Covered Entity Details

DSH340047AD NORTH CAROLINA BAPTIST HOSPITAL (Active) - information as of 5/3/2025 11:27:42 PM

Main Details

Name

NORTH CAROLINA BAPTIST HOSPITAL

Subdivision Name

Brookstown Pain Management Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340047AD

Medicare Provider Number

340047

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/15/2013

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

North Carolina Baptist Hospital
Michael Thomas Waid, Sr Vice President - Health System Operations and Integration
(336) 716-0433

Primary Contact

North Carolina Baptist Hospital
Bibi W Wishart, Program Director, 340B
(336) 713-3426

Addresses

Street Address

605 Cotton St
Winston-Salem, NC 27101

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
NC	3400047	1144211301

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	422 GALLIMORE DAIRY RD	SUITE A	GREENSBORO	NC	27409	04/25/2018	07/01/2018	04/16/2018	05/18/2018
Contract Detail	ACCREDO HEALTH GROUP INC	422 GALLIMORE DAIRY RD	SUITE A	GREENSBORO	NC	27409	04/25/2018	07/01/2018	04/16/2018	06/11/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/25/2018	07/01/2018	04/16/2018	06/11/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/25/2018	07/01/2018	04/16/2018	06/11/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/25/2018	07/01/2018	04/16/2018	06/11/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/25/2018	07/01/2018	04/16/2018	06/11/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH340047AA	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Travel PBC	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AB	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Allergy PBC	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AC	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds Pulmonary	2311 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AD	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Brookstown Pain Management Clinic	605 Cotton St	Winston-Salem	NC	Active
DSH340047AE	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds Hematology	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AF	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Internal Medicine	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AG	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Pediatrics	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AH	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Benign Breast	2341 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AJ	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - ENT	2341 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AK	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds Endocrinology	2311 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AL	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds ENT	2341 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AM	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds Neurology	2311 Lewisville-Clemmons Rd	Clemmons	NC	Terminated
DSH340047AN	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Peds GI	2311 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AP	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Hem/Oncology	2311 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AQ	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - OB-GYN	2341 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AR	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Mam/Breast Care	2341 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AS	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Clemmons - Spine	2341 Lewisville-Clemmons Rd	Clemmons	NC	Active
DSH340047AT	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Hem/Onc - Mt Airy	450 Price Street	Mt Airy	NC	Active
DSH340047AU	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Diabetes & Endocrinology Center	4610 COUNTRY CLUB RD.	WINSTON SALEM	NC	Active
DSH340047AV	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	NEUROLOGY - CLEMMONS / General Neurology	2341 LEWISVILLE-CLEMMONS RD	CLEMMONS	NC	Terminated
DSH340047AW	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Hematology and Oncology - Elkin	401 Eldon Parks Dr	Elkin	NC	Active
DSH340047AX	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	VEIN SERVICES CLEMMONS	2341 LEWISVILLE-CLEMMONS RD	CLEMMONS	NC	Active
DSH340047AY	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Dialysis Access Group - Miller	120 Miller Street	Winston-Salem	NC	Active
DSH340047AZ	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	COMPREHENSIVE FETAL CARE CENTER	500 SHEPHERD ST.	WINSTON-SALEM	NC	Active
DSH340047BA	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Brenner Children's Specialty Services - Clemmons	2311 Lewisville-Clemmons Rd, 3rd Floor	Clemmons	NC	Terminated
DSH340047BB	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Neurology - Shepherd Street	500 Shepherd St.	Winston-Salem	NC	Active
DSH340047BC	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Outpatient Pre-Post Transplant Unit	140 CHARLOIS BLVD 2	WINSTON SALEM	NC	Terminated
DSH340047BD	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	OSC Minor Procedures Suite - Minor Procedures	131 Miller St.	Winston-Salem	NC	Active
DSH340047BE	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Hem-Onc-Premier - Hematology Oncology	4515 Premier Dr	High Point	NC	Terminated
