Covered Entity Details

DSH190002H LAFAYETTE GENERAL MEDICAL CENTER (Terminated) - information as of 5/16/2025 11:31:59 PM

Main Details

Name

LAFAYETTE GENERAL MEDICAL CENTER

Subdivision Name

Outpatient Lab

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190002H

Medicare Provider Number

190002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

6/11/2013

Last Recertification Date

8/16/2021

Termination Date
Termination Reason

7/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Lafayette General Medical Center
Al Jude Patin, Chief Executive Officer
(337) 354-9334

Primary Contact

Ochsner Lafayette General
Rodney J Good, AVP Pharmacy
(337) 289-7888

Addresses

Street Address

1211 Coolidge Street
Second floor
Lafayette, LA 70503

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
TX	107886701
MS	00220138
CA	XHSP42102
FL	914486200
OH	3138858
LA	1730092	1275536799

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
DSH190002A	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Mammography LGMH SC09 - OLGH BREAST CENTER MAMMOGRAPHY	1448 South College	Lafayette	LA	Active
DSH190002AA	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Recovery Svcs LGOH AC02 - LGOH HOLDING	2810 Ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002AB	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO Telemetry	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002AC	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Infectious Disease LGMP HD04 - OLGC INFECTIOUS DISEASE	116B HOSPITAL DR	LAFAYETTE	LA	Active
DSH190002AD	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Pre/postoperative LGSH PR06 - LGSH PRE/POST-OP	1000 W Pinhook Rd.	Lafayette	LA	Active
DSH190002AE	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	General Surgery LGSH PR06 - LGSH ENDOSCOPY	1000 W Pinhook Rd.	Lafayette	LA	Active
DSH190002AF	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Recovery Svcs LGSH PR06 - LGSH PACU	1000 W Pinhook Rd.	Lafayette	LA	Active
DSH190002AG	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Rheumatology LGMP CB05 - OLGC BRACC RHEUMATOLOGY	1211 Coolidge Blvd	Lafayette	LA	Active
DSH190002AH	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Surgical Oncology LGMP CB05 - OLGC BRACC SURGICAL ONCOLOGY	1211 Coolidge Blvd	Lafayette	LA	Active
DSH190002AJ	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Nephrology LGMP SC10 - OLGC NEPHROLOGY	1460 S College Rd	Lafayette	LA	Active
DSH190002AK	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Breast Ctr Surg Onc LGMP SC09 - OLGC BREAST CENTER BREAST SURGERY	1448 S College Rd	Lafayette	LA	Active
DSH190002AL	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Neurology LGMP HD01 - OLGC NEUROSCIENCE SUITE 100	136 Hospital Dr	Lafayette	LA	Active
DSH190002AM	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Hyperbarics LGMH CB11 - LGOH WOUND CARE	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002AN	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	OP Diagnostics LGMH CB05 - OLGH BRACC DIAGNOSTIC CLINIC	1211 Coolidge Boulevard	Lafayette	LA	Terminated
DSH190002AP	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Renal Dialysis LGOH AC02 - LGOH DIALYSIS	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002AQ	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Physical Therapy LGSH PR06 - LGSH PHYSICAL THERAPY	1000 West Pinhook Road	Lafayette	LA	Active
DSH190002AR	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Anesthesia LGSH PR06 - LGSH ANESTHESIOLOGY	1000 West Pinhook Road	Lafayette	LA	Active
DSH190002AS	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Laboratory LGSH PR06 - LGSH LABORATORY	1000 West Pinhook Road	Lafayette	LA	Active
DSH190002AT	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Occupational Therapy LGOH AC02 - LGOH OCCUPATIONAL THERAPY	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002AU	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Bariatric Program LGMH CB11 - LGSH BARIATRIC SURGERY CLASS	1000 West Pinhook Road	Lafayette	LA	Active
DSH190002AV	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Sleep Lab LGMH HD01 - OLGH SLEEP LAB SUITE 201	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002AW	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Radiation Oncology LGMH HD02 - OLGH RADIATION THERAPY	155 Hospital Drive	Lafayette	LA	Active
DSH190002AX	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Radiology LGSH PR06 - LGSH XRAY	1000 West Pinhook Road	Lafayette	LA	Active
DSH190002AY	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Speech Therapy LGOH AC02 - LGOH SPEECH THERAPY	2810 Ambassador Caffery Parkway	Lafayette	LA	ToBeTerminated
DSH190002AZ	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Laboratory LGOH AC02 - LGOH BLOOD BANK	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002B	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Coumadin LGMH CB11 - OLGH BRACC COUMADIN	1211 Coolidge Street	Lafayette	LA	Active
DSH190002BA	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	CCA Head & Neck LGMP CB05 - OLGC BRACC HEAD AND NECK SURGICAL ONCOLOGY	1211 Coolidge Boulevard	Lafayette	LA	ToBeTerminated
