Covered Entity Details

DSH370037F SSM HEALTH ST ANTHONY HOSPITAL - OKC (Active) - information as of 6/6/2025 12:40:45 PM

Main Details

Name

SSM HEALTH ST ANTHONY HOSPITAL - OKC

Subdivision Name

St. Anthony Family Medicine Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH370037F

Medicare Provider Number

370037

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/9/2014

Participating Start Date

7/1/2014

Participating Approval Date

5/29/2014

Last Recertification Date

8/31/2024

Contacts

Authorizing Official

- SSM ST ANTHONY HOSPITAL
Shasta Manuel, VP of Finance CFO
(405) 272-7282

Primary Contact

SSM Health
Nathan Przybysz, 340b Program Manager
(314) 989-2214

Addresses

Street Address

1110 N. Lee Ave., Suite 300
OKLAHOMA CITY, OK 73103

Billing Address

St. Anthony Hospital - Oklahoma City
1000 N Lee Ave
Oklahoma City, OK 73102

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
OK	100699540A	1366545311

Shipping Addresses

Shipping Address 1

St. Anthony Hospital - Oklahoma City
1000 N Lee Ave
Oklahoma City, OK 73102

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
DSH370037A	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	BONE AND JOINT REPLACE CTR OP OBS	1111 N DEWEY AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AA	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SSM ST ANTHONY SOUTH DAY TREATMENT CLINIC	2129 SW 59TH STREET	OKLAHOMA CITY	OK	Active
DSH370037AB	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Physicians Healthplex North	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037AC	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Healthplex North ED	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037AD	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	ST ANTHONY PHYSICIANS RHEUMATOLOGY	13401 N WESTERN AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AF	Child	DSH	SSM ST ANTHONY HOSPITAL	St Anthony Physicians Endocrinology	13401 N WESTERN AVE, STE 407	OKLAHOMA CITY	OK	Terminated
DSH370037AG	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Midtown Surgery Center	1110 N Lee Ave	Oklahoma City	OK	Active
DSH370037AH	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Physicians Neurology Associates	535 NW 9th St	Oklahoma City	OK	Active
DSH370037AJ	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Physicians Pulmonary Clinic	608 NW 9th St	Oklahoma City	OK	Active
DSH370037AK	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Cancer Specialists of Oklahoma	3525 NW 56th St	Oklahoma City	OK	Active
DSH370037AL	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	BONE AND JOINT HOSPITAL ANESTHESIA - BONE AND JOINT HOSPITAL ANESTHESIA	1111 N DEWEY AVENUE	OKLAHOMA CITY	OK	Active
DSH370037AM	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Edmond Outpatient Behavioral Health Services	416 W 15th St Building 700	Edmond	OK	Active
DSH370037AN	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Bone and Joint Hospital Physical Therapy	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AP	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SSM St. Anthony South Adolescent Treatment Clinic	2129 SW 59th Street	Oklahoma City	OK	Active
DSH370037AQ	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Bone and Joint Hospital Radiology	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AR	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Bone and Joint Surgery	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AS	Child	DSH	SSM ST ANTHONY HOSPITAL	BONE AND JOINT PHARMACY - BONE AND JOINT PHARMACY	1111 N DEWEY	OKLAHOMA CITY	OK	Terminated
DSH370037AT	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Bone and Joint Acute Care	1111 N Dewey Ave	Oklahoma City	OK	Active
DSH370037AU	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Hospital Healthplex West ED - Emergency Department	3333 Territory Ln	El Reno	OK	Active
DSH370037AV	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Healthplex East Specialists (Neuro Oncology)	3400 S Douglas Blvd	Oklahoma City	OK	Active
DSH370037AW	Child	DSH	SSM ST ANTHONY HOSPITAL	SAS-Partial Hospital / SAP BHS STAGES - SAS-Partial Hospital / SAP BHS STAGES	2129 SW 59th St	OKLAHOMA CITY	OK	Terminated
DSH370037AX	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO MED ONC	1000 N Lee Ave	OKLAHOMA CITY	OK	ToBeTerminated
DSH370037AY	Child	DSH	SSM ST ANTHONY HOSPITAL	Ortho Sports Med MT / SAPO ORTH SPTS MED MT - Ortho Sports Med MT / SAPO ORTH SPTS MED MT	1110 N Lee Avenue	OKLAHOMA CITY	OK	Terminated