DSH340047BF	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	DIABETES CTR ADULT MULTISPECIALTY - Diabetes Education	4610 COUNTRY CLUB RD	WINSTON SALEM	NC	Active
DSH340047BG	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	OBSTETRICS & GYNECOLOGY - Gynecology Oncology PBC	500 SHEPHERD ST	WINSTON SALEM	NC	Terminated
DSH340047BH	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Hematology and Oncology - Lexington - Hematology Oncology	107 W Medical Park Dr	Lexington	NC	Active
DSH340047BJ	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Colorectal Surgery-Shepherd - Colorectal Surgery	500 Shepherd Street	Winston-Salem	NC	Active
DSH340047BK	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Physical Medicine & Rehabilitation-Miller - Physical Medicine & Rehabilitation	131 Miller St	Winston-Salem	NC	Active
DSH340047BL	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	DIABETES CTR ADULT MULTISPECIALTY - Diabetes Education DHP	1200 N Martin Luther King Jr Dr	Winston-Salem	NC	Active
DSH340047BM	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	INTERNAL MEDICINE - CLEMMONS RHEUMATOLOGY	2311 LEWISVILLE CLEMMONS RD	CLEMMONS	NC	Active
DSH340047E	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Winston East Pediatric	2295 East 14th Street	Winston-Salem	NC	Active
DSH340047F	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	UIMA PBC	4614 Country Club Rd	Winston-Salem	NC	Terminated
DSH340047G	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Rheumatology PBC - Shepherd St.	500 Shepherd St.	Winston-Salem	NC	Terminated
DSH340047H	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Peds Diabetes PBC	4610 Country Club Rd.	Winston-Salem	NC	Active
DSH340047J	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Neurology Comp Rehab PBC	131 Miller St.	Winston-Salem	NC	Active
DSH340047K	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Rehab Neurology PBC	131 Miller St.	Winston-Salem	NC	Active
DSH340047L	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Otolaryngology PBC	131 Miller St.	Winston-Salem	NC	Active
DSH340047M	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Orthopedics PBC	131 Miller St.	Winston-Salem	NC	Active
DSH340047N	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	General Dermatology PBC	4618 Country Club Rd.	Winston-Salem	NC	Active
DSH340047P	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Dermatology Surgery PBC	4618 Country Club Rd.	Winston-Salem	NC	Active
DSH340047Q	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Family Medicine PBC	1920 W. First St.	Winston-Salem	NC	Terminated
DSH340047R	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	General Gynecology PBC	500 Shepherd St.	Winston-Salem	NC	Active
DSH340047S	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Shepherd St Central PBC	500 Shepherd St.	Winston-Salem	NC	Terminated
DSH340047T	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	DHP OB/GYN	1200 N Martin Luther King Jr Dr	Winston-Salem	NC	Active
DSH340047U	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	DHP Pediatrics	1200 N Martin Luther King Jr Dr	Winston-Salem	NC	Active
DSH340047V	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	DHP Adult	1200 N Martin Luther King Jr Dr	Winston-Salem	NC	Active
DSH340047W	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center	DHP Ophthalmology	1200 N. Martin Luther King Dr.	Winston-Salem	NC	Terminated
DSH340047X	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Cardiology PBC	4610 Country Club Rd.	Winston-Salem	NC	Active
DSH340047Y	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Endocrinology PBC	4610 Country Club Rd.	Winston-Salem	NC	Terminated
DSH340047Z	Child	DSH	NORTH CAROLINA BAPTIST HOSPITAL	Gastroenterology PBC	500 Shepherd St.	Winston-Salem	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	AO Change Request	Wishart, Bibi Program Director, 340B North Carolina Baptist Hospital 3367133426	Wishart, Bibi W Program Director, 340B North Carolina Baptist Hospital 3367133426	9/30/2024 9:45 AM
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:11:47 AM	8/23/2024 10:10:01 AM	8/23/2024 10:10 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 8:49:16 AM	8/16/2023 11:11:47 AM	8/16/2023 11:11 AM
Contacts	Primary Contact	Update	Profile Change Request	Wishart, Bibi System Manager, 340B North Carolina Baptist Hospital 3367133426	Wishart, Bibi Program Director, 340B North Carolina Baptist Hospital 3367133426	1/10/2023 4:36 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 8:46:37 AM	8/29/2022 8:49:16 AM	8/29/2022 8:49 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 9:17:16 AM	8/17/2021 8:46:37 AM	8/17/2021 8:46 AM
Contacts	Authorizing Official	Update	Change Request	Emmerich, Conrad Sr. Vice President,Hospital & Business Services North Carolina Baptist Hospital 3367168941	Waid, Michael Thomas Sr Vice President - Health System Operations and Integration North Carolina Baptist Hospital 3367160433	11/18/2020 8:18 AM
Medicaid Billing	NPI: State	Update	Recertification		NC	8/26/2020 9:17 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 8:08:53 AM	8/26/2020 9:17:16 AM	8/26/2020 9:17 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 1:14:58 PM	8/20/2019 8:08:53 AM	8/20/2019 8:08 AM
