| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 4/15/2025 9:08 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1164628426 | 4/15/2025 9:08 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MI | 4/15/2025 9:08 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1164628426 | 4/15/2025 9:08 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 4/15/2025 9:08 AM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2023 9:40:29 AM | 8/20/2024 9:33:22 AM | 8/20/2024 9:33 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 9:32:41 AM | 8/15/2023 9:40:29 AM | 8/15/2023 9:40 AM |
| Details | Entity Subname | Update | Change Request | OMH Medical Group - Gaylord | OMH Medical Group Family Practice - Gaylord | 4/18/2023 8:23 AM |
| Contacts | Authorizing Official | Update | Change Request | Maly, Kathleen Maly
Interim Chief Financial Officer
Munson Healthcare
2488851252 | LaRaia, Kathleen M
Vice President
Munson Healthcare
2313928410 | 3/22/2023 12:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/15/2021 8:42:08 AM | 8/29/2022 9:32:41 AM | 8/29/2022 9:32 AM |
| Contacts | Authorizing Official | Update | Change Request | Maitland, Alicia
CFO
Munson Healthcare
2319357840 | Maly, Kathleen Maly
Interim Chief Financial Officer
Munson Healthcare
2488851252 | 7/28/2022 11:03 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Niemi, Sam Patrick
Manager Reimbursement
Munson Healthcare
2319357761 | Niemi, Sam Patrick
System Director Reimbursement
Munson Healthcare
2319357761 | 5/2/2022 12:31 PM |
| Contacts | Primary Contact | Update | Recertification | DELUCA, KAY HANNA
DIRECTOR, PHARMACY
Otsego Memorial Hospital
9897312138 | Niemi, Sam Patrick
Manager Reimbursement
Munson Healthcare
2319357761 | 9/15/2021 8:42 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2020 8:08:40 AM | 9/15/2021 8:42:08 AM | 9/15/2021 8:42 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Hepler, Mark
CFO
Munson Healthcare
2319356702 | Maitland, Alicia
CFO
Munson Healthcare
2319357840 | 6/23/2021 9:52 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Lemon, Thomas R
President & CEO
Munson Healthcare Otsego Memorial Hospital
9897312215 | Hepler, Mark
CFO
Munson Healthcare
2319356702 | 4/7/2021 9:10 AM |
| Addresses | Shipping Address | Delete | Recertification | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49738 | | 8/18/2020 8:08 AM |
| Addresses | Shipping Address | Insert | Recertification | | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49735 | 8/18/2020 8:08 AM |
| Addresses | Main Address | Update | Recertification |
829 N CENTER AVE
GAYLORD, MI 49738 |
829 N CENTER AVE
GAYLORD, MI 49735 | 8/18/2020 8:08 AM |
| Addresses | Billing Address | Update | Recertification | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49738 | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49735 | 8/18/2020 8:08 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2019 6:22:56 AM | 8/18/2020 8:08:40 AM | 8/18/2020 8:08 AM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2018 6:11:44 AM | 9/9/2019 6:22:56 AM | 9/9/2019 6:22 AM |
| Contacts | Authorizing Official | Update | AO Change Request | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
Otsego Memorial Hospital
9897312215 | Lemon, Thomas R
President & CEO
Munson Healthcare Otsego Memorial Hospital
9897312215 | 9/3/2019 10:58 AM |
| Details | Entity Name | Update | Change Request | OTSEGO MEMORIAL HOSPITAL | MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL | 9/14/2018 8:31 AM |
| Details | Last Recertification Date | Update | Recertification | 11/6/2017 5:53:51 AM | 8/15/2018 6:11:44 AM | 8/15/2018 6:11 AM |
