Covered Entity Details

CAH521358-02 DOOR COUNTY MEMORIAL HOSPITAL (Active) - information as of 6/27/2025 12:24:11 AM

Main Details

Name

DOOR COUNTY MEMORIAL HOSPITAL

Subdivision Name

STURGEON BAY CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH521358-02

Medicare Provider Number

521358

Outpatient Facility Provider Number

528531

Additional Details

Current Program Status

Active

Registration Date

7/15/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/9/2013

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Door County Memorial Hospital
Brian C. Stephens, CEO
(920) 746-3737

Primary Contact

Door County Memorial Hospital
Amy Konop, Pharmacist
(920) 746-3633

Addresses

Street Address

323 SOUTH 18TH AVENUE
STURGEON BAY, WI 54235

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?
No

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
CAH521358-01	Child	CAH	DOOR COUNTY MEMORIAL HOSPITAL	SISTER BAY CLINIC	2345 CANTERBURY LANE	SISTER BAY	WI	Active
CAH521358-02	Child	CAH	DOOR COUNTY MEMORIAL HOSPITAL	STURGEON BAY CLINIC	323 SOUTH 18TH AVENUE	STURGEON BAY	WI	Active
CAH521358-03	Child	CAH	DOOR COUNTY MEMORIAL HOSPITAL	ALGOMA CLINIC	815 JEFFERSON STREET	ALGOMA	WI	Active
CAH521358-04	Child	CAH	DOOR COUNTY MEMORIAL HOSPITAL	WASHINGTON ISLAND CLINIC	910 MAIN RD.	WASHINGTON ISLAND	WI	Active
CAH521358-05	Child	CAH	DOOR COUNTY MEMORIAL HOSPITAL	DirectCare	911 GREEN BAY RD	STURGEON BAY	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 2:25:31 PM	8/14/2024 2:26:52 PM	8/14/2024 2:26 PM
Contacts	Primary Contact	Update	Profile Change Request	Konop, Amy Pharmacist Door County Memorial Hospital 9207463731	Konop, Amy Pharmacist Door County Memorial Hospital 9207463633	8/13/2024 2:20 PM
Contacts	Primary Contact	Update	Profile Change Request	Konop, Amy DIRECTOR OF PHARMACY Door County Memorial Hospital 9207463731	Konop, Amy Pharmacist Door County Memorial Hospital 9207463731	8/13/2024 2:20 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 10:36:45 AM	8/15/2023 2:25:31 PM	8/15/2023 2:25 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 5:13:05 PM	8/29/2022 10:36:45 AM	8/29/2022 10:36 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 11:18:21 AM	8/25/2021 5:13:05 PM	8/25/2021 5:13 PM
Contacts	Authorizing Official	Update	Profile Change Request	Stephens, Brian C. CFO Door County Memorial Hospital 9207463737	Stephens, Brian C. CEO Door County Memorial Hospital 9207463737	8/24/2021 11:40 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:45:44 PM	8/20/2020 11:18:21 AM	8/20/2020 11:18 AM
Details	Last Recertification Date	Update	Recertification	9/5/2018 10:48:08 AM	8/20/2019 12:45:44 PM	8/20/2019 12:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	32823300 (WI)		1/16/2019 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1578892857 ( )		1/16/2019 5:17 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 11:41:19 AM	9/5/2018 10:48:08 AM	9/5/2018 10:48 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/3/2017 11:41:19 AM	11/3/2017 11:41 AM
Contacts	Primary Contact	Update	Recertification	Konop, Amy DIRECTOR OF PHARMACY 9207463731	Konop, Amy DIRECTOR OF PHARMACY Door County Memorial Hospital 9207463731	10/25/2017 9:15 AM
Contacts	Authorizing Official	Update		Stephens, Brian C. CFO 9207463737	Stephens, Brian C. CFO Door County Memorial Hospital 9207463737	10/2/2017 12:09 PM
Contacts	Primary Contact	Update		Konop, Amy DIRECTOR OF PHARMACY 9207463731	Konop, Amy DIRECTOR OF PHARMACY 9207463731	3/1/2017 8:34 AM
Contacts	Signed By	Insert			SCIESZINSKI, ROBERT C. CFO 9207463636	3/1/2017 8:34 AM
Contacts	Authorizing Official	Insert			Stephens, Brian C. CFO 9207463737	3/1/2017 8:34 AM
Addresses	Main Address	Insert			323 SOUTH 18TH AVENUE STURGEON BAY, WI 54235	3/1/2017 8:34 AM
Details	Entity Subname	Update		NORTH SHORE MEDICAL - STURGEON BAY	STURGEON BAY CLINIC	3/1/2017 8:34 AM
Contacts	Primary Contact	Insert			Konop, Amy DIRECTOR OF PHARMACY 9207463731	8/17/2016 2:42 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 2:42 PM
Details	Last Recertification Date	Update		9/4/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/4/2014 11:51 AM
Medicaid Billing	Medicaid: Number	Insert			32823300	9/4/2014 11:51 AM
Medicaid Billing	Medicaid: State	Insert			WI	9/4/2014 11:51 AM
Medicaid Billing	NPI: Number	Insert			1578892857	9/4/2014 11:51 AM
Details	Last Recertification Date	Update			9/4/2014 12:00:00 AM	9/4/2014 11:51 AM
Dates	Participating Approval Date	Update			9/9/2013 12:00:00 AM	9/9/2013 11:23 AM
Details	State	Update		Pending	Active	9/9/2013 11:23 AM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/9/2013 11:23 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	CAH521358-02	8/14/2013 2:08 PM
Details	Last Recertification Date	Insert				7/15/2013 3:34 PM
Details	Grant Number	Insert				7/15/2013 3:34 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/15/2013 3:34 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2013 3:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2013 3:34 PM
Details	Medicare Provider Number	Insert			521358	7/15/2013 3:34 PM
Details	Entity Name	Insert			DOOR COUNTY MEMORIAL HOSPITAL	7/15/2013 3:34 PM
Details	Program Code	Insert			CAH	7/15/2013 3:34 PM
Details	Entity Subname	Insert			NORTH SHORE MEDICAL - STURGEON BAY	7/15/2013 3:34 PM
Dates	Participating Approval Date	Insert				7/15/2013 3:34 PM
Details	State	Insert			Pending	7/15/2013 3:34 PM
Dates	Registration Date	Insert			7/15/2013 12:00:00 AM	7/15/2013 3:34 PM
Dates	Signed By Date	Insert			7/15/2013 12:00:00 AM	7/15/2013 3:34 PM
Dates	Start Date	Insert				7/15/2013 3:34 PM
Terminations	Termination Comments	Insert				7/15/2013 3:34 PM
Terminations	Termination Date	Insert				7/15/2013 3:34 PM
Terminations	Termination Effective Date	Insert				7/15/2013 3:34 PM
Terminations	Termination Reason	Insert				7/15/2013 3:34 PM