Covered Entity Details

DSH210002G UNIVERSITY OF MARYLAND MEDICAL CENTER (Active) - information as of 6/8/2025 11:58:54 PM

Main Details

Name

UNIVERSITY OF MARYLAND MEDICAL CENTER

Subdivision Name

UMH: Otorhinolaryngology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH210002G

Medicare Provider Number

210002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2014

Participating Start Date

4/1/2014

Participating Approval Date

2/24/2014

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

University of Maryland Medical Center
Joseph Dicubellis, Senior Director of Pharmacy
(410) 328-6746

Primary Contact

University of Maryland Medical Center
Robert Stachowski, Director of Business and 340B Operations
(410) 328-6886

Addresses

Street Address

16 S Eutaw Street
4th Floor Frenkil Building Ste 400
Baltimore, MD 21201

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
MD	700360900	1174660120

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
DSH210002A	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	Clinic Addiction Deaf - Addiction	1001 W Pratt Street	Baltimore	MD	Terminated
DSH210002AA	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	CLINIC TRANSPLANT TRANSIT CARE - TRANSPLANT	16 SOUTH EUTAW STREET	BALTIMORE	MD	Active
DSH210002B	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Speech O/P	16 S Eutaw Street	Baltimore	MD	Active
DSH210002C	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Frenkil Pt	16 S Eutaw Street	Baltimore	MD	Terminated
DSH210002D	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: University Health Center	16 S Eutaw Streeet	Baltimore	MD	Active
DSH210002E	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: O/P Addiction Svcs	701 W Pratt Street	Baltimore	MD	Active
DSH210002F	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Fayette Clinic	701 W Pratt Street	Baltimore	MD	Active
DSH210002G	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Otorhinolaryngology	16 S Eutaw Street	Baltimore	MD	Active
DSH210002J	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Neun Neurolgy Clinic	16 S Eutaw Street	Baltimore	MD	Active
DSH210002K	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Adult O/P	701 W Pratt Street	Baltimore	MD	Terminated
DSH210002L	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Psyn Ambltry Child	701 W Pratt Street	Baltimore	MD	Terminated
DSH210002M	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Infc Hiv/Aids	16 S Eutaw Street	Baltimore	MD	Terminated
DSH210002N	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Hiv Psychiatric Srvs	16 S Eutaw Street	Baltimore	MD	Terminated
DSH210002Q	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Geropsych Mgmt Proj	701 W Pratt Street	Baltimore	MD	Terminated
DSH210002T	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Psych Ambulatory Clinic	701 W. Pratt Street	Baltimore	MD	Active
DSH210002U	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: INFUSION CLINIC TOWSON	7601 Osler Drive	Towson	MD	Active
DSH210002V	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UNIVERSITY OF MARYLAND MEDICAL SYSTEM - UMH: DRUG TREATMENT CENTER	1001 West Pratt Street	Baltimore	MD	Active
DSH210002W	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: MULTI D CLINIC TOWSON	7601 Osler Drive	Towson	MD	Active
DSH210002X	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: INFUSION CLINIC BEL AIR	500 Upper Chesapeake Drive	Bel Air	MD	Active
DSH210002Y	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UNIVERSITY OF MARYLAND MEDICAL SYSTEM - UMH: Adap Clinic	1001 West Pratt Street	Baltimore	MD	Terminated
DSH210002Z	Child	DSH	UNIVERSITY OF MARYLAND MEDICAL CENTER	UMH: Psyn Ambltry Child - Psychology	701 W Pratt Street	Baltimore	MD	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:34:16 AM	8/20/2024 10:14:48 AM	8/20/2024 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	419016500 (MD)		6/1/2024 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2024 12:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		700360900	6/1/2024 12:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	6/1/2024 12:45 PM
Contacts	Authorizing Official	Update	Change Request	Fleischmann, Craig Vice President of Finance University of Maryland Medical System 4103281092	Dicubellis, Joseph Senior Director of Pharmacy University of Maryland Medical Center 4103286746	8/21/2023 7:06 AM
Contacts	Primary Contact	Update	PC Change Request	Dicubellis, Joseph Senior Director of Pharmacy University of Maryland Medical Center 4103286746	Stachowski, Robert Director of Business and 340B Operations University of Maryland Medical Center 4103286886	8/18/2023 6:37 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 9:22:05 AM	8/16/2023 11:34:16 AM	8/16/2023 11:34 AM