| Details | Entity Subname | Update | Change Request | MEDGRP | OMH Medical Group - Gaylord | 7/25/2018 3:25 PM |
| Details | Last Recertification Date | Update | Recertification | 10/25/2017 5:58:44 AM | 11/6/2017 5:53:51 AM | 11/6/2017 5:53 AM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 10/25/2017 5:58:44 AM | 10/25/2017 5:58 AM |
| Contacts | Primary Contact | Update | | DELUCA, KAY HANNA
DIRECTOR, PHARMACY
9897312138 | DELUCA, KAY HANNA
DIRECTOR, PHARMACY
Otsego Memorial Hospital
9897312138 | 10/16/2017 8:33 AM |
| Contacts | Authorizing Official | Update | | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
9897312215 | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
Otsego Memorial Hospital
9897312215 | 10/3/2017 7:03 AM |
| Contacts | Authorizing Official | Update | | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
9897312215 | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
9897312215 | 9/11/2017 3:29 PM |
| Contacts | Authorizing Official | Insert | | | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
9897312215 | 8/9/2017 11:54 AM |
| Contacts | Signed By | Insert | | | LEMON, THOMAS
CHIEF EXECUTIVE OFFICER
9897312215 | 8/9/2017 11:54 AM |
| Contacts | Primary Contact | Insert | | | DELUCA, KAY HANNA
DIRECTOR, PHARMACY
9897312138 | 7/12/2017 11:18 AM |
| Addresses | Main Address | Insert | | |
829 N CENTER AVE
GAYLORD, MI 49738 | 6/28/2017 12:46 PM |
| Addresses | Billing Address | Insert | | | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49738 | 6/28/2017 12:46 PM |
| Addresses | Shipping Address | Insert | | | Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49738 | 6/28/2017 12:46 PM |
| Details | Last Recertification Date | Update | | 8/5/2015 12:00:00 AM | 8/10/2016 12:00:00 AM | 8/10/2016 12:04 PM |
| Details | Last Recertification Date | Update | | 8/7/2014 12:00:00 AM | 8/5/2015 12:00:00 AM | 8/5/2015 2:50 PM |
| Details | Last Recertification Date | Update | | | 8/7/2014 12:00:00 AM | 8/7/2014 10:56 AM |
| Dates | Participating Approval Date | Update | | | 9/9/2013 12:00:00 AM | 9/9/2013 12:22 PM |
| Details | State | Update | | Pending | Active | 9/9/2013 12:22 PM |
| Dates | Start Date | Update | | | 10/1/2013 12:00:00 AM | 9/9/2013 12:22 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | SCH230133-02 | 8/2/2013 8:06 AM |
| Details | Entity Subname | Update | | OMH MEDGRP | MEDGRP | 8/2/2013 8:06 AM |
| Details | Last Recertification Date | Insert | | | | 7/12/2013 11:14 AM |
| Details | Grant Number | Insert | | | | 7/12/2013 11:14 AM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 7/12/2013 11:14 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/12/2013 11:14 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/12/2013 11:14 AM |
| Details | Medicare Provider Number | Insert | | | 230133 | 7/12/2013 11:14 AM |
| Details | Entity Name | Insert | | | OTSEGO MEMORIAL HOSPITAL | 7/12/2013 11:14 AM |
| Details | Program Code | Insert | | | SCH | 7/12/2013 11:14 AM |
| Details | Entity Subname | Insert | | | OMH MEDGRP | 7/12/2013 11:14 AM |
| Dates | Participating Approval Date | Insert | | | | 7/12/2013 11:14 AM |
| Details | State | Insert | | | Pending | 7/12/2013 11:14 AM |
| Dates | Registration Date | Insert | | | 7/12/2013 12:00:00 AM | 7/12/2013 11:14 AM |
| Dates | Signed By Date | Insert | | | 7/12/2013 12:00:00 AM | 7/12/2013 11:14 AM |
| Dates | Start Date | Insert | | | | 7/12/2013 11:14 AM |
| Terminations | Termination Comments | Insert | | | | 7/12/2013 11:14 AM |
| Terminations | Termination Date | Insert | | | | 7/12/2013 11:14 AM |
| Terminations | Termination Effective Date | Insert | | | | 7/12/2013 11:14 AM |
| Terminations | Termination Reason | Insert | | | | 7/12/2013 11:14 AM |