DSH370037AZ	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Nuclear Med-Heart/Va / SAH HEART & VASC NM - Nuclear Med-Heart/Va / SAH HEART & VASC NM	608 NW 9th	OKLAHOMA CITY	OK	Active
DSH370037B	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St Anthony Physicians North	6201 N. Santa Fe	Oklahoma City	OK	Active
DSH370037BA	Child	DSH	SSM ST ANTHONY HOSPITAL	BHS Adult / SAH BHS ADULT - BHS Adult / SAH BHS ADULT	2129 S.W. 59th	OKLAHOMA CITY	OK	ToBeTerminated
DSH370037BB	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO ENDO ASSOC-Medical / SAPO ENDO ASSOC - SAPO ENDO ASSOC-Medical / SAPO ENDO ASSOC	1111 N. Lee	Oklahoma City	OK	Terminated
DSH370037BC	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Healthplx Mustang CT / HPM CT / HPM RADIOLOGY - Healthplx Mustang CT / HPM CT / HPM RADIOLOGY	201 S Sara Rd	MUSTANG	OK	Active
DSH370037BD	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	Healthplex North MRI / HPN MRI - Healthplex North MRI / HPN MRI	13401 N Western Ave	OKLAHOMA CITY	OK	Active
DSH370037BE	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO MWC PAIN / SAPO MWC PAIN - SAPO MWC PAIN / SAPO MWC PAIN	1800 S. Douglas Blvd	Midwest City	OK	Terminated
DSH370037BF	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	HP North IV Therapy / HPN IV THERAPY - HP North IV Therapy / HPN IV THERAPY	13401 N Western Ave	OKLAHOMA CITY	OK	Active
DSH370037BG	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO CARDVASC DISEA / SAPO CARDVASC DISEASE - SAPO CARDVASC DISEA / SAPO CARDVASC DISEASE	608 NW 9th St	Oklahoma City	OK	Terminated
DSH370037BH	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO ORTH SPTS MED MUS / SAPO ORTH SPTS MED MUS - SAPO ORTH SPTS MED MUS / SAPO ORTH SPTS MED MUS	201 S Sara Rd	MUSTANG	OK	Active
DSH370037BJ	Child	DSH	SSM ST ANTHONY HOSPITAL	Cancer Care Pet CT / SAPO CSOO PET\CT - Cancer Care Pet CT / SAPO CSOO PET\CT	3525 NW 56th Street	Oklahoma City	OK	Terminated
DSH370037BK	Child	DSH	SSM ST ANTHONY HOSPITAL	Bone and Joint Hospital / Anesthesia - Bone and Joint Hospital / Anesthesia	1110 North Lee Avenue	Oklahoma City	OK	Terminated
DSH370037BL	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians' Office / Family Medicine - St. Anthony Physicians' Office / Family Medicine	6201 N. Santa Fe, Suite 2020	Oklahoma City	OK	Terminated
DSH370037BM	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Neurovascular Surgery - Neurovascular Surgery	800 NW 9th St	Oklahoma City	OK	Active
DSH370037BN	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Endocrinology - Endocrinology	6205 N Santa Fe Ave	Oklahoma City	OK	Active
DSH370037BP	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Neurosurgical Oncology - Neurosurgical Oncology	800 NW 9th St	Oklahoma City	OK	Active
DSH370037BQ	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Gastrology MOB 235 - Gastrology	535 NW 9th St	Oklahoma City	OK	Active
DSH370037BR	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Healthplex Mustang Pain Care - Pain	201 S Sara Road	Mustang	OK	Active
DSH370037BS	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Healthplex Mustang Pediatrics - Pediatrics	201 S Sara Road	Mustang	OK	Active
DSH370037BT	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Cardiology Healthplex Mustang - Cardiology	201 S Sara Road	Mustang	OK	Active
DSH370037BU	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Healthplex South Pediatrics - Pediatrics	13500 S Tulsa Dr	Oklahoma City	OK	Active
DSH370037BV	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Sleep Healthplex North - Sleep Medicine	6205 N Santa Fe Ave	Oklahoma City	OK	Active
DSH370037BW	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Pulmonary Healthplex North - Pulmonology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BX	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Pain Healthplex North - Pain	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BY	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Neurology Healthplex North - Neurology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037BZ	Child	DSH	SSM ST ANTHONY HOSPITAL	SAPO Healthplex North Primary Care - Primary Care	13401 N Western Ave	Oklahoma City	OK	Terminated
DSH370037CA	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SAPO Cardiology Healthplex North - Cardiology	13401 N Western Ave	Oklahoma City	OK	Active
DSH370037D	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Physicians Choctaw	15679 NE 23rd Street	Choctaw	OK	Active
