Covered Entity Details

DSH230092AN W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital (Active) - information as of 5/3/2025 11:31:56 PM

Main Details

Name

W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital

Subdivision Name

Henry Ford Family Medicine - Townsend

Type

Disproportionate Share Hospital

Rural

340B ID

DSH230092AN

Medicare Provider Number

230092

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/6/2014

Participating Start Date

4/1/2014

Participating Approval Date

2/28/2014

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health
Laura Ratcliff, 340B Program Coordinator
(517) 205-7557

Addresses

Street Address

400 Hinckley Blvd.
Suite 100
Jackson, MI 49203

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
MI		1053403402,1265528939

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
DSH230092AE	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Allegiance Senior Health Center	100 E. Michigan Avenue	JACKSON	MI	Terminated
DSH230092AF	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Wound Care Center - Springport Road	2200 Springport Road	JACKSON	MI	Active
DSH230092AG	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Diabetes & Nutrition Education - Springport Road	2200 Springport Road	JACKSON	MI	Active
DSH230092AH	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Osteoporosis Center - Cascade Ridge	3333 Spring Arbor Rd	Jackson	MI	Active
DSH230092AJ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Mason	810 N. Hogsback Road	Mason	MI	Active
DSH230092AK	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Spring Arbor	7845 Spring Arbor Road	Spring Arbor	MI	Active
DSH230092AL	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford General Surgery - Jackson	1100 E Michigan Ave	Jackson	MI	Active
DSH230092AM	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Gastroenterology - Jackson	744 W. Michigan Avenue	Jackson	MI	Active
DSH230092AN	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Townsend	400 Hinckley Blvd.	Jackson	MI	Active
DSH230092AO	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Internal Medicine - Jackson	100 E. Michigan Avenue	Jackson	MI	Active
DSH230092AP	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - East Michigan	3235 E. Michigan Avenue	Jackson	MI	Active
DSH230092AQ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Vascular Health	300 W. Washington	Jackson	MI	Active
DSH230092AR	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Albion	27931 C Drive North	Albion	MI	Active
DSH230092AS	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Cascade Ridge	3305 Spring Arbor Rd	Jackson	MI	Active
DSH230092AT	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - North Street	1401 W. North Street	Jackson	MI	Active
DSH230092AU	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Leslie	130 N. Sherman	Leslie	MI	Active
DSH230092AV	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Grass Lake	12369 E. Michigan Avenue	Grass Lake	MI	Active
DSH230092AW	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Rheumatology - Jackson	744 W Michigan	Jackson	MI	Active
DSH230092AX	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Orthopedics - Jackson	1201 E. Michigan Avenue	Jackson	MI	Active
DSH230092AY	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Physical Medicine & Rehabilitation - Jackson	1201 E. Michigan Avenue	Jackson	MI	Active
DSH230092AZ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Neurology - Jackson	1201 E. Michigan Avenue	Jackson	MI	Active
DSH230092B	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Radiation Oncology - Tejada	1102 E. Michigan Avenue	Jackson	MI	Active
DSH230092BA	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Cardiac Surgery - Jackson	1100 E. Michigan Avenue	Jackson	MI	Active
DSH230092BB	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	Henry Ford Allegiance Digestive Health - Ann Arbor Road	4400 Ann Arbor Road	Jackson	MI	Terminated
DSH230092BC	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	Henry Ford Allegiance Family Medicine - Onsted	8958 West M-50	Onsted	MI	Terminated
DSH230092BD	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Neurosurgery - Jackson	1201 E. Michigan Avenue	JACKSON	MI	Active
DSH230092BE	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Ear, Nose & Throat - Teneyck	1111 Teneyck Street	Jackson	MI	Active
DSH230092BF	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Cardiology - Page	309 Page Avenue	Jackson	MI	Active
DSH230092BG	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Hyperbaric Center - Springport Rd	2200 Springport Road	Jackson	MI	Active
DSH230092BH	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Same Day Clinic - North Street	1401 W North Street	Jackson	MI	Active
DSH230092BJ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Endocrinology - Cascade Ridge	3333 Spring Arbor Rd	Jackson	MI	Active
DSH230092BK	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Thoracic Surgery - Jackson	1100 E Michigan Avenue	Jackson	MI	Active
DSH230092BL	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	Henry Ford Allegiance Outpatient Trauma	205 N. East Avenue	Jackson	MI	Terminated
DSH230092BM	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	Henry Ford Allegiance Endocrinology NMS	1201 E. Michigan Ave	Jackson	MI	Terminated
DSH230092BN	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Medication Management Clinic - Springport Rd	2200 SPRINGPORT RD	JACKSON	MI	Active
DSH230092BP	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Pediatrics - Jackson	214 N. West Avenue	Jackson	MI	Active
DSH230092BQ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Family Medicine - Brooklyn	153 Wamplers Lake Rd	Brooklyn	MI	Active
DSH230092BR	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	UM / Pediatric Cardiology	760 W Franklin St	Jackson	MI	Terminated
DSH230092BS	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Vascular Laboratory - Jackson	300 W Washington Ave	Jackson	MI	Active
DSH230092BT	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Women's Health - Jackson	3305 SPRING ARBOR RD	JACKSON	MI	Active
DSH230092BU	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	HENRY FORD ALLEGIANCE - DERMATOLOGY - Henry Ford Allegiance Dermatology	3333 SPRING ARBOR RD	JACKSON	MI	Terminated
DSH230092BV	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Plastic Surgery - Cascade Ridge	3333 Spring Arbor Rd	JACKSON	MI	Active
DSH230092BW	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Pediatrics - Cascade Ridge	3305 Spring Arbor Rd	JACKSON	MI	Terminated
DSH230092BX	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Infectious Disease - Springport Rd	2200 SPRINGPORT RD	JACKSON	MI	Active
