Covered Entity Details

DSH360112J MERCY HEALTH - ST. VINCENT MEDICAL CENTER (Active) - information as of 5/13/2025 11:06:44 PM

Main Details

Name

MERCY HEALTH - ST. VINCENT MEDICAL CENTER

Subdivision Name

Mercy Health - Perrysburg Cancer Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360112J

Medicare Provider Number

360112

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/9/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/15/2013

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Mercy Health - St. Vincent Mercy Medical Center
Michael Whipple, Hospital CFO
(419) 251-6935

Primary Contact

Bon Secours Mercy Health - St Vincent Medical Center
Phillip Nelson, Dir Pharmacy
(419) 251-2540

Addresses

Street Address

12623 Eckel Junction Road
Perrysburg, OH 43551

Billing Address

Mercy St Vincent Medical Center
2213 Cherry St
Toledo, OH 43608

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
OH	0227410	1154420560,1467493551,1891458303,1063175578

Shipping Addresses

Shipping Address 1

Mercy Health - St Vincent Medical Center - Perrysburg Pharmacy
12623 Eckel Junction Road
Perrysburg, OH 43551

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
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	04/14/2015	07/01/2015		09/06/2018	09/10/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH360112AA	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health-Physical Therapy/Sports Medicine Clinic	30335 OREGON RD	PERRYSBURG	OH	Terminated
DSH360112AB	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY CANCER CENTER - OREGON	3851 Navarre Ave	OREGON	OH	Terminated
DSH360112AC	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health - Ft. Meigs Outpatient Rehabilitation &Therapy	13415 ECKEL JUNCTION RD	PERRYSBURG	OH	Terminated
DSH360112AD	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health - Sunforest Ct Outpatient Rehabilitation & Therapy	3930 SUNFOREST CT 100	TOLEDO	OH	Terminated
DSH360112AE	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health Jefferson Ave Family Physicians – Gandy Surgery - Gandy Surgery	2200 Jefferson Ave	Toledo	OH	Active
DSH360112AF	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg Emergency Room - Emergency Room	12621 Eckel Junction Rd	Perrysburg	OH	Active
DSH360112AG	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health Franklin Ave Medical Center – OB/GYN - OB/GYN	2213 Franklin Ave 1st Fl	Toledo	OH	Active
DSH360112AH	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health Franklin Ave Medical Center – Pediatrics - Pediatrics	2213 Franklin Ave	Toledo	OH	Terminated
DSH360112AJ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health Franklin Ave Medical Center – Internal Medicine - Internal Medicine	2213 Franklin Ave 2nd Fl	Toledo	OH	Active
DSH360112AK	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health Jefferson Ave Family Physicians – Family Practice at Gandy - Family Practice	2200 Jefferson Ave	Toledo	OH	Active
DSH360112AL	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg Imaging Services - Imaging Services	12621 Eckel Junction Rd	Perrysburg	OH	Terminated
DSH360112AM	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Arrowhead Occupational Therapy - Occupational Therapy	1360 Arrowhead Dr	Maumee	OH	Terminated
DSH360112AN	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Sylvania Radiation Oncology - Sylvania Radiation Oncology	4126 N. Holland Sylvania Rd	Toledo	OH	Terminated
DSH360112AP	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg Radiation Oncology - Perrysburg Radiation Oncology	12623 Eckel Junction Road	Perrysburg	OH	Active
DSH360112AQ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric Cardiology - Pediatric Cardiology	2222 Cherry St	Toledo	OH	Terminated
DSH360112AR	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric Nephrology - Pediatric Nephrology	2222 Cherry St	Toledo	OH	Terminated
DSH360112AS	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric Hematology/Oncology - Pediatric Hematology/Oncology	2222 Cherry St	Toledo	OH	Terminated
DSH360112AT	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric Endocrinology - Pediatric Endocrinology	2222 Cherry St	Toledo	OH	Terminated
DSH360112AU	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg Stress Lab - Stress Lab	12621 Eckel Junction Road	Perrysburg	OH	Active
DSH360112AV	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg Nuclear Medicine - Nuclear Medicine	12623 Eckel Junction Road	Perrysburg	OH	Active
