Covered Entity Details

DSH310019K St. Joseph’s University Medical Center (Active) - information as of 5/26/2025 12:52:53 AM

Main Details

Name

St. Joseph’s University Medical Center

Subdivision Name

St. Joseph's Cardiovascular Center - Wayne

Type

Disproportionate Share Hospital

Rural

340B ID

DSH310019K

Medicare Provider Number

310019

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2013

Participating Start Date

1/1/2014

Participating Approval Date

11/17/2013

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

St. Joseph's Health
Robert Joseph Nesselbush, Chief Financial Officer
(973) 754-2023

Primary Contact

St. Joseph’s University Medical Center
Alexander Lee, 340B Program Manager
(973) 754-4823

Addresses

Street Address

246 Hamburg Turnpike
Suite 201
Wayne, NJ 07470

Billing Address

St. Joseph's Hospital and Medical Center
703 Main Street
Paterson, NJ 07503

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
NJ	4136403	1669462420
CT	3024783	1669462420
FL	092525000	1669462420
PA	0009472940006	1669462420
TN	Q049230	1669462420
OK	200308250A	1669462420
VT	0310019	1669462420
AK		1669462420
AZ		1669462420
AR		1669462420
CA		1669462420
CO		1669462420
DE		1669462420
GA		1669462420
HI		1669462420
ID		1669462420
IN		1669462420
IA		1669462420
KS		1669462420
LA		1669462420
ME		1669462420
MD		1669462420
MI		1669462420
MN		1669462420
MS		1669462420
MO		1669462420
MT		1669462420
NE		1669462420
NH		1669462420
NM		1669462420
NY		1669462420
NC		1669462420
ND		1669462420
OR		1669462420
RI		1669462420
SD		1669462420
TX		1669462420
UT		1669462420
VI		1669462420
VA		1669462420
WA		1669462420
DC		1669462420
WV		1669462420
WI		1669462420
WY		1669462420