DSH230092BY	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Outpatient Infusion Therapy - Anderson Building	205 N EAST AVE	JACKSON	MI	Active
DSH230092BZ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Occupational Health - Jackson	100 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092C	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Hematology & Oncology - Jackson	1100 E Michigan Ave	Jackson	MI	Active
DSH230092CA	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	HFA BEHAVIORAL HEALTH - E. MICHIGAN - Henry Ford Allegiance Behavioral Health - East Michigan	3235 E MICHIGAN AVE	JACKSON	MI	Terminated
DSH230092CB	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Procedure Center - Jackson	1100 E. Michigan Avenue	JACKSON	MI	Active
DSH230092CC	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Heart Failure Clinic - Jackson	1100 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092CD	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Acute Care Clinic - Jackson	1100 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092CE	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Urology - Spring Arbor Road	2800 SPRING ARBOR RD	JACKSON	MI	Terminated
DSH230092CF	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Same Day Care - Leslie	130 N SHERMAN ST	LESLIE	MI	Terminated
DSH230092CG	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Sports Medicine - Specialty Center	1201 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092CH	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Bariatric Surgery - West Michigan	744 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092CJ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Urology - Jackson	150 S. East Avenue	JACKSON	MI	Active
DSH230092CK	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Podiatry - Jackson	1201 E Michigan Ave	JACKSON	MI	Active
DSH230092CM	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Same Day Clinic - E Michigan Ave	3235 E Michigan Ave	JACKSON	MI	Active
DSH230092CP	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	HENRY FORD ALLEGIANCE VASCULAR HEALTH - Henry Ford Allegiance Vascular Health - Albion	27931 C Drive North	Albion	MI	Terminated
DSH230092CQ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Behavioral Health Access Center - Jackson	205 N EAST AVE	JACKSON	MI	Active
DSH230092CR	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	HENRY FORD ALLEGIANCE ORTHOPEDICS - Henry Ford Allegiance Orthopedic Walk-In Clinic	1201 E MICHIGAN AVE	JACKSON	MI	Terminated
DSH230092CS	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Trauma Clinic - Jackson	1100 E MICHIGAN AVE	JACKSON	MI	Active
DSH230092CT	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	HENRY FORD ALLEGIANCE VASCULAR HEALTH - Henry Ford Allegiance Vascular Health - Mason	810 N Hogsback	Mason	MI	Terminated
DSH230092CU	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Electrophysiology - Jackson	1100 E Michigan Ave	Jackson	MI	Active
DSH230092CV	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Maternal Fetal Medicine - Jackson Hospital	205 N East Ave	Jackson	MI	Active
DSH230092CW	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Allegiance Vascular Lab - Mason - Henry Ford Allegiance Vascular Lab - Mason	810 N Hogsback Rd	Mason	MI	Terminated
DSH230092CX	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Allegiance Vascular Lab - Albion - Henry Ford Allegiance Vascular Lab - Albion	27931 C Drive North	Albion	MI	Terminated
DSH230092CY	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Urology - Chelsea	1145 S Main St	Chelsea	MI	Active
DSH230092CZ	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Orthopedics - Chelsea	1145 S Main St	Chelsea	MI	Active
DSH230092DA	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Sports Medicine - Chelsea	1145 S Main St	Chelsea	MI	Active
DSH230092DB	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Same Day Clinic - Chelsea	1145 S Main St	Chelsea	MI	Active
DSH230092E	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford General Surgery - Professional Building	1100 E. MICHIGAN AVENUE	JACKSON	MI	Terminated
DSH230092F	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Surgery Center - Jackson	1125 E. Michigan Avenue	Jackson	MI	Active
DSH230092H	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Pain Management - Jackson	1201 E. Michigan Avenue	Jackson	MI	Active
DSH230092P	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Behavioral Health Outpatient Services - Jackson	205 N. East Avenue	Jackson	MI	Active
DSH230092S	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Joint Replacement Center - Jackson Hospital	205 N. East Avenue	Jackson	MI	Active
DSH230092T	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Sleep Center - Jackson	205 N. East Avenue	Jackson	MI	Active
DSH230092U	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Digestive Health - East Avenue	205 S. East Avenue	Jackson	MI	Active
DSH230092X	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Allegiance Addiction Recovery Center	2424 W. Washington Avenue	Jackson	MI	Terminated
DSH230092Y	Child	DSH	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	Henry Ford Substance Abuse Services - Jackson	2424 W. Washington Avenue	JACKSON	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 2:16:57 PM	8/26/2024 1:38:18 PM	8/26/2024 1:38 PM
Details	Entity Subname	Update	Change Request	Henry Ford Allegiance Family Medicine - Townsend	Henry Ford Family Medicine - Townsend	8/6/2024 7:46 AM
Contacts	Authorizing Official	Update	Change Request	Bongiorno, Jim CFO Henry Ford Allegiance Health 5172054899	Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	1/24/2024 4:05 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 11:18:18 AM	8/18/2023 2:16:57 PM	8/18/2023 2:16 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 1:12:30 PM	8/29/2022 11:18:18 AM	8/29/2022 11:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841774262 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053858910 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700355195 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073547964 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1942740311 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1538606348 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1598776718 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1417494378 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1134666092 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1134666936 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1952848822 