Covered Entity Details

DSH370028C INTEGRIS BAPTIST MEDICAL CENTER (Active) - information as of 5/7/2025 10:48:04 PM

Main Details

Name

INTEGRIS BAPTIST MEDICAL CENTER

Subdivision Name

INTEGRIS COMPREHENSIVE BREAST CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH370028C

Medicare Provider Number

370028

Outpatient Facility Provider Number

370028

Additional Details

Current Program Status

Active

Registration Date

12/19/2019

Participating Start Date

1/1/2020

Participating Approval Date

12/26/2019

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

INTEGRIS Health
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842

Primary Contact

INTEGRIS Health
Christopher K. Yang, 340B Coordinator
(405) 795-2545

Addresses

Street Address

3525 NW 56TH STREET
SUITE C100
Oklahoma City, OK 73112

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
OK	100806400C,100699740B,100690810A	1831663657,1831103654

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
DSH370028A	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER, INC.	INTEGRIS SAMARITAN INFUSION	3500 NW 56TH, SUITE 201	OKLAHOMA CITY	OK	Terminated
DSH370028AA	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Portland Avenue Campus - Anesthesiology Services	5501 N. Portland Ave	OKLAHOMA CITY	OK	Active
DSH370028AB	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - PHYSICAL MEDICINE	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AC	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - DIAGNOSTIC CARDIOLOGY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AD	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - NEURO-DIAGNOSTIC SERVICE	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AE	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - MRI	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AF	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Portland Avenue Campus - Labor & Delivery	5501 N. Portland Ave	OKLAHOMA CITY	OK	Terminated
DSH370028AG	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - WOUND CARE CENTER	5700 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AH	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - COMPUTED TOMOGRAPHY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AJ	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS ADVANCED CARDIAC CARE - PULMONARY HYPERTENSION	3400 NW EXPRESSWAY, Building C	OKLAHOMA CITY	OK	Active
DSH370028AK	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - EMERGENCY ROOM	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AL	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - HEART ACQUISITION	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Terminated
DSH370028AM	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS HEART HOSPITAL - NUCLEAR CARDIOLOGY	3433 NW 56TH BUILDING B	OKLAHOMA CITY	OK	Active
DSH370028AN	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - INTERVENTIONAL RADIOLOGY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AP	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - ANATOMIC PATHOLOGY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028AQ	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - PANCREAS ACQUISITION	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Active
DSH370028AR	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - RADIATION THERAPY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AS	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - AMBULATORY INFUSION CENTER	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AT	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	MEDICATION MANAGEMENT CLINIC AND SERVICES	3300 NW Expressway	OKLAHOMA CITY	OK	Active
DSH370028AU	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - ANATOMIC PATHOLOGY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AV	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - COMPUTED TOMOGRAPHY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AW	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - CLINICAL LABORATORY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AX	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - NUCLEAR MEDICINE	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AY	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - ULTRASONOGRAPHY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028AZ	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - KIDNEY ACQUISITION	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Active
