Covered Entity Details

DSH220116A TUFTS MEDICAL CENTER (Terminated) - information as of 5/29/2025 2:00:14 AM

Main Details

Name

TUFTS MEDICAL CENTER

Subdivision Name

South Boston Day Hospital

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220116A

Medicare Provider Number

220116

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/5/2013

Participating Start Date

7/1/2013

Participating Approval Date

6/11/2013

Last Recertification Date

8/26/2021

Termination Date
Termination Reason

1/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Tufts Medical Center
Kristine Hanscom, CFO
(617) 636-7767

Primary Contact

Tufts Medical Center
Ross Thompson, VP, Clinical Operations
(617) 636-4663

Addresses

Street Address

58 Old Colony Ave
South Boston, MA 02127

Billing Address

Tufts Medical Center
800 Washington Street
Boston, MA 02111

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
MA	110020611G,110020611D	1730132515,1053350306,1851337141
RI	OP20116,0220116	1730132515,1053350306,1851337141
CT	003079789,003032570	1730132515,1053350306,1851337141
VT	0220116	1730132515,1053350306,1851337141
NH	3071222	1730132515,1053350306,1851337141
NY	01608240	1730132515,1053350306,1851337141
ME		1730132515,1851337141,1053350306

Shipping Addresses

Shipping Address 1

Tufts Medical Center
800 Washington Street
Boston, MA 02111

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
DSH220116A	Child	DSH	TUFTS MEDICAL CENTER	South Boston Day Hospital	58 Old Colony Ave	South Boston	MA	Terminated
DSH220116B	Child	DSH	TUFTS MEDICAL CENTER	Kidney and Blood Pressure Clinic	35 Kneeland Street	BOSTON	MA	Active
DSH220116C	Child	DSH	TUFTS MEDICAL CENTER	TUFTS MEDICAL CENTER CANCER CENTER - Hematology / Oncology Clinic	41 MONTVALE AVE	STONEHAM	MA	Active
DSH220116D	Child	DSH	TUFTS MEDICAL CENTER	TUFTS MEDICAL CENTER, INC - Tufts Medical Center Cancer Center - Infusion Center	41 MONTVALE AVE	STONEHAM	MA	Active
DSH220116E	Child	DSH	TUFTS MEDICAL CENTER	Tufts Medical Center (Neurology - Medford) - Neurology	170 Governors Ave	Medford	MA	Active
DSH220116F	Child	DSH	TUFTS MEDICAL CENTER	Tufts Medical Center Gastrointestinal Stoneham - Gastrointestinal	51 Montvale Ave	Stoneham	MA	Active
DSH220116G	Child	DSH	TUFTS MEDICAL CENTER	Tufts Medical Center Rheumatology Reading - Rheumatology	30 New Crossing Road	Reading	MA	Active
DSH220116H	Child	DSH	TUFTS MEDICAL CENTER	Tufts Medical Center (Endocrine / Diabetes - Medford) - Endocrine, Diabetes	170 Governors Ave	Medford	MA	Active
DSH220116J	Child	DSH	TUFTS MEDICAL CENTER	Tufts Medical Center (Endocrine/Diabetes) - Melrose - Endocrine/Diabetes	585 Lebanon Street	Melrose	MA	Active
DSH220116K	Child	DSH	TUFTS MEDICAL CENTER	TUFTS MEDICAL CENTER FRAMINGHAM - Infusion Center	99 LINCOLN ST	FRAMINGHAM	MA	Active
DSH220116L	Child	DSH	TUFTS MEDICAL CENTER	TUFTS MEDICAL CENTER FRAMINGHAM - Hematology / Oncology Clinic	99 LINCOLN ST	FRAMINGHAM	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Thompson, Ross Director of Pharmacy Tufts Medical Center 6176368981	Thompson, Ross VP, Clinical Operations Tufts Medical Center 6176364663	9/1/2022 11:41 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/17/2021 12:00:00 AM	10/8/2021 8:28 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/8/2021 8:28 AM
Terminations	Termination Comments	Update	Termination Request		This clinical practice was closed as a result of a business decision made by Tufts MC.	10/8/2021 8:28 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	10/8/2021 8:28 AM
Terminations	Termination Effective Date	Update	Termination Request		9/17/2021 12:00:00 AM	10/8/2021 8:28 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	10/8/2021 8:28 AM
Details	Last Recertification Date	Update	Recertification	8/23/2020 7:12:29 PM	8/26/2021 11:59:33 AM	8/26/2021 11:59 AM
Addresses	Shipping Address	Insert	Group Change Request		Tufts Medical Center 800 Washington Street Boston, MA 02111	7/15/2021 10:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003032570	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110020611D	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0220116	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01608240	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508948613 (MA)		7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1881884617 (MA)		7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730132515	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730132515	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730132515	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730132515	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730132515	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053350306	