DSH360112AW	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health - Perrysburg Hospital - Perrysburg OR	12623 Eckel Junction Road	Perrysburg	OH	Active
DSH360112AX	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - MRI - MRI	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112AY	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - OPERATING ROOM - OPERATING ROOM	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112AZ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - EMERGENCY DEPARTMENT - EMERGENCY DEPARTMENT	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112D	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY CANCER CENTER AT ST. ANNE	3404 W. SYLVANIA AVENUE	TOLEDO	OH	Active
DSH360112DA	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH -SYLVANIA MEDICAL CENTER - EMERGENCY DEPARMENT - EMERGENCY DEPARMENT	3100 KING RD	TOLEDO	OH	Active
DSH360112DB	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - OPERATING ROOM - OPERATING ROOM	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DC	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - NUCLEAR MEDICINE - NUCLEAR MEDICINE	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DD	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - PULMONARY FUNCTION TESTING - PULMONARY FUNCTION TESTING	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DE	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - ULTRASOUND - ULTRASOUND	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DF	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - PACU - PACU	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DG	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - ENDOSCOPY - ENDOSCOPY	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DH	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - PULMONARY FUNCTION TESTING - PULMONARY FUNCTION TESTING	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DJ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - PAIN PROCEDURES - PAIN PROCEDURES	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DK	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - RADIOLOGY - RADIOLOGY	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DL	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - STRESS LAB - STRESS LAB	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DM	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - RADIOLOGY - RADIOLOGY	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DN	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - BEHAVIORAL HEALTH - BEHAVIORAL HEALTH	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DP	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - CT SCAN - CT SCAN	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DQ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - EMERGENCY DEPARTMENT - EMERGENCY DEPARTMENT	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DR	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - MAMMOGRAPHY - MAMMOGRAPHY	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DS	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - SPECIAL PROCEDURES - SPECIAL PROCEDURES	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DT	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - STRESS LAB - STRESS LAB	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DU	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - NUCLEAR MEDICINE - NUCLEAR MEDICINE	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DV	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MAUMEE INTERVENTIONAL PAIN MANAGEMENT - PAIN MANAGEMENT	1360 ARROWHEAD DR	MAUMEE	OH	Active
DSH360112DW	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - MRI - MRI	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DX	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. ANNE HOSPITAL - CATH LAB - CATH LAB	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112DY	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH - ST. CHARLES HOSPITAL - OP INFUSION - OP INFUSION	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112DZ	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH PERRYSBURG MEDICAL CTR - CATH LAB	12621 ECKEL JUNCTION RD	PERRYSBURG	OH	Active
DSH360112E	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Arrowhead Surgery Center	1360 Arrowhead	Maumee	OH	Terminated
DSH360112EA	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH-ST ANNE HOSPITAL - WOUND CARE	3404 W SYLVANIA AVE	TOLEDO	OH	Active