DSH190002BB	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Neurology LGMP HD01 - OLGC NEUROSCIENCE SUITE 303	155 Hospital Drive	Lafayette	LA	Active
DSH190002BC	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Neuro Diagnostic Svc LGMH CB11 - LGOH ELECTROENCEPHALOGRAPHY	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002BD	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	MRI LGOH AC02 - LGOH MRI	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002BE	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	CAT Scanner LGOH AC02 - LGOH CT SCAN	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002BF	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Ultrasound LGOH AC02 - LGOH ULTRASOUND	2810 Ambassador Caffery Parkway	Lafayette	LA	Active
DSH190002BG	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Laboratory LGMH CB11 - OLGH BRACC HEMATOLOGY ONCOLOGY LABORATORY	1211 Coolidge Boulevard	Lafayette	LA	Active
DSH190002BH	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Oncology CR03 - BRACC ONCOLOGY SURGICAL SPECIALTY	1305 Crowley Rayne Hwy	Crowley	LA	Active
DSH190002C	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	G I Lab LGMH CB11 - OLGH BRACC ENDO PRE/POST-OP	1211 Coolidge Street	Lafayette	LA	Active
DSH190002D	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Cancer Ctr Infusion LGMH CB05 - OLGH BRACC CHEMOTHERAPY INFUSION	1211 Coolidge Street	Lafayette	LA	Active
DSH190002E	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Imaging Center LGMH CB05 - OLGH BRACC CT SCAN IMAGING CENTER	1211 Coolidge Street	Lafayette	LA	Active
DSH190002F	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	MRI Diagnostics	1211 Coolidge Street	Lafayette	LA	Terminated
DSH190002G	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Cyberknife LGMH HD02 - OLGH RADIOSURGERY	155 Hospital Drive	Lafayette	LA	ToBeTerminated
DSH190002H	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Outpatient Lab	1211 Coolidge Street	Lafayette	LA	Terminated
DSH190002J	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Cancer Ctr Acadiana LGMP CB05 - OLGC BRACC HEMATOLOGY ONCOLOGY	1211 COOLIDGE BLVD	LAFAYETTE	LA	Active
DSH190002K	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Respiratory Therapy LGOH AC02 - LGOH OUTPATIENT RESPIRATORY THERAPY	2810 Ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002L	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Physical Therapy LGOH AC02 - LGOH PHYSICAL THERAPY	2810 Ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002M	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGSW Cath Lab	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002N	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Card Noninvasive Lab LGOH AC02 - LGOH ECHOCARDIOGRAPHY	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002P	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Nuclear Medicine LGOH AC02 - LGOH NUCLEAR MEDICINE	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002Q	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Radiology LGOH AC02 - LGOH XRAY	2810 Ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002R	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO Hyperbarics	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002S	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Emergency Med Svcs LGOH AC02 - LGOH EMERGENCY DEPARTMENT	2810 Ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002T	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO Recovery Room	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002U	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	General Surgery LGOH AC02 - LGOH INTRA-OP	2810 Ambassador caffery Pkwy	Lafayette	LA	Active
DSH190002V	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	Anesthesia LGOH AC02 - LGOH ANESTHESIOLOGY	2810 ambassador Caffery Pkwy	Lafayette	LA	Active
DSH190002W	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO Pre-Op	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002X	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO Day Surgery	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002Y	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGSW Card Cath Rehab	2810 Ambassador Caffery Pkwy	Lafayette	LA	Terminated
DSH190002Z	Child	DSH	LAFAYETTE GENERAL MEDICAL CENTER	LGO ICU	2810 Ambasador Caffery Pkwy	Lafayette	LA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/30/2021 12:00:00 AM	4/18/2022 1:21 PM
Details	State	Update	Termination Request	Active	To Be Terminated	4/18/2022 1:21 PM
Terminations	Termination Date	Update	Termination Request		7/1/2022 12:00:00 AM	4/18/2022 1:21 PM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	4/18/2022 1:21 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	4/18/2022 1:21 PM
Contacts	Primary Contact	Update	PC Change Request	Good, Rodney System Director of Pharmacy Lafayette General Medical Center 3372897888	Good, Rodney J AVP Pharmacy Ochsner Lafayette General 3372897888	4/13/2022 1:15 PM
Contacts	Authorizing Official	Update	AO Change Request	patin, al jude SVP, Chief Operating Officer Lafayette General Medical Center 3372897743	Patin, Al Jude Chief Executive Officer Lafayette General Medical Center 3373549334	11/4/2021 12:44 PM