DSH370037E	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Healthplex East Internal Medicine	3400 S. Douglas Blvd.	Oklahoma City	OK	Active
DSH370037F	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Family Medicine Center	1110 N. Lee Ave., Suite 300	OKLAHOMA CITY	OK	Active
DSH370037G	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Physicians Heart and Vascular Clinic	608 N.W. 9th	Oklahoma CIty	OK	Terminated
DSH370037H	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SSM Health Neurology	800 NW 9th St	Oklahoma City	OK	Active
DSH370037J	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Hematology Oncology Radiation	1011 N. Dewey Ave	Oklahoma City	OK	Active
DSH370037K	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Physicians Heart and Vascular Clinic	608 N.W. 9th St.	Oklahoma City	OK	Active
DSH370037L	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Vascular Associates	608 N.W. 9th St.	Oklahoma City	OK	Terminated
DSH370037M	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Pulmonary Specialty Clinic	6205 N. Santa Fe	Oklahoma CIty	OK	Terminated
DSH370037N	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Family Medicine South	13500 S. Tulsa Dr	Oklahoma City	OK	Active
DSH370037P	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Family Medicine East	3400 S. Douglas	OKLAHOMA CITY	OK	Active
DSH370037Q	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Hospital Healthplex South ED	13500 S. Tulsa Drive	Oklahoma City	OK	Active
DSH370037R	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Healthplex East ED	3400 S. Douglas	Oklahoma City	OK	Active
DSH370037S	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Midtown Pediatrics	608 N.W. 9th	Oklahoma City	OK	Active
DSh370037T	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Behaviorial Medicine	1031 N. Lee Ave	Oklahoma City	OK	Active
DSH370037U	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Shawnee Physicians Shawnee Family Medicine	3214 Kethley Road	Shawnee	OK	Terminated
DSH370037V	Child	DSH	SSM ST ANTHONY HOSPITAL	St. Anthony Shawnee Physicians	3315 Kethley Road	Shawnee	OK	Terminated
DSH370037W	Child	DSH	SSM ST ANTHONY HOSPITAL	Saints Pediatric Associates	608 N.W. 9th Street	OKLAHOMA CITY	OK	Terminated
DSH370037X	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	St. Anthony Healthplex Mustang ED	201 S Sara Road	Mustang	OK	Active
DSH370037Y	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	SSM HEALTH CARE OF OKLAHOMA, INC./ST ANTHONY PHYSICIANS MUSTANG	201 S Sara Road	Mustang	OK	Active
DSH370037Z	Child	DSH	SSM HEALTH ST ANTHONY HOSPITAL - OKC	ST ANTHONY PHYSICIANS GASTROENTEROLOGY IBD	535 NW 9th St	Oklahoma City	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	SSM ST ANTHONY HOSPITAL	SSM HEALTH ST ANTHONY HOSPITAL - OKC	6/5/2025 12:27 PM
Contacts	Primary Contact	Update	PC Change Request	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	Przybysz, Nathan 340b Program Manager SSM Health 3149892214	5/20/2025 11:07 AM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	5/19/2025 2:43 PM
Details	Last Recertification Date	Update	Recertification	8/31/2023 9:37:13 AM	8/31/2024 2:11:50 PM	8/31/2024 2:11 PM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	5/7/2024 9:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2024 5:59 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100699540A	4/10/2024 5:59 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/10/2024 5:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366545311	4/10/2024 5:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/10/2024 5:59 PM
Contacts	Primary Contact	Update	PC Change Request	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	9/19/2023 6:42 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 9:55:14 AM	8/31/2023 9:37:13 AM	8/31/2023 9:37 AM
Addresses	Main Address	Update	Change Request	608 N.W. 9th Suite 1100 OKLAHOMA CITY, OK 73102	1110 N. Lee Ave., Suite 300 OKLAHOMA CITY, OK 73103	2/17/2023 7:43 AM
Contacts	Primary Contact	Update	Group Change Request	Violette, Chelsea Director of Optimization Spendmend 8452066019	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	12/2/2022 8:49 AM
Addresses	Billing Address	Insert	Group Change Request		St. Anthony Hospital - Oklahoma City 1000 N Lee Ave Oklahoma City, OK 73102	11/28/2022 8:35 AM
Addresses	Shipping Address	Insert	Group Change Request		St. Anthony Hospital - Oklahoma City 1000 N Lee Ave Oklahoma City, OK 73102	11/28/2022 8:35 AM