DSH370028B	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA (ICIO)	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028BA	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - LUNG ACQUISITION	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Active
DSH370028BB	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - AMBULATORY INFUSION CENTER	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BC	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - BLOOD BANK/TRANSFUSION	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BD	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - ENDOSCOPY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BE	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Portland Avenue Campus - Hemodialysis	5501 N. Portland Ave	OKLAHOMA CITY	OK	Terminated
DSH370028BF	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - ULTRASONOGRAPHY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BG	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - CLINICAL LABORATORY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BH	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Portland Avenue Campus - Mammography	5501 N. Portland Ave	OKLAHOMA CITY	OK	Terminated
DSH370028BJ	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - NUCLEAR MEDICINE	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BK	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - PULMONARY MEDICINE	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BL	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - DIAGNOSTIC RADIOLOGY	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BM	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - MAIN OR	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BN	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - SURGICAL ADMISSION UNIT	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028BP	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - HEMATOLOGY/ONCOLOGY CLINIC	5915 WEST MEMORIAL ROAD	Oklahoma City	OK	Active
DSH370028C	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS COMPREHENSIVE BREAST CENTER	3525 NW 56TH STREET	Oklahoma City	OK	Active
DSH370028D	Child	DSH	INTEGRIS Baptist Medical Center	INTEGRIS Cardiolgy Cath and Nuclear Lab	3433 NW 56th Street, Suite 500	Oklahoma City	OK	Terminated
DSH370028E	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS Baptist Medical Center Surgery Center	3433 Northwest 56th Street, Suite 300	OKLAHOMA CITY	OK	Terminated
DSH370028F	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS Baptist Medical Center - Kidney Clinic	3400 NW EXPRESSWAY SUITE 700	OKLAHOMA CITY	OK	Terminated
DSH370028G	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS BAPTIST MEDICAL CENTER - SLEEP MEDICINE	3300 NW 56TH STREET	Oklahoma City	OK	Active
DSH370028H	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS Baptist Medical Center - Cardiovascular Imaging	3433 NW 56TH STREET, SUITE 380	OKLAHOMA CITY	OK	Terminated
DSH370028J	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - JIM THORPE OUTPATIENT REHABILITATION	5915 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Terminated
DSH370028L	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS BAPTIST MEDICAL CENTER - / Advanced Cardiac Care	3400 NW EXPRESSWAY	OKLAHOMA CITY	OK	Terminated
DSH370028M	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS HEART HOSPITAL - DIAGNOSTIC CARDIOLOGY	3433 NW 56TH BUILDING B	OKLAHOMA CITY	OK	Active
DSH370028N	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	CARDIAC REHABILITATION - CARDIOPULMONARY REHAB	3433 NW 56TH BUILDING B	OKLAHOMA CITY	OK	Active
DSH370028P	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - LUNG POST TRANSPLANT	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Active
DSH370028Q	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Nazih Zuhdi Transplant Institute - Heart Post Transplant	3400 NW Expressway Building C	OKLAHOMA CITY	OK	Terminated
DSH370028R	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS Advanced Cardiac Care - Heart Failure Center	3400 NW Expressway Building C	OKLAHOMA CITY	OK	Terminated