Contacts	Primary Contact	Update	Profile Change Request	Wishart, Bibi Interim Assistant Director North Carolina Baptist Hospital 3367133426	Wishart, Bibi System Manager, 340B North Carolina Baptist Hospital 3367133426	6/3/2019 12:07 PM
Contacts	Primary Contact	Update	Change Request	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL 3367139418	Wishart, Bibi Interim Assistant Director North Carolina Baptist Hospital 3367133426	9/26/2018 10:06 AM
Contacts	Authorizing Official	Update	Profile Change Request	Emmerich, Conrad Sr. Vice President,Hospital & Business Services North Carolina Baptist Hospital dba Wake Forest Baptist Medical Center 3367168941	Emmerich, Conrad Sr. Vice President,Hospital & Business Services North Carolina Baptist Hospital 3367168941	8/21/2018 8:56 AM
Details	Last Recertification Date	Update	Recertification	11/30/2017 5:12:18 PM	8/16/2018 1:14:58 PM	8/16/2018 1:14 PM
Details	Entity Name	Update	Change Request	NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center	NORTH CAROLINA BAPTIST HOSPITAL	8/15/2018 1:56 PM
Contacts	Primary Contact	Update	Profile Change Request	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center 3367139418	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL 3367139418	8/6/2018 1:58 PM
Contacts	Authorizing Official	Update	AO Change Request	High, Kevin P. Executive Vice President, Health Systems Affairs Wake Forest Baptist 3367166211	Emmerich, Conrad Sr. Vice President,Hospital & Business Services North Carolina Baptist Hospital dba Wake Forest Baptist Medical Center 3367168941	12/29/2017 7:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3400047	11/30/2017 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	11/30/2017 5:12 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/30/2017 5:12:18 PM	11/30/2017 5:12 PM
Contacts	Primary Contact	Update	Profile Change Request	Konopko, Martin System Manager 340b Wake Forest Baptist Health 3367139418	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center 3367139418	11/13/2017 12:04 PM
Contacts	Primary Contact	Update	Change Request	Orsborn, Adam Director or Pharmacy, Operations and Finance 3367166267	Konopko, Martin System Manager 340b Wake Forest Baptist Health 3367139418	10/1/2017 11:46 AM
Contacts	Authorizing Official	Update	Change Request	High, Kevin P. Executive Vice President, Health Systems Affairs 3367166211	High, Kevin P. Executive Vice President, Health Systems Affairs Wake Forest Baptist 3367166211	9/29/2017 1:12 PM
Contacts	Authorizing Official	Update		Carbone, Karen B. President, COO 3367166211	High, Kevin P. Executive Vice President, Health Systems Affairs 3367166211	8/14/2017 2:34 PM
Contacts	Signed By	Insert			MCCONNELL, JOHN D. CEO 3367163408	8/14/2017 2:33 PM
Addresses	Main Address	Insert			605 Cotton St Winston-Salem, NC 27101	8/14/2017 2:33 PM
Details	Entity Name	Update		NORTH CAROLINA BAPTIST HOSPITAL	NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center	8/14/2017 2:33 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 12:43 PM
Details	Last Recertification Date	Update		9/5/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 1:02 PM
Contacts	Primary Contact	Insert			Orsborn, Adam Director or Pharmacy, Operations and Finance 3367166267	4/27/2015 4:04 PM
Contacts	Authorizing Official	Update		Sibert, Thomas E. President, COO 3367166211	Carbone, Karen B. President, COO 3367166211	3/9/2015 10:13 AM
Details	Last Recertification Date	Update		9/11/2013 12:00:00 AM	9/5/2014 12:00:00 AM	9/5/2014 10:36 AM
Contacts	Authorizing Official	Insert			Sibert, Thomas E. President, COO 3367166211	7/1/2014 9:14 AM
Medicaid Billing	NPI: Number	Insert			1144211301	7/1/2014 8:57 AM
Details	Last Recertification Date	Update			9/11/2013 12:00:00 AM	9/11/2013 1:18 PM
Details	340B ID	Update		ISDMDSH340047AD	DSH340047AD	5/15/2013 1:40 PM
Dates	Participating Approval Date	Update			5/15/2013 12:00:00 AM	5/15/2013 1:40 PM
Details	State	Update		Pending	Active	5/15/2013 1:40 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/15/2013 1:40 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISDMDSH340047AD	4/26/2013 2:53 PM
Details	Last Recertification Date	Insert				4/15/2013 10:39 AM
Details	Grant Number	Insert				4/15/2013 10:39 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/15/2013 10:39 AM
Details	Is Authorizing Official EHB Data	Insert				4/15/2013 10:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2013 10:39 AM
Details	Medicare Provider Number	Insert			340047	4/15/2013 10:39 AM
Details	Entity Name	Insert			NORTH CAROLINA BAPTIST HOSPITAL	4/15/2013 10:39 AM
Details	Program Code	Insert			DSH	4/15/2013 10:39 AM
Details	Entity Subname	Insert			Brookstown Pain Management Clinic	4/15/2013 10:39 AM
Dates	Participating Approval Date	Insert				4/15/2013 10:39 AM
Details	State	Insert			Pending	4/15/2013 10:39 AM
Dates	Registration Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 10:39 AM
Dates	Signed By Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 10:39 AM
Dates	Start Date	Insert				4/15/2013 10:39 AM
Terminations	Termination Comments	Insert				4/15/2013 10:39 AM
Terminations	Termination Date	Insert				4/15/2013 10:39 AM
Terminations	Termination Effective Date	Insert				4/15/2013 10:39 AM
Terminations	Termination Reason	Insert				4/15/2013 10:39 AM