Contacts	Primary Contact	Update	Group Change Request	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	Violette, Chelsea Director of Optimization Spendmend 8452066019	11/17/2022 8:15 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 11:38:09 AM	9/16/2022 9:55:14 AM	9/16/2022 9:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Sharrow, Nicholas Director of Pharmacy SSM Health 9203246757	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	8/17/2022 5:26 PM
Contacts	Primary Contact	Update	Group Change Request	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	Sharrow, Nicholas Director of Pharmacy SSM Health 9203246757	6/29/2022 7:32 AM
Details	Last Recertification Date	Update	Recertification	9/9/2020 4:03:53 PM	9/9/2021 11:38:09 AM	9/9/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100699540Q (OK)		7/15/2021 10:27 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487677456 (OK)		7/15/2021 10:27 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487677456	9/9/2020 4:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/9/2020 4:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1487677456 ( )		9/9/2020 4:03 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 12:21:17 PM	9/9/2020 4:03:53 PM	9/9/2020 4:03 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 5:49:47 PM	9/5/2019 12:21:17 PM	9/5/2019 12:21 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487677456	8/28/2018 5:49 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 1:50:09 PM	8/28/2018 5:49:47 PM	8/28/2018 5:49 PM
Contacts	Primary Contact	Update	Recertification	Dreyling, Charles Director of Pharmacy SSM ST ANTHONY HOSPITAL 4052726393	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	12/5/2017 1:50 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	12/5/2017 1:50:09 PM	12/5/2017 1:50 PM
Contacts	Primary Contact	Update		Dreyling, Charles Director of Pharmacy 4052726393	Dreyling, Charles Director of Pharmacy SSM ST ANTHONY HOSPITAL 4052726393	10/25/2017 12:03 PM
Contacts	Authorizing Official	Update		Manuel, Shasta VP of Finance CFO 4052727282	Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	9/29/2017 2:33 PM
Contacts	Authorizing Official	Insert			Manuel, Shasta VP of Finance CFO 4052727282	8/9/2017 3:59 PM
Contacts	Signed By	Insert			Manuel, Shasta Regional Vice President Finance/CFO 4052727279	8/9/2017 11:43 AM
Contacts	Primary Contact	Insert			Dreyling, Charles Director of Pharmacy 4052726393	7/12/2017 4:29 PM
Addresses	Main Address	Insert			608 N.W. 9th Suite 1100 OKLAHOMA CITY, OK 73102	7/12/2017 4:29 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/16/2016 12:00:00 AM	8/16/2016 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/3/2015 7:14 PM
Medicaid Billing	Medicaid: Number	Insert			100699540Q	11/3/2015 7:14 PM
Medicaid Billing	Medicaid: State	Insert			OK	11/3/2015 7:14 PM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 11:13 AM
Details	Last Recertification Date	Update			8/7/2014 12:00:00 AM	8/7/2014 2:27 PM
Dates	Participating Approval Date	Update			5/29/2014 12:00:00 AM	5/29/2014 12:09 PM
Details	State	Update		Pending	Active	5/29/2014 12:09 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	5/29/2014 12:09 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH370037F	4/14/2014 9:03 AM
Details	Last Recertification Date	Insert				4/9/2014 4:07 PM
Details	Grant Number	Insert				4/9/2014 4:07 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/9/2014 4:07 PM
Details	Is Authorizing Official EHB Data	Insert				4/9/2014 4:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/9/2014 4:07 PM
Details	Medicare Provider Number	Insert			370037	4/9/2014 4:07 PM
Details	Entity Name	Insert			SSM ST ANTHONY HOSPITAL	4/9/2014 4:07 PM
Details	Program Code	Insert			DSH	4/9/2014 4:07 PM
Details	Entity Subname	Insert			St. Anthony Family Medicine Center	4/9/2014 4:07 PM
Dates	Participating Approval Date	Insert				4/9/2014 4:07 PM
Details	State	Insert			Pending	4/9/2014 4:07 PM
Dates	Registration Date	Insert			4/9/2014 12:00:00 AM	4/9/2014 4:07 PM
Dates	Signed By Date	Insert			4/9/2014 12:00:00 AM	4/9/2014 4:07 PM
Dates	Start Date	Insert				4/9/2014 4:07 PM
Terminations	Termination Comments	Insert				4/9/2014 4:07 PM
Terminations	Termination Date	Insert				4/9/2014 4:07 PM
Terminations	Termination Effective Date	Insert				4/9/2014 4:07 PM
Terminations	Termination Reason	Insert				4/9/2014 4:07 PM