DSH370028S	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - CARDIOPULMONARY REHAB	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028T	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS BAPTIST MEDICAL CENTER - CATH LAB/ANGIOGRAPHY	3433 NW 56TH STREET	OKLAHOMA CITY	OK	Active
DSH370028U	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	NAZIH ZUHDI TRANSPLANT INSTITUTE - KIDNEY/PANCREAS POST TRANSPLANT	3400 NW EXPRESSWAY BUILDING C	OKLAHOMA CITY	OK	Active
DSH370028V	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - MRI	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active
DSH370028W	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	Portland Avenue Campus - Cath lab/angiography	5501 N. Portland Ave	OKLAHOMA CITY	OK	Terminated
DSH370028X	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS CANCER INSTITUTE OF OKLAHOMA - DIAGNOSTIC RADIOLOGY	5911 WEST MEMORIAL ROAD	OKLAHOMA CITY	OK	Active
DSH370028Y	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	INTEGRIS BAPTIST MEDICAL CENTER - JIM THORPE OUTPATIENT REHAB	5300 N INDEPENDENCE AVENUE	OKLAHOMA CITY	OK	Active
DSH370028Z	Child	DSH	INTEGRIS BAPTIST MEDICAL CENTER	PORTLAND AVENUE CAMPUS - PACU	5501 N PORTLAND AVE	OKLAHOMA CITY	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Dooley, Ryan Dale 340B Compliance Manager INTEGRIS Health 4058026057	Yang, Christopher K. 340B Coordinator INTEGRIS Health 4057952545	11/7/2024 7:55 AM
Addresses	Main Address	Update	Recertification	3525 NW 56th St, Ste C100 Oklahoma City, OK 73112	3525 NW 56TH STREET SUITE C100 Oklahoma City, OK 73112	8/29/2024 12:42 PM
Details	Last Recertification Date	Update	Recertification	8/23/2023 3:53:54 PM	8/29/2024 12:42:37 PM	8/29/2024 12:42 PM
Details	Entity Subname	Update	Recertification	INTEGRIS Comprehensive Breast Center	INTEGRIS COMPREHENSIVE BREAST CENTER	8/29/2024 12:42 PM
Contacts	Primary Contact	Update	Group Change Request	Wilkinson, Anja 340B Compliance Director Integris Health 9182316358	Dooley, Ryan Dale 340B Compliance Manager INTEGRIS Health 4058026057	9/8/2023 1:47 PM
Details	Last Recertification Date	Update	Recertification	9/2/2022 8:59:57 AM	8/23/2023 3:53:54 PM	8/23/2023 3:53 PM
Contacts	Authorizing Official	Update	Profile Change Request	Lunday, Georg F. Chief Pharmacy Officer INTEGRIS Health 4059493039	Lunday, Georg F. Chief Pharmacy Officer INTEGRIS Health 4054014842	4/12/2023 1:32 PM
Contacts	Primary Contact	Update	Profile Change Request	Wilkinson, Anja 340B Compliance Director Integris Health 4056446998	Wilkinson, Anja 340B Compliance Director Integris Health 9182316358	4/4/2023 10:16 AM
Contacts	Authorizing Official	Update	Change Request	Hubbard, Brent Chief Operating Officer INTEGRIS Health 4059493502	Lunday, Georg F. Chief Pharmacy Officer INTEGRIS Health 4059493039	9/9/2022 12:05 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 2:13:22 PM	9/2/2022 8:59:57 AM	9/2/2022 8:59 AM
Contacts	Authorizing Official	Update	Change Request	Hammes, Chris Executive Vice President INTEGRIS Health System 4059493400	Hubbard, Brent Chief Operating Officer INTEGRIS Health 4059493502	6/9/2022 8:24 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 3:43:29 PM	8/23/2021 2:13:22 PM	8/23/2021 2:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100699740B	9/3/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/3/2020 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100690810A	9/3/2020 3:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/3/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831103654	9/3/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/3/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831663657	9/3/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/3/2020 3:43 PM
Details	Last Recertification Date	Update	Recertification		9/3/2020 3:43:29 PM	9/3/2020 3:43 PM
Contacts	Authorizing Official	Update	Change Request	Van Meter, Rex P. COO INTEGRIS Baptist 4057177963	Hammes, Chris Executive Vice President INTEGRIS Health System 4059493400	2/3/2020 1:13 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Update	Reinstatement	Johnsen, Tim President 4059518110	Van Meter, Rex P. COO INTEGRIS Baptist 4057177963	12/26/2019 1:40 PM