Details	Last Recertification Date	Update	Recertification	8/23/2020 1:09:39 PM	8/16/2021 5:15:20 PM	8/16/2021 5:15 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0073009 (LA)		7/8/2021 3:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/8/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1730092	7/8/2021 3:22 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	7/8/2021 3:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		XHSP42102	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		914486200	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		3138858	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	7/7/2021 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		107886701	8/23/2020 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/23/2020 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2020 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00220138	8/23/2020 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	8/23/2020 1:09 PM
Medicaid Billing	NPI: State	Update	Recertification		LA	8/23/2020 1:09 PM
Contacts	Primary Contact	Update	Recertification	Robinson, Daniel Director Pharmacy Lafayette General Medical Center 3372897888	Good, Rodney System Director of Pharmacy Lafayette General Medical Center 3372897888	8/23/2020 1:09 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 8:39:02 PM	8/23/2020 1:09:39 PM	8/23/2020 1:09 PM
Contacts	Primary Contact	Update	Recertification	Bruno, Philip Director of Pharmacy Lafayette General Hospital 3372897888	Robinson, Daniel Director Pharmacy Lafayette General Medical Center 3372897888	8/21/2019 8:39 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 4:21:18 PM	8/21/2019 8:39:02 PM	8/21/2019 8:39 PM
Contacts	Authorizing Official	Update	Change Request	LeMaistre, Court McLeod Chief Operating Officer Lafayette General Health 3372897166	patin, al jude SVP, Chief Operating Officer Lafayette General Medical Center 3372897743	11/14/2018 1:45 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 10:31:53 AM	8/27/2018 4:21:18 PM	8/27/2018 4:21 PM
Contacts	Authorizing Official	Update	Change Request	GANDY, PATRICK CEO Lafayette General Medical Center 3372897475	LeMaistre, Court McLeod Chief Operating Officer Lafayette General Health 3372897166	8/7/2018 3:52 PM
Contacts	Primary Contact	Update	Change Request	Domingue, Shane Director of Pharmacy Lafayette GEneral Medical Center 3372897888	Bruno, Philip Director of Pharmacy Lafayette General Hospital 3372897888	8/7/2018 3:26 PM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/7/2017 10:31:53 AM	11/7/2017 10:31 AM
Contacts	Authorizing Official	Update		GANDY, PATRICK CEO 3372897475	GANDY, PATRICK CEO Lafayette General Medical Center 3372897475	9/28/2017 3:23 PM
Contacts	Primary Contact	Update		Domingue, Shane Director of Pharmacy 3372897888	Domingue, Shane Director of Pharmacy Lafayette GEneral Medical Center 3372897888	9/26/2017 6:37 PM
Contacts	Authorizing Official	Insert			GANDY, PATRICK CEO 3372897475	8/1/2017 11:38 AM
Contacts	Primary Contact	Insert			Domingue, Shane Director of Pharmacy 3372897888	8/1/2017 11:38 AM
Contacts	Signed By	Insert			GANDY, PATRICK CEO 3372897475	8/1/2017 11:38 AM
Addresses	Main Address	Insert			1211 Coolidge Street Second floor Lafayette, LA 70503	8/1/2017 11:38 AM
Medicaid Billing	NPI: Number	Insert			1275536799	1/10/2017 10:05 AM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 10:45 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 8:25 AM
Details	Last Recertification Date	Update		8/20/2013 7:05:31 AM	8/7/2014 12:00:00 AM	8/7/2014 8:10 AM
Details	Last Recertification Date	Update			8/20/2013 7:05:31 AM	8/20/2013 7:05 AM
Details	340B ID	Update		IS-FF-DSH190002H	DSH190002H	6/11/2013 9:12 AM
Dates	Participating Approval Date	Update			6/11/2013 12:00:00 AM	6/11/2013 9:12 AM
Details	State	Update		Pending	Active	6/11/2013 9:12 AM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	6/11/2013 9:12 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-FF-DSH190002H	5/14/2013 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2013 10:48 AM
Medicaid Billing	Medicaid: Number	Insert			0073009	4/12/2013 10:48 AM
Medicaid Billing	Medicaid: State	Insert			LA	4/12/2013 10:48 AM
Details	Last Recertification Date	Insert				4/12/2013 10:48 AM
Details	Grant Number	Insert				4/12/2013 10:48 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 10:48 AM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 10:48 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 10:48 AM
Details	Medicare Provider Number	Insert			190002	4/12/2013 10:48 AM
Details	Entity Name	Insert			LAFAYETTE GENERAL MEDICAL CENTER	4/12/2013 10:48 AM
Details	Program Code	Insert			DSH	4/12/2013 10:48 AM
Details	Entity Subname	Insert			Outpatient Lab	4/12/2013 10:48 AM
Dates	Participating Approval Date	Insert				4/12/2013 10:48 AM
Details	State	Insert			Pending	4/12/2013 10:48 AM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 10:48 AM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 10:48 AM
Dates	Start Date	Insert				4/12/2013 10:48 AM
Terminations	Termination Comments	Insert				4/12/2013 10:48 AM
Terminations	Termination Date	Insert				4/12/2013 10:48 AM
Terminations	Termination Effective Date	Insert				4/12/2013 10:48 AM
Terminations	Termination Reason	Insert				4/12/2013 10:48 AM