Shipping Addresses

Shipping Address 1

St. Joseph's Hospital and Medical Center
703 Main Street
Paterson, NJ 07503

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
DSH310019A	Child	DSH	St. Joseph's Hospital and Medical Center	Great Falls	11 Getty Avenue	Paterson	NJ	Terminated
DSH310019AA	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Podiatry	11 Getty Avenue	Paterson	NJ	Active
DSH310019AB	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Plastic Surgery	11 Getty Avenue	Paterson	NJ	Active
DSH310019AC	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Neurology/Stroke	11 Getty Avenue	Paterson	NJ	Active
DSH310019AD	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic - Breast	11 Getty Avenue	Paterson	NJ	Active
DSH310019AE	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic - Cardiology	11 Getty Avenue	Paterson	NJ	Active
DSH310019AF	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Dermatology	11 Getty Avenue	Paterson	NJ	Active
DSH310019AG	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Endocrinology	11 Getty Avenue	Paterson	NJ	Active
DSH310019AH	Child	DSH	St. Joseph’s University Medical Center	Mobile ICU	11 Getty Avenue	Paterson	NJ	Active
DSH310019AJ	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Ambulatory Imaging - Clifton	1135 Broad Street	Clifton	NJ	Active
DSH310019AK	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / PACU	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019AL	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / University Imaging	246 Hamburg Turnpike	Wayne	NJ	Active
DSH310019AM	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / Emergency Dept.	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019AN	Child	DSH	St. Joseph’s University Medical Center	DePaul Center /Specialty Clinic/ Feeding & Swallowing	11 Getty Avenue	Paterson	NJ	Active
DSH310019AP	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Dental	11 Getty Avenue	Paterson	NJ	Active
DSH310019AQ	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Urology GYN	11 Getty Avenue	Paterson	NJ	Active
DSH310019AR	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Infertility	11 Getty Avenue	Paterson	NJ	Active
DSH310019AS	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / GYN-Oncology	11 Getty Avenue	Paterson	NJ	Active
DSH310019AT	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / GYN	11 Getty Avenue	Paterson	NJ	Active
DSH310019AU	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Episodic Clinic	11 Getty Avenue	Paterson	NJ	Active
DSH310019AV	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Cancer Screening	11 Getty Avenue	Paterson	NJ	Active
DSH310019AW	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Infectious Diseases	11 Getty Avenue	Paterson	NJ	Active
DSH310019AX	Child	DSH	St. Joseph’s University Medical Center	DePaul Center Comprehensive Care / HIV Primary Care Services-Adults/Peds	11 Getty Avenue	Paterson	NJ	Active
DSH310019AY	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Primary Care Pediatrics	11 Getty Avenue	Paterson	NJ	Active
DSH310019AZ	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Primary Care Adult Medicine	11 Getty Avenue	Paterson	NJ	Active
DSH310019B	Child	DSH	St. Joseph's Hospital and Medical Center	DePaul Ambulatory Center	11 Getty Avenue	Paterson	NJ	Terminated
DSH310019BA	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Surgical Adult/Peds	11 Getty Avenue	Paterson	NJ	Active
DSH310019BB	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Rheumatology	11 Getty Avenue	Paterson	NJ	Active
DSH310019BC	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Ortho/Fracture Scoliosis - Adults/Peds	11 Getty Avenue	Paterson	NJ	Active
DSH310019BD	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Gastroenterology	11 Getty Avenue	Paterson	NJ	Active
DSH310019BE	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Adults & Peds Eye	11 Getty Avenue	Paterson	NJ	Active
DSH310019BF	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / ENT	11 Getty Avenue	Paterson	NJ	Active
DSH310019BG	Child	DSH	St. Joseph’s University Medical Center	ST JOSEPH'S REGIONAL MEDICAL CENTER / DePaul - Adolescent	11 GETTY AVE, BLDG 275	PATERSON	NJ	Terminated
DSH310019BH	Child	DSH	St. Joseph’s University Medical Center	ST JOSEPH'S REGIONAL MEDICAL CENTER / St. Joseph's Wayne Hospital - Cardiac Cath Lab	224 HAMBURG TURNPIKE	WAYNE	NJ	Active
DSH310019BJ	Child	DSH	St. Joseph’s University Medical Center	ST JOSEPH'S REGIONAL MEDICAL CENTER / DePaul - Teen OB	11 GETTY AVE, BLDG 275	PATERSON	NJ	Active
DSH310019BK	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Infusion Center - Infusion	234 Hamburg Turnpike	Wayne	NJ	Active