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1790222651 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1962953034 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1326585522 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649717448 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1407393374 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1598203655 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1699212803 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1497292361 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1982141123 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1194245472 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1134666001 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1235676446 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1396282356 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1366988347 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1114464377 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1518404466 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1356888549 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1255878062 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1144784448 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891232740 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1316484512 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1235676180 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1780121970 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1255878112 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1912445677 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1356888218 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1144883620 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1598202459 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1306386586 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073051199 (MI)		7/12/2022 4:13 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1124565098 (MI)		7/12/2022 4:13 PM
Details	Entity Name	Update	Change Request	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital	4/21/2022 7:56 AM
Contacts	Primary Contact	Update	Group Change Request	Ratcliff, Laura Manager - Pharmacy Regulatory Program W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172057557	Ratcliff, Laura 340B Program Coordinator W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172057557	10/18/2021 9:10 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 12:35:03 PM	8/30/2021 1:12:30 PM	8/30/2021 1:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053403402	11/19/2020 12:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	11/19/2020 12:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265528939	11/19/2020 12:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	11/19/2020 12:59 PM
Contacts	Authorizing Official	Update	Profile Change Request	Bongiorno, Jim CFO Henry Ford Allegiance Health 5172054889	Bongiorno, Jim CFO Henry Ford Allegiance Health 5172054899	9/2/2020 12:19 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	9/1/2020 12:35 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 3:23:00 PM	9/1/2020 12:35:03 PM	9/1/2020 12:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841774262	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053858910	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700355195	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073547964	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942740311	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538606348	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598776718	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1417494378	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134666092	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134666936	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952848822	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1790222651	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1962953034	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1326585522	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649717448	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1407393374	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598203655	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1699212803	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497292361	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982141123	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1194245472	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134666001	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235676446	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396282356	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366988347	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1114464377	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1518404466	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1356888549	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1255878062	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144784448	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1891232740	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316484512	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235676180	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780121970	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1255878112	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912445677	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1356888218	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144883620	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598202459	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1306386586	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073051199	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124565098	7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265528939 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1215974332 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1629000708 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1053403402 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1235676180 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1326585522 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366988347 ( )		7/14/2020 6:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1962953034 ( )		7/14/2020 6:54 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	148834 (AZ)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95008363 (CO)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	92063100 (FL)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003163476A (GA)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053403402 (ID)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	382027689001 (IL)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053403402 (IA)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1410125 (KY)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1749401 (LA)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053403402 (MN)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100264034-00 (NE)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	83136614 (NM)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3143657 (NY)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2855754 (OH)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11580A (SC)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	230092 (TN)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1028429 (VT)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053403402 (VA)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2029584 (WA)		1/21/2020 2:38 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053403402 (WI)		1/21/2020 2:38 PM
Contacts	Primary Contact	Update	Profile Change Request	Ratcliff, Laura 340B Program Coordinator W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172057557	Ratcliff, Laura Manager - Pharmacy Regulatory Program W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172057557	1/15/2020 3:58 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 1:27:19 PM	9/3/2019 3:23:00 PM	9/3/2019 3:23 PM
Contacts	Authorizing Official	Update	Change Request	Leonard, Kevin Vice President of Finance W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172054899	Bongiorno, Jim CFO Henry Ford Allegiance Health 5172054889	8/21/2019 6:20 AM
Details	Last Recertification Date	Update	Recertification	11/22/2017 10:44:46 AM	8/16/2018 1:27:19 PM	8/16/2018 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/22/2017 10:44:46 AM	11/22/2017 10:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		148834	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95008363	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		92063100	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003163476A	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053403402	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		382027689001	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053403402	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1410125	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1749401	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053403402	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100264034-00	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		83136614	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3143657	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2855754	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11580A	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		230092	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1028429	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053403402	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2029584	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053403402	10/17/2017 4:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	10/17/2017 4:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235676180	10/17/2017 4:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1326585522	10/17/2017 4:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366988347	10/17/2017 4:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1962953034	10/17/2017 4:31 PM
Contacts	Authorizing Official	Update	Change Request	Leonard, Kevin Vice President of Finance 5177884899	Leonard, Kevin Vice President of Finance W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172054899	10/12/2017 11:07 AM
Contacts	Primary Contact	Update		Ratcliff, Laura 340B Program Coordinator 5172057557	Ratcliff, Laura 340B Program Coordinator W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health 5172057557	9/19/2017 3:36 PM
Contacts	Authorizing Official	Insert			Leonard, Kevin Vice President of Finance 5177884899	7/31/2017 7:02 PM
Contacts	Primary Contact	Insert			Ratcliff, Laura 340B Program Coordinator 5172057557	7/31/2017 7:02 PM
Contacts	Signed By	Insert			WICKENS, JEANNE SVP OF FINANCE/CFO 5178416979	7/31/2017 7:02 PM
Addresses	Main Address	Insert			400 Hinckley Blvd. Suite 100 Jackson, MI 49203	7/31/2017 7:02 PM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 2:42 PM
Details	Entity Name	Update		W.A. FOOTE MEMORIAL HOSPITAL D/B/A ALLEGIANCE HEALTH	W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health	5/17/2016 11:11 AM
Details	Entity Subname	Update		Allegiance Family Medicine - Townsend	Henry Ford Allegiance Family Medicine - Townsend	5/17/2016 11:11 AM
Medicaid Billing	NPI: Number	Insert			1053403402	1/20/2016 3:39 PM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 2:19 PM
Medicaid Billing	NPI: Number	Insert			1265528939	10/21/2014 7:19 PM
Medicaid Billing	NPI: Number	Insert			1215974332	10/21/2014 7:19 PM
Medicaid Billing	NPI: Number	Insert			1629000708	10/21/2014 7:19 PM
Details	Last Recertification Date	Update			8/11/2014 12:00:00 AM	8/11/2014 9:54 AM
Dates	Participating Approval Date	Update			2/28/2014 12:00:00 AM	2/28/2014 5:14 PM
Details	State	Update		Pending	Active	2/28/2014 5:14 PM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	2/28/2014 5:14 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH230092AN	2/28/2014 11:18 AM
Details	Last Recertification Date	Insert				1/6/2014 2:34 PM
Details	Grant Number	Insert				1/6/2014 2:34 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/6/2014 2:34 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2014 2:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2014 2:34 PM
Details	Medicare Provider Number	Insert			230092	1/6/2014 2:34 PM
Details	Entity Name	Insert			W.A. FOOTE MEMORIAL HOSPITAL D/B/A ALLEGIANCE HEALTH	1/6/2014 2:34 PM
Details	Program Code	Insert			DSH	1/6/2014 2:34 PM
Details	Entity Subname	Insert			Allegiance Family Medicine - Townsend	1/6/2014 2:34 PM
Dates	Participating Approval Date	Insert				1/6/2014 2:34 PM
Details	State	Insert			Pending	1/6/2014 2:34 PM
Dates	Registration Date	Insert			1/6/2014 12:00:00 AM	1/6/2014 2:34 PM
Dates	Signed By Date	Insert			1/6/2014 12:00:00 AM	1/6/2014 2:34 PM
Dates	Start Date	Insert				1/6/2014 2:34 PM
Terminations	Termination Comments	Insert				1/6/2014 2:34 PM
Terminations	Termination Date	Insert				1/6/2014 2:34 PM
Terminations	Termination Effective Date	Insert				1/6/2014 2:34 PM
Terminations	Termination Reason	Insert				1/6/2014 2:34 PM