DSH360112EB	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH ST CHARLES HOSPITAL - WOUND CARE	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112EC	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH-ST CHARLES HOSPITAL - OUTPATIENT SURGERY	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112ED	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH ST CHARLES HOSPITAL - RADIOLOGY - CT	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112EE	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH ST CHARLES HOSPITAL - SPECIAL PROCEDURES	2600 NAVARRE AVE	OREGON	OH	Active
DSH360112EF	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	MERCY HEALTH LIGHTHOUSE WAY FAMILY - FAMILY MEDICINE	7045 LIGHTHOUSE WAY	PERRYSBURG	OH	Active
DSH360112F	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	St. Vincent Family Care Center	2213 Franklin Ave	Toledo	OH	Terminated
DSH360112G	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Family Practice at Gandy Center	2200 Jefferson Ave.	Toledo	OH	Terminated
DSH360112H	Child	DSH	MERCY ST VINCENT MEDICAL CENTER	Mercy Family Practice at St. Charles	2702 Navarre Ave	Oregon	OH	Terminated
DSH360112J	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Mercy Health - Perrysburg Cancer Center	12623 Eckel Junction Road	Perrysburg	OH	Active
DSH360112K	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Arrowhead / Imaging, Laboratory	500 The Boulevard	Maumee	OH	Terminated
DSH360112L	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Perrysburg / Perrysburg ED Imaging and Services	12621 Eckel Junction Rd	Perrysburg	OH	Terminated
DSH360112M	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric - Infectious Disease	2222 CHERRY ST SUITE 2600	TOLEDO	OH	Terminated
DSH360112N	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric Pulmonary	2222 Cherry St. Suite 2900	Toledo	OH	Terminated
DSH360112P	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric-Gastroenterology	2222 Cherry St. Suite 1600	Toledo	OH	Terminated
DSH360112Q	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric-Hematology/Oncology, Congenital Heart	2222 Cherry St Suite 2800	Toledo	OH	Terminated
DSH360112R	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric-Neurology	2222 Cherry St. Suite 2300	Toledo	OH	Terminated
DSH360112S	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pediatric-Urology	2222 Cherry St.	Toledo	OH	Terminated
DSH360112T	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	EKG	2400 Cherry St	Toledo	OH	Terminated
DSH360112U	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	CARDIAC CATH LAB	2400 Cherry St	Toledo	OH	Active
DSH360112V	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Electrophysiology Lab	2400 Cherry St	Toledo	OH	Active
DSH360112W	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Heart Failure Services	2400 Cherry St	Toledo	OH	Active
DSH360112X	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Vascular Lab	2400 Cherry St	Toledo	OH	Active
DSH360112Y	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pulmonary Function	2400 Cherry St	Toledo	OH	Active
DSH360112Z	Child	DSH	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	Pain Therapy	2222 Cherry St, Suite 800	Toledo	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	Nelson, Phillip Dir Pharmacy Bon Secours Mercy Health - St Vincent Medical Center 4192512540	11/5/2024 9:02 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0865194 (OH)		10/10/2024 11:39 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1316186315 (OH)		10/10/2024 11:39 AM
Contacts	Primary Contact	Update	PC Change Request	Nelson, Phillip Dir Pharmacy Bon Secours Mercy Health - St Vincent Medical Center 4192512540	Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	10/7/2024 2:53 PM
Details	Last Recertification Date	Update	Recertification	8/24/2023 3:12:10 PM	8/27/2024 2:08:18 PM	8/27/2024 2:08 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 1:24:24 PM	8/24/2023 3:12:10 PM	8/24/2023 3:12 PM
Contacts	Authorizing Official	Update	AO Change Request	Grosteffon, Brad CFO Toledo Market Mercy Health 4192510755	Whipple, Michael Hospital CFO Mercy Health - St. Vincent Mercy Medical Center 4192516935	7/28/2023 4:36 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0615534 (OH)		7/17/2023 2:11 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0655367 (OH)		7/17/2023 2:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033213616 (OH)		7/17/2023 2:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1518063429 (OH)		7/17/2023 2:11 PM