DSH310019C	Child	DSH	St. Joseph's Hospital and Medical Center	Comprehensive Care Center	11 Getty Avenue	Paterson	NJ	Terminated
DSH310019D	Child	DSH	St. Joseph’s University Medical Center	Family Medicine at Clifton	1135 Broad Street	Clifton	NJ	Active
DSH310019E	Child	DSH	St. Joseph's Hospital and Medical Center	Family Health Center	11 Getty Avenue	Paterson	NJ	Terminated
DSH310019F	Child	DSH	St. Joseph’s University Medical Center	Harbor House	645 Main Street	Paterson	NJ	Active
DSH310019G	Child	DSH	St. Joseph’s University Medical Center	Outpatient Mental Health Clinic	641 Main Street	Paterson	NJ	Active
DSH310019H	Child	DSH	St. Joseph’s University Medical Center	Access Outpatient Mental Health	621 Main Street	Paterson	NJ	Active
DSH310019K	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Cardiovascular Center - Wayne	246 Hamburg Turnpike	Wayne	NJ	Active
DSH310019L	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Cardiovascular Center - Woodland Park	999 McBride Avenue	Woodland Park	NJ	Active
DSH310019M	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Cardiovascular Center - Nutley	181 Franklin Avenue	Nutley	NJ	Terminated
DSH310019N	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / Operating Room	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019P	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / Radiology	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019Q	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / Ambulatory Care Center	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019R	Child	DSH	St. Joseph’s University Medical Center	St. Joseph's Wayne Hospital / Endoscopy	224 Hamburg Turnpike	Wayne	NJ	Active
DSH310019S	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Teen GYN	11 Getty Avenue	Paterson	NJ	Active
DSH310019T	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Obstetrics	11 Getty Avenue	Paterson	NJ	Active
DSH310019U	Child	DSH	St. Joseph’s University Medical Center	DePaul Center / Homebound Program	11 Getty Avenue	Paterson	NJ	Active
DSH310019V	Child	DSH	St. Joseph’s University Medical Center	DePaul Center Comprehensive Care / GYN Services	11 Getty Avenue	Paterson	NJ	Active
DSH310019W	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Hematology/Oncology	11 Getty Avenue	Paterson	NJ	Active
DSH310019X	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Renal	11 Getty Avenue	Paterson	NJ	Active
DSH310019Z	Child	DSH	St. Joseph’s University Medical Center	DePaul Center - Specialty Clinic / Pulmonology	11 Getty Avenue	Paterson	NJ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Brady, LIsa SVP St. Joseph's University Medical Center 2014035905	Nesselbush, Robert Joseph Chief Financial Officer St. Joseph's Health 9737542023	3/25/2025 10:51 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 2:12:21 PM	8/21/2024 9:58:00 AM	8/21/2024 9:58 AM
Contacts	Authorizing Official	Update	Change Request	Riccio, Dustin President St. Joseph's Health 9737542010	Brady, LIsa SVP St. Joseph's University Medical Center 2014035905	7/17/2024 2:38 PM
Contacts	Authorizing Official	Update	AO Change Request	Mendrzycki, Jennifer SVP COO St. Joseph's University Medical Center 9737542003	Riccio, Dustin President St. Joseph's Health 9737542010	3/19/2024 8:10 AM
Contacts	Authorizing Official	Update	AO Change Request	Slavin, Kevin President and CEO St. Joseph's University Medical Center 9737542010	Mendrzycki, Jennifer SVP COO St. Joseph's University Medical Center 9737542003	1/25/2024 7:05 AM
Contacts	Primary Contact	Update	Change Request	Roemer, Dennis CFO St. Joseph's Health 9737542023	Lee, Alexander 340B Program Manager St. Joseph’s University Medical Center 9737544823	10/25/2023 3:53 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 11:45:43 AM	8/15/2023 2:12:21 PM	8/15/2023 2:12 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 4:00:41 PM	8/24/2022 11:45:43 AM	8/24/2022 11:45 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 3:59:36 PM	9/9/2021 4:00:41 PM	9/9/2021 4:00 PM