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/12/2021 5:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851337141	7/12/2021 5:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/12/2021 5:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP20116	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003079789	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0220116	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3071222	8/23/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	8/23/2020 7:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1508948613	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/23/2020 7:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881884617	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/23/2020 7:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1730132515	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/23/2020 7:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1851337141	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/23/2020 7:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053350306	8/23/2020 7:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/23/2020 7:12 PM
Details	Last Recertification Date	Update	Recertification	9/4/2019 11:24:56 AM	8/23/2020 7:12:29 PM	8/23/2020 7:12 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 9:31:17 AM	9/4/2019 11:24:56 AM	9/4/2019 11:24 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 4:12:38 PM	8/27/2018 9:31:17 AM	8/27/2018 9:31 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/13/2017 4:12:38 PM	11/13/2017 4:12 PM
Contacts	Authorizing Official	Update		Hanscom, Kristine CFO 6176367767	Hanscom, Kristine CFO Tufts Medical Center 6176367767	10/16/2017 8:44 AM
Contacts	Primary Contact	Update		Thompson, Ross Director of Pharmacy 6176368981	Thompson, Ross Director of Pharmacy Tufts Medical Center 6176368981	10/5/2017 2:23 PM
Contacts	Authorizing Official	Insert			Hanscom, Kristine CFO 6176367767	7/18/2017 8:51 AM
Addresses	Main Address	Insert			58 Old Colony Ave South Boston, MA 02127	8/24/2016 10:31 AM
Contacts	Primary Contact	Update		Cattaneo, Luca Assistant Director Outpatient Pharmacy Services 6176360720	Thompson, Ross Director of Pharmacy 6176368981	8/24/2016 10:31 AM
Contacts	Signed By	Insert			Agba, Chibueze CFO 6176364242	8/24/2016 10:31 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 10:31 AM
Addresses	Billing Address	Insert			Tufts Medical Center 800 Washington Street Boston, MA 02111	3/15/2016 11:09 AM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 4:43 PM
Details	Last Recertification Date	Update		9/5/2013 6:02:20 AM	8/11/2014 12:00:00 AM	8/11/2014 9:53 AM
Contacts	Primary Contact	Insert			Cattaneo, Luca Assistant Director Outpatient Pharmacy Services 6176360720	7/3/2014 4:20 PM
Details	Last Recertification Date	Update			9/5/2013 6:02:20 AM	9/5/2013 6:02 AM
Details	340B ID	Update		ISAPDSH220116A	DSH220116A	6/11/2013 8:56 AM
Dates	Participating Approval Date	Update			6/11/2013 12:00:00 AM	6/11/2013 8:56 AM
Details	State	Update		Pending	Active	6/11/2013 8:56 AM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	6/11/2013 8:56 AM
Details	340B ID	Update		AP040813D	ISAPDSH220116A	4/10/2013 4:36 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	AP040813D	4/8/2013 3:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2013 11:31 AM
Medicaid Billing	Medicaid: Number	Insert			110020611G	4/5/2013 11:31 AM
Medicaid Billing	Medicaid: State	Insert			MA	4/5/2013 11:31 AM
Medicaid Billing	NPI: Number	Insert			1730132515	4/5/2013 11:31 AM
Details	Last Recertification Date	Insert				4/5/2013 11:31 AM
Details	Grant Number	Insert				4/5/2013 11:31 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/5/2013 11:31 AM
Details	Is Authorizing Official EHB Data	Insert				4/5/2013 11:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/5/2013 11:31 AM
Details	Medicare Provider Number	Insert			220116	4/5/2013 11:31 AM
Details	Entity Name	Insert			TUFTS MEDICAL CENTER	4/5/2013 11:31 AM
Details	Program Code	Insert			DSH	4/5/2013 11:31 AM
Details	Entity Subname	Insert			South Boston Day Hospital	4/5/2013 11:31 AM
Dates	Participating Approval Date	Insert				4/5/2013 11:31 AM
Details	State	Insert			Pending	4/5/2013 11:31 AM
Dates	Registration Date	Insert			4/5/2013 12:00:00 AM	4/5/2013 11:31 AM
Dates	Signed By Date	Insert			4/5/2013 12:00:00 AM	4/5/2013 11:31 AM
Dates	Start Date	Insert				4/5/2013 11:31 AM
Terminations	Termination Comments	Insert				4/5/2013 11:31 AM
Terminations	Termination Date	Insert				4/5/2013 11:31 AM
Terminations	Termination Effective Date	Insert				4/5/2013 11:31 AM
Terminations	Termination Reason	Insert				4/5/2013 11:31 AM