Contacts	Authorizing Official	Update	AO Change Request	Whipple, Michael Hospital CFO Mercy Health - St. Vincent Mercy Medical Center 4192516935	Grosteffon, Brad CFO Toledo Market Mercy Health 4192510755	7/10/2023 6:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891458303	8/31/2022 1:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/31/2022 1:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1063175578	8/31/2022 1:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/31/2022 1:24 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 10:53:51 AM	8/31/2022 1:24:24 PM	8/31/2022 1:24 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 1:30:35 PM	8/25/2021 10:53:51 AM	8/25/2021 10:53 AM
Addresses	Shipping Address	Delete	Change Request	Mercy St Vincent Medical Center 2213 Cherry St Toledo, OH 43608		11/25/2020 8:03 AM
Addresses	Shipping Address	Insert	Change Request		Mercy Health - St Vincent Medical Center - Perrysburg Pharmacy 12623 Eckel Junction Road Perrysburg, OH 43551	11/25/2020 8:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/29/2020 8:35 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0227410	9/29/2020 8:35 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	9/29/2020 8:35 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7649905 (OH)		9/29/2020 8:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1033213616	9/3/2020 1:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154420560	9/3/2020 1:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316186315	9/3/2020 1:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1467493551	9/3/2020 1:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518063429	9/3/2020 1:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1467493551 ( )		9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1316186315 ( )		9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1154420560 ( )		9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1518063429 ( )		9/3/2020 1:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1033213616 ( )		9/3/2020 1:30 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 2:24:37 PM	9/3/2020 1:30:35 PM	9/3/2020 1:30 PM
Details	Last Recertification Date	Update	Recertification	8/20/2018 2:08:30 PM	8/29/2019 2:24:37 PM	8/29/2019 2:24 PM
Contacts	Primary Contact	Update	Change Request	Tewers, Amy 340B Pharmacy Coordinator Mercy Health-St Vincent Medical Center 4192514789	Nelson, Phillip Dir Pharmacy Bon Secours Mercy Health - St Vincent Medical Center 4192512540	7/23/2019 9:40 AM
Contacts	Authorizing Official	Update	Change Request	Sinclair, Jennifer C Regional CFO Mercy 4192510755	Whipple, Michael Hospital CFO Mercy Health - St. Vincent Mercy Medical Center 4192516935	4/2/2019 1:19 PM
Addresses	Shipping Address	Insert	Change Request		Mercy St Vincent Medical Center 2213 Cherry St Toledo, OH 43608	3/19/2019 8:44 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1295839892 ( )		9/12/2018 11:20 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 3:44:02 PM	8/20/2018 2:08:30 PM	8/20/2018 2:08 PM
Contacts	Primary Contact	Update	Change Request	Screptock, Suzanne M. Medical Manager-Cancer Center Mercy Health - St Vincent Medical Center 4194071151	Tewers, Amy 340B Pharmacy Coordinator Mercy Health-St Vincent Medical Center 4192514789	8/10/2018 9:06 AM
Contacts	Authorizing Official	Update	Change Request	Whipple, Michael Hospital CFO Mercy Health - St. Vincent Mercy Medical Center 4192516935	Sinclair, Jennifer C Regional CFO Mercy 4192510755	3/13/2018 10:15 AM
Contacts	Authorizing Official	Update	Profile Change Request	Whipple, Michael Hospital CFO Mercy Health - St. Charles Hospital 4196965003	Whipple, Michael Hospital CFO Mercy Health - St. Vincent Mercy Medical Center 4192516935	1/10/2018 1:13 PM
Contacts	Authorizing Official	Update	Change Request	Grosteffon, Brad CFO Mercy Health St. Vincent Medical Center Mercy Health 4192516935	Whipple, Michael Hospital CFO Mercy Health - St. Charles Hospital 4196965003	12/13/2017 12:37 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	301555593 (MI)		12/13/2017 10:32 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	405172616 (MI)		12/13/2017 10:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0615534	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0655367	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0865194	12/7/2017 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	12/7/2017 9:53 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1518063429	12/7/2017 9:53 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1033213616	12/7/2017 9:53 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1295839892	12/7/2017 9:53 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/13/2017 3:44:02 PM	11/13/2017 3:44 PM