Contacts	Primary Contact	Update	Reinstatement	Lunday, Georg F. Admin. System Director INTEGRIS Health 4059493039	Wilkinson, Anja 340B Compliance Director Integris Health 4056446998	12/26/2019 1:40 PM
Details	Last Recertification Date	Update	Reinstatement	8/18/2016 12:00:00 AM		12/26/2019 1:40 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	11/28/2016 12:00:00 AM		12/26/2019 1:40 PM
Details	Entity Name	Update	Reinstatement	INTEGRIS BAPTIST MEDICAL CENTER, INC.	INTEGRIS BAPTIST MEDICAL CENTER	12/26/2019 1:40 PM
Dates	Participating Approval Date	Update	Reinstatement	9/15/2013 12:00:00 AM	12/26/2019 1:40:15 PM	12/26/2019 1:40 PM
Details	State	Update	Reinstatement	Terminated	Approved	12/26/2019 1:40 PM
Dates	Registration Date	Update	Reinstatement	7/9/2013 12:00:00 AM	12/19/2019 3:44:49 PM	12/26/2019 1:40 PM
Dates	Signed By Date	Update	Reinstatement	7/9/2013 12:00:00 AM	12/20/2019 7:26:35 AM	12/26/2019 1:40 PM
Dates	Start Date	Update	Reinstatement	10/1/2013 12:00:00 AM	1/1/2020 12:00:00 AM	12/26/2019 1:40 PM
Terminations	Termination Date	Update	Reinstatement	1/1/2017 12:00:00 AM		12/26/2019 1:40 PM
Terminations	Termination Effective Date	Update	Reinstatement	11/28/2016 12:00:00 AM		12/26/2019 1:40 PM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		12/26/2019 1:40 PM
Contacts	Authorizing Official	Update	Reinstatement	Johnsen, Tim President 4059518110	Van Meter, Rex P. COO INTEGRIS Baptist 4057177963	11/15/2019 1:56 PM
Contacts	Primary Contact	Update		Lunday, Georg F. Admin. System Director 4059493039	Lunday, Georg F. Admin. System Director INTEGRIS Health 4059493039	10/6/2017 4:14 PM
Contacts	Primary Contact	Insert			Lunday, Georg F. Admin. System Director 4059493039	5/5/2017 12:03 PM
Contacts	Authorizing Official	Insert			Johnsen, Tim President 4059518110	12/12/2016 1:08 PM
Contacts	Signed By	Insert			Johnsen, Tim President 4059518110	12/12/2016 1:08 PM
Addresses	Main Address	Insert			3525 NW 56th St, Ste C100 Oklahoma City, OK 73112	12/12/2016 1:07 PM
Dates	Last Date That 340B Drugs Purchased	Update			11/28/2016 12:00:00 AM	12/12/2016 1:07 PM
Details	State	Update		Active	Terminated	12/12/2016 1:07 PM
Terminations	Termination Date	Update			1/1/2017 12:00:00 AM	12/12/2016 1:07 PM
Terminations	Termination Effective Date	Update			11/28/2016 12:00:00 AM	12/12/2016 1:07 PM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	12/12/2016 1:07 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 4:21 PM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 10:05 AM
Details	Last Recertification Date	Update			8/7/2014 12:00:00 AM	8/7/2014 2:26 PM
Details	340B ID	Update		ISJMDSH370028C	DSH370028C	9/15/2013 10:42 PM
Dates	Participating Approval Date	Update			9/15/2013 12:00:00 AM	9/15/2013 10:42 PM
Details	State	Update		Pending	Active	9/15/2013 10:42 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/15/2013 10:42 PM
Details	340B ID	Update		JMDSH370028C	ISJMDSH370028C	8/13/2013 10:58 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	JMDSH370028C	8/7/2013 5:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/9/2013 3:37 PM
Medicaid Billing	Medicaid: Number	Insert			100806400C	7/9/2013 3:37 PM
Medicaid Billing	Medicaid: State	Insert			OK	7/9/2013 3:37 PM
Details	Last Recertification Date	Insert				7/9/2013 3:37 PM
Details	Grant Number	Insert				7/9/2013 3:37 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/9/2013 3:37 PM
Details	Is Authorizing Official EHB Data	Insert				7/9/2013 3:37 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/9/2013 3:37 PM
Details	Medicare Provider Number	Insert			370028	7/9/2013 3:37 PM
Details	Entity Name	Insert			INTEGRIS BAPTIST MEDICAL CENTER, INC.	7/9/2013 3:37 PM
Details	Program Code	Insert			DSH	7/9/2013 3:37 PM
Details	Entity Subname	Insert			INTEGRIS Comprehensive Breast Center	7/9/2013 3:37 PM
Dates	Participating Approval Date	Insert				7/9/2013 3:37 PM
Details	State	Insert			Pending	7/9/2013 3:37 PM
Dates	Registration Date	Insert			7/9/2013 12:00:00 AM	7/9/2013 3:37 PM
Dates	Signed By Date	Insert			7/9/2013 12:00:00 AM	7/9/2013 3:37 PM
Dates	Start Date	Insert				7/9/2013 3:37 PM
Terminations	Termination Comments	Insert				7/9/2013 3:37 PM
Terminations	Termination Date	Insert				7/9/2013 3:37 PM
Terminations	Termination Effective Date	Insert				7/9/2013 3:37 PM
Terminations	Termination Reason	Insert				7/9/2013 3:37 PM