vanderbilt University Medical Center 6153220084	Moore, Cecelia Britt Chief Financial Officer Vanderbilt University Medical Center 6153220084	12/16/2019 8:23 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 11:24:36 AM	9/12/2019 4:17:11 PM	9/12/2019 4:17 PM
Contacts	Primary Contact	Update	Profile Change Request	HAYMAN, JIMMY Chief Pharmacy Officer Vanderbilt University Medical Center 6153222374	HAYMAN, JIMMY Chief Pharmacy Officer Vanderbilt University Medical Center 6158755031	5/7/2019 1:20 PM
Contacts	Primary Contact	Update	Profile Change Request	HAYMAN, JIMMY PHARMACY ADMINISTRATOR Vanderbilt University Medical Center 6153222374	HAYMAN, JIMMY Chief Pharmacy Officer Vanderbilt University Medical Center 6153222374	5/7/2019 1:16 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 1:22:29 PM	8/23/2018 11:24:36 AM	8/23/2018 11:24 AM
Details	Last Recertification Date	Update	Recertification	8/25/2016 12:00:00 AM	11/8/2017 1:22:29 PM	11/8/2017 1:22 PM
Contacts	Authorizing Official	Update		Moore, Cecelia Associate Vice Chancellor 6153220084	Moore, Cecelia B Associate Vice Chancellor Vanderbilt University Medical Center 6153220084	10/11/2017 5:49 PM
Contacts	Primary Contact	Update		HAYMAN, JIMMY PHARMACY ADMINISTRATOR 6153222374	HAYMAN, JIMMY PHARMACY ADMINISTRATOR Vanderbilt University Medical Center 6153222374	9/29/2017 8:28 AM
Contacts	Authorizing Official	Insert			Moore, Cecelia Associate Vice Chancellor 6153220084	8/9/2017 12:48 PM
Contacts	Primary Contact	Insert			HAYMAN, JIMMY PHARMACY ADMINISTRATOR 6153222374	7/30/2017 10:47 AM
Contacts	Signed By	Insert			Beck, Warren E. Sr. Vice-President of Finance-VUMC 6153439908	7/5/2017 6:50 AM
Addresses	Main Address	Insert			1211 21ST AVENUE SUITE 514 NASHVILLE, TN 37212	11/4/2016 1:44 PM
Addresses	Billing Address	Insert			VANDERBILT UNIVERSITY HOSPITAL AND CLINIC 726 MELROSE AVE NASHVILLE, TN 37211-2151	11/4/2016 1:44 PM
Addresses	Shipping Address	Insert			Vanderbilt Medical Group CLINIC PHARMACY 1211 MEDICAL CENTER DRIVE TVC 1815 NASHVILLE, TN 37232	11/4/2016 1:44 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/25/2016 12:00:00 AM	8/25/2016 9:53 AM
Details	Entity Name	Update		VANDERBILT UNIVERSITY HOSPITAL AND CLINIC	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	5/3/2016 2:07 PM
Details	Entity Subname	Update		Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	THE VANDERBILT CLINIC- CENTER FOR HUMAN NUTRITION	5/3/2016 2:07 PM
Details	Entity Subname	Update		THE VANDERBILT CLINIC- CENTER FOR HUMAN NUTRITION	Vanderbilt University Medical Center d/b/a Vanderbilt University Hospital and Clinic	5/3/2016 12:22 PM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 12:40 PM
Details	Last Recertification Date	Update		9/10/2013 11:11:40 AM	8/15/2014 12:00:00 AM	8/15/2014 12:46 PM
Details	Last Recertification Date	Update			9/10/2013 11:11:40 AM	9/10/2013 11:11 AM
Details	340B ID	Update		ISDR-DSH440039L	DSH440039L	1/22/2013 4:54 PM
Dates	Participating Approval Date	Update			1/22/2013 12:00:00 AM	1/22/2013 4:54 PM
Details	State	Update		Pending	Active	1/22/2013 4:54 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	1/22/2013 4:54 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISDR-DSH440039L	1/16/2013 5:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2013 6:27 PM
Medicaid Billing	Medicaid: Number	Insert			440039	1/15/2013 6:27 PM
Medicaid Billing	Medicaid: State	Insert			TN	1/15/2013 6:27 PM
Medicaid Billing	NPI: Number	Insert			1396882205	1/15/2013 6:27 PM
Details	Last Recertification Date	Insert				1/15/2013 6:27 PM
Details	Grant Number	Insert				1/15/2013 6:27 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/15/2013 6:27 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2013 6:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2013 6:27 PM
Details	Medicare Provider Number	Insert			440039	1/15/2013 6:27 PM
Details	Entity Name	Insert			VANDERBILT UNIVERSITY HOSPITAL AND CLINIC	1/15/2013 6:27 PM
Details	Program Code	Insert			DSH	1/15/2013 6:27 PM
Details	Entity Subname	Insert			THE VANDERBILT CLINIC- CENTER FOR HUMAN NUTRITION	1/15/2013 6:27 PM
Dates	Participating Approval Date	Insert				1/15/2013 6:27 PM
Details	State	Insert			Pending	1/15/2013 6:27 PM
Dates	Registration Date	Insert			1/15/2013 12:00:00 AM	1/15/2013 6:27 PM
Dates	Signed By Date	Insert			1/15/2013 12:00:00 AM	1/15/2013 6:27 PM
Dates	Start Date	Insert				1/15/2013 6:27 PM
Terminations	Termination Comments	Insert				1/15/2013 6:27 PM
Terminations	Termination Date	Insert				1/15/2013 6:27 PM
Terminations	Termination Effective Date	Insert				1/15/2013 6:27 PM
Terminations	Termination Reason	Insert				1/15/2013 6:27 PM