Contacts	Authorizing Official	Update	Change Request	Kline, Donald E. Chief Financial Officer, Markets 3308847118	Grosteffon, Brad CFO Mercy Health St. Vincent Medical Center Mercy Health 4192516935	10/10/2017 3:15 PM
Contacts	Primary Contact	Update	Change Request	Tewers, Amy 340B Pharmacy Coordinator 4192514789	Screptock, Suzanne M. Medical Manager-Cancer Center Mercy Health - St Vincent Medical Center 4194071151	9/25/2017 3:23 PM
Contacts	Signed By	Insert			Kline, Donald E. Chief Financial Officer, Northern Division 3308847118	8/14/2017 1:07 PM
Addresses	Main Address	Insert			12623 Eckel Junction Road Perrysburg, OH 43551	8/3/2017 7:44 PM
Addresses	Billing Address	Insert			Mercy St Vincent Medical Center 2213 Cherry St Toledo, OH 43608	8/3/2017 7:44 PM
Contacts	Primary Contact	Update		MEYER, STEVEN DIRECTOR OF PHARMACY SERVICES INTEGRATION 4192514507	Tewers, Amy 340B Pharmacy Coordinator 4192514789	8/3/2017 7:44 PM
Medicaid Billing	NPI: Number	Insert			1154420560	6/15/2017 1:09 PM
Details	Entity Name	Update		MERCY ST VINCENT MEDICAL CENTER	MERCY HEALTH - ST. VINCENT MEDICAL CENTER	2/17/2017 5:03 PM
Details	Entity Subname	Update		Mercy Cancer Center - Oregon	Mercy Health - Perrysburg Cancer Center	11/15/2016 12:22 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 1:59 PM
Contacts	Authorizing Official	Insert			Kline, Donald E. Chief Financial Officer, Markets 3308847118	3/31/2016 1:14 PM
Contacts	Primary Contact	Update		MEYER, STEVEN DIRECTOR OF PHARMACY SERVICES INTEGRATION 4192514507	MEYER, STEVEN DIRECTOR OF PHARMACY SERVICES INTEGRATION 4192514507	3/3/2016 11:18 AM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 2:51 PM
Contacts	Primary Contact	Insert			MEYER, STEVEN DIRECTOR OF PHARMACY SERVICES INTEGRATION 4192514507	8/4/2015 2:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/9/2015 2:51 PM
Medicaid Billing	Medicaid: Number	Insert			301555593	7/9/2015 2:51 PM
Medicaid Billing	Medicaid: State	Insert			MI	7/9/2015 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/9/2015 2:51 PM
Medicaid Billing	Medicaid: Number	Insert			405172616	7/9/2015 2:51 PM
Medicaid Billing	Medicaid: State	Insert			MI	7/9/2015 2:51 PM
Medicaid Billing	NPI: Number	Insert			1467493551	7/9/2015 2:51 PM
Medicaid Billing	NPI: Number	Insert			1316186315	7/9/2015 2:51 PM
Details	Last Recertification Date	Update			9/3/2014 12:00:00 AM	9/3/2014 1:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/17/2014 9:25 AM
Medicaid Billing	Medicaid: Number	Insert			7649905	6/17/2014 9:25 AM
Medicaid Billing	Medicaid: State	Insert			OH	6/17/2014 9:25 AM
Details	340B ID	Update		ISJMDSH360112I	DSH360112J	9/15/2013 10:37 PM
Dates	Participating Approval Date	Update			9/15/2013 12:00:00 AM	9/15/2013 10:37 PM
Details	State	Update		Pending	Active	9/15/2013 10:37 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/15/2013 10:37 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISJMDSH360112I	8/15/2013 3:41 PM
Details	Last Recertification Date	Insert				7/9/2013 8:28 AM
Details	Grant Number	Insert				7/9/2013 8:28 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/9/2013 8:28 AM
Details	Is Authorizing Official EHB Data	Insert				7/9/2013 8:28 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/9/2013 8:28 AM
Details	Medicare Provider Number	Insert			360112	7/9/2013 8:28 AM
Details	Entity Name	Insert			MERCY ST VINCENT MEDICAL CENTER	7/9/2013 8:28 AM
Details	Program Code	Insert			DSH	7/9/2013 8:28 AM
Details	Entity Subname	Insert			Mercy Cancer Center - Oregon	7/9/2013 8:28 AM
Dates	Participating Approval Date	Insert				7/9/2013 8:28 AM
Details	State	Insert			Pending	7/9/2013 8:28 AM
Dates	Registration Date	Insert			7/9/2013 12:00:00 AM	7/9/2013 8:28 AM
Dates	Signed By Date	Insert			7/9/2013 12:00:00 AM	7/9/2013 8:28 AM
Dates	Start Date	Insert				7/9/2013 8:28 AM
Terminations	Termination Comments	Insert				7/9/2013 8:28 AM
Terminations	Termination Date	Insert				7/9/2013 8:28 AM
Terminations	Termination Effective Date	Insert				7/9/2013 8:28 AM
Terminations	Termination Reason	Insert				7/9/2013 8:28 AM