Details	Last Recertification Date	Update	Recertification	9/8/2021 2:23:23 PM	9/9/2022 9:22:05 AM	9/9/2022 9:22 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 2:25:45 PM	9/8/2021 2:23:23 PM	9/8/2021 2:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174660120	8/20/2020 2:25 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/20/2020 2:25 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1174660120 ( )		8/20/2020 2:25 PM
Details	Last Recertification Date	Update	Recertification	8/19/2019 10:55:49 AM	8/20/2020 2:25:45 PM	8/20/2020 2:25 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:33:04 PM	8/19/2019 10:55:49 AM	8/19/2019 10:55 AM
Contacts	Authorizing Official	Update	Change Request	Persinger, Keith D. Executive Vice President – Chief Operating & Financial Officer UMMC 4103281382	Fleischmann, Craig Vice President of Finance University of Maryland Medical System 4103281092	1/11/2019 2:34 PM
Details	Last Recertification Date	Update	Recertification	11/27/2017 10:54:27 AM	8/21/2018 4:33:04 PM	8/21/2018 4:33 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/27/2017 10:54:27 AM	11/27/2017 10:54 AM
Contacts	Authorizing Official	Update		Persinger, Keith Executive Vice President – Chief Operating & Financial Officer 4103281382	Persinger, Keith D. Executive Vice President – Chief Operating & Financial Officer UMMC 4103281382	10/6/2017 9:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Dicubellis, Joseph Senior Director of Finance University of Maryland Medical Center 4103286746	Dicubellis, Joseph Senior Director of Pharmacy University of Maryland Medical Center 4103286746	10/3/2017 9:16 AM
Contacts	Primary Contact	Update		Dicubellis, Joseph Senior Director of Finance 4103286746	Dicubellis, Joseph Senior Director of Finance University of Maryland Medical Center 4103286746	10/3/2017 9:13 AM
Contacts	Primary Contact	Update		Stachowski, Robert Pharmacy Services Manager 4103286886	Dicubellis, Joseph Senior Director of Finance 4103286746	6/14/2017 11:31 AM
Contacts	Signed By	Insert			RIVEST, JEFFREY President and Chief Executive Officer 4103280313	6/14/2017 11:31 AM
Contacts	Authorizing Official	Insert			Persinger, Keith Executive Vice President – Chief Operating & Financial Officer 4103281382	6/14/2017 11:31 AM
Addresses	Main Address	Insert			16 S Eutaw Street 4th Floor Frenkil Building Ste 400 Baltimore, MD 21201	6/14/2017 11:30 AM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/16/2016 12:00:00 AM	8/16/2016 1:56 PM
Details	Last Recertification Date	Update		9/4/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 3:25 PM
Contacts	Primary Contact	Insert			Stachowski, Robert Pharmacy Services Manager 4103286886	1/6/2015 3:10 PM
Details	Last Recertification Date	Update			9/4/2014 12:00:00 AM	9/4/2014 2:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/20/2014 12:33 PM
Medicaid Billing	Medicaid: Number	Insert			419016500	3/20/2014 12:33 PM
Medicaid Billing	Medicaid: State	Insert			MD	3/20/2014 12:33 PM
Medicaid Billing	NPI: Number	Insert			1174660120	3/20/2014 12:33 PM
Dates	Participating Approval Date	Update			2/24/2014 12:00:00 AM	2/24/2014 11:44 AM
Details	State	Update		Pending	Active	2/24/2014 11:44 AM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	2/24/2014 11:44 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH210002G	2/19/2014 6:01 PM
Details	Last Recertification Date	Insert				1/15/2014 4:22 PM
Details	Grant Number	Insert				1/15/2014 4:22 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/15/2014 4:22 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2014 4:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2014 4:22 PM
Details	Medicare Provider Number	Insert			210002	1/15/2014 4:22 PM
Details	Entity Name	Insert			UNIVERSITY OF MARYLAND MEDICAL CENTER	1/15/2014 4:22 PM
Details	Program Code	Insert			DSH	1/15/2014 4:22 PM
Details	Entity Subname	Insert			UMH: Otorhinolaryngology	1/15/2014 4:22 PM
Dates	Participating Approval Date	Insert				1/15/2014 4:22 PM
Details	State	Insert			Pending	1/15/2014 4:22 PM
Dates	Registration Date	Insert			1/15/2014 12:00:00 AM	1/15/2014 4:22 PM
Dates	Signed By Date	Insert			1/15/2014 12:00:00 AM	1/15/2014 4:22 PM
Dates	Start Date	Insert				1/15/2014 4:22 PM
Terminations	Termination Comments	Insert				1/15/2014 4:22 PM
Terminations	Termination Date	Insert				1/15/2014 4:22 PM
Terminations	Termination Effective Date	Insert				1/15/2014 4:22 PM
Terminations	Termination Reason	Insert				1/15/2014 4:22 PM