Contacts	Authorizing Official	Update	AO Change Request	Slavin, Kevin President and CEO St. Joseph's Hospital & Medical Center 9737542002-9737542010	Slavin, Kevin President and CEO St. Joseph's University Medical Center 9737542010	5/13/2021 10:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3024783	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		092525000	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0009472940006	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q049230	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200308250A	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0310019	9/11/2020 3:59 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1669462420 ( )		9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		HI	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		ND	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		SD	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		VI	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/11/2020 3:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669462420	9/11/2020 3:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/11/2020 3:59 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 10:08:54 AM	9/11/2020 3:59:36 PM	9/11/2020 3:59 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:21:43 PM	8/20/2019 10:08:54 AM	8/20/2019 10:08 AM
Details	Last Recertification Date	Update	Recertification	11/3/2017 3:50:33 PM	8/16/2018 12:21:43 PM	8/16/2018 12:21 PM
Details	Entity Name	Update	Change Request	St. Joseph’s Hospital and Medical Center	St. Joseph’s University Medical Center	5/3/2018 9:37 AM
Details	Entity Name	Update	Recertification	St. Joseph's Hospital and Medical Center	St. Joseph’s Hospital and Medical Center	11/6/2017 7:21 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/3/2017 3:50:33 PM	11/3/2017 3:50 PM
Contacts	Authorizing Official	Update		Slavin, Kevin President and CEO 9737542002	Slavin, Kevin President and CEO St. Joseph's Hospital & Medical Center 9737542002-9737542010	11/2/2017 2:34 PM
Contacts	Primary Contact	Update		Roemer, Dennis CFO 9737542023	Roemer, Dennis CFO St. Joseph's Health 9737542023	10/20/2017 12:14 PM
Contacts	Primary Contact	Update		Alexander, David CFO 9737542023	Roemer, Dennis CFO 9737542023	7/27/2017 2:27 PM
Contacts	Authorizing Official	Insert			Slavin, Kevin President and CEO 9737542002	7/27/2017 2:27 PM
Contacts	Signed By	Insert			Robinson, Jack D. CFO 9737542023	7/27/2017 2:26 PM
Addresses	Main Address	Insert			246 Hamburg Turnpike Suite 201 Wayne, NJ 07470	7/27/2017 2:26 PM
Addresses	Billing Address	Insert			St. Joseph's Hospital and Medical Center 703 Main Street Paterson, NJ 07503	7/27/2017 2:26 PM
Addresses	Shipping Address	Insert			St. Joseph's Hospital and Medical Center 703 Main Street Paterson, NJ 07503	7/27/2017 2:26 PM
Contacts	Primary Contact	Update		Halushka Katz, Francine Vice President & General Counsel 9737542036	Alexander, David CFO 9737542023	8/18/2016 12:12 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 11:59 AM
Details	Last Recertification Date	Update		8/14/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 11:29 AM
Contacts	Primary Contact	Insert			Halushka Katz, Francine Vice President & General Counsel 9737542036	1/22/2015 8:45 PM
Details	Last Recertification Date	Update			8/14/2014 12:00:00 AM	8/14/2014 12:36 PM
Dates	Participating Approval Date	Update			11/17/2013 12:00:00 AM	11/17/2013 7:28 AM
Details	State	Update		Pending	Active	11/17/2013 7:28 AM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	11/17/2013 7:28 AM
Details	340B ID	Update		WDSJ1OUTPATIENT_ONLINE_REG	DSH310019K	11/5/2013 10:24 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	WDSJ1OUTPATIENT_ONLINE_REG	11/5/2013 8:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/9/2013 9:52 AM
Medicaid Billing	Medicaid: Number	Insert			4136403	10/9/2013 9:52 AM
Medicaid Billing	Medicaid: State	Insert			NJ	10/9/2013 9:52 AM
Medicaid Billing	NPI: Number	Insert			1669462420	10/9/2013 9:52 AM
Details	Last Recertification Date	Insert				10/9/2013 9:52 AM
Details	Grant Number	Insert				10/9/2013 9:52 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/9/2013 9:52 AM
Details	Is Authorizing Official EHB Data	Insert				10/9/2013 9:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2013 9:52 AM
Details	Medicare Provider Number	Insert			310019	10/9/2013 9:52 AM
Details	Entity Name	Insert			St. Joseph's Hospital and Medical Center	10/9/2013 9:52 AM
Details	Program Code	Insert			DSH	10/9/2013 9:52 AM
Details	Entity Subname	Insert			St. Joseph's Cardiovascular Center - Wayne	10/9/2013 9:52 AM
Dates	Participating Approval Date	Insert				10/9/2013 9:52 AM
Details	State	Insert			Pending	10/9/2013 9:52 AM
Dates	Registration Date	Insert			10/9/2013 12:00:00 AM	10/9/2013 9:52 AM
Dates	Signed By Date	Insert			10/9/2013 12:00:00 AM	10/9/2013 9:52 AM
Dates	Start Date	Insert				10/9/2013 9:52 AM
Terminations	Termination Comments	Insert				10/9/2013 9:52 AM
Terminations	Termination Date	Insert				10/9/2013 9:52 AM
Terminations	Termination Effective Date	Insert				10/9/2013 9:52 AM
Terminations	Termination Reason	Insert				10/9/2013 9:52 AM