Covered Entity Details

DSH330195D LONG ISLAND JEWISH MEDICAL CENTER (Terminated) - information as of 4/25/2025 8:30:57 PM

Main Details

Name

LONG ISLAND JEWISH MEDICAL CENTER

Subdivision Name

North Shore - LIJ Medical Group Urgent Care Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330195D

Medicare Provider Number

330195

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2014

Participating Start Date

7/1/2014

Participating Approval Date

6/11/2014

Last Recertification Date

8/31/2016

Termination Date
Termination Reason

10/1/2016
Site closure

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

95-25 Queens Blvd
Rego Park, NY 11374

Billing Address

LONG ISLAND JEWISH MEDICAL CENTER
270-05 76th Ave
New Hyde Park, NY 11040

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
NY	00243903,02998887
		1285641514

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
DSH330195A	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - METHADONE CLINIC	75-59 263RD ST.	GLEN OAKS	NY	Active
DSH330195AA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital-Multi Speciality Clinic Rego Park / Ob/Gyn & Prenatal Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195AB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / CAT Scan	102-01 66th Road	Forest Hills	NY	Active
DSH330195AC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / MRI	102-01 66th Road	Forest Hills	NY	Active
DSH330195AD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Radiology	102-01 66th Road	Forest Hills	NY	Active
DSH330195AE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Interventional/Special Procedures	102-01 66th Road	Forest Hills	NY	Active
DSH330195AF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Endoscopy	102-01 66th Road	Forest Hills	NY	Active
DSH330195AG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Ambulatory Surgery	102-01 66th Road	Forest Hills	NY	Active
DSH330195AH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Emergency Deptartment	102-01 66th Road	Forest Hills	NY	Active
DSH330195AJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Institute - Great South Bay	440 East Main Street	Bayshore	NY	Active
DSH330195AK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SCHOOL BASED HC - John Adams	101-01 Rockaway Blvd	Ozone Park	NY	Active
DSH330195AL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Radiation Oncology	450 Lakeville Road	Lake Success	NY	Active
DSH330195AM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Project Outreach	600 Hempstead Turnpike	West Hempstead	NY	Active
DSH330195AN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Garden City Treatment Center	711 Stewart Avenue	Garden City	NY	Active
DSH330195AP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway Treatment Center	1600 Central Avenue	Far Rockaway	NY	Active
DSH330195AQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore-Radiology Diagnostic	440 East Main Street	Bay Shore	NY	Active
DSH330195AR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - Radioisotope	440 East Main Street	Bay Shore	NY	Active
DSH330195AS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - MRI	440 East Main Street	Bay Shore	NY	Active
DSH330195AT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJMC/ Medicine Specialties at Glen Oaks - Clinic	25611 Union Turnpike	Glen Oaks	NY	Active
DSH330195AU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Center - Cancer Treatment Services	270 Pulaski Rd.	Greenlawn	NY	Active
DSH330195AV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - August Martin - School-based Health Center	156-10 Baisley Blvd	Jamaica	NY	Active
DSH330195AW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / EHS - Employee Health Services	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195AX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Hearing and Speech Center - Clinic	430 Lakeville Road	New Hyde Park	NY	Active
DSH330195AY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Pre-Surgical Testing - Pre Surgical Testing	102-01 66th Road	Forest Hills	NY	Active
DSH330195AZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hospital / Women's Health - Ultrasound Diagnostic	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195B	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zuckerberg Cancer Center	450 LAKEVILLE ROAD	LAKE SUCCESS	NY	Active
DSH330195BA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / EKG/ECHO - Electrocardiology	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Personalized Recovery Oriented Services - All Other OASAS Programs O/P	205-07 Hillside Ave	Hollis	NY	Active
DSH330195BC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Lab - Laboratory	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Pre Surgical Testing - Pre Surgical Testing	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Martin Van Buren High School Clinic - Mental Health Clinic	230-17 Hillside Ave	Queens Village	NY	Active
DSH330195BF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP PSY/Social Work Svc Tran - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP Occupat Therapy Trans - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - DAERHS - ALL OTHER OASIS PROGRAMS	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - ELECTROCONVULSIVE THERAPY CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - MEDICAL SPECIALTIES CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - AMBULATORY CARE - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Psych Centers - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CTC CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CRISIS INTERVENTION - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Urology Clinic - Urology	95-25 Queens Boulevard 2nd floor	Rego Park	NY	Active
DSH330195BR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	BACKSTRETCH CLINIC AT BELMONT RACETRACK - Clinic	2150 HEMPSTEAD TURNPIKE COTTAGE 58C	BELMONT	NY	Active
DSH330195BS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Clinic - Peds Immunology	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195BT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital - OBS Check & Call - OBS Check & Call	102-01 66th Road	Forest Hills	NY	Active
DSH330195BU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Perinatal	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - OCD	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Early Treatment	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Bipolar	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - On Track	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - College Partnership	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195C	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - Franklin K Lane	999 Jamaica Ave	Brooklyn	NY	Active
DSH330195CA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Ketamine Infusion Services	75-59 263RD ST	GLEN OAKS	NY	Active
DSH330195CB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Queens Cancer Center	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195D	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	North Shore - LIJ Medical Group Urgent Care Center	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195E	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Recovery Room Ambulatory Surgery	450 Lakeville Rd	Lake Success	NY	Active
DSH330195F	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway HS Clinic SBHC	821 Bay 25th Street	Far Rockaway	NY	Active
DSH330195G	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Brian Picolo MS53 Clinic SBHC	1045 Nameoke Street	Far Rockaway	NY	Active
DSH330195H	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / General Pediatrics	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195J	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / Adolescent Medicine	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195K	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Eye Care Center	600 Northern Blvd	Great Neck	NY	Terminated
DSH330195L	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Medical Center LIJ Satellite Dialysis Center	220-22 Hillside Avenue	Queens Village	NY	Active
DSH330195M	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Nuclear Stress	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195N	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Cardiology Echo	102-01 66th Road	Forest Hills	NY	Active
DSH330195P	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Recovery Room	900 Franklin Ave	Valley Stream	NY	Active
DSH330195Q	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Radiology	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195R	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / HYPERBARIC OXYGEN THERAPY	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195S	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Wound Care	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195T	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Ambulatory Surgery	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195U	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Emergency Department	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195V	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Internal Medicine	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195W	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / General Surgery	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195X	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Cardiology	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195Y	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Wound Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195Z	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills-Rego Park Multi-Specialty Clinic / Podiatry	95-25 Queens Blvd	Rego Park	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5168766061	Cusack, Michele L SVP & CFO Northwell Health 5163216058	1/19/2018 2:42 PM
Contacts	Authorizing Official	Update	AO Change Request	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	Cusack, Michele L SVP & CFO Northwell Health 5168766061	1/9/2018 3:20 PM
Contacts	Authorizing Official	Update	AO Change Request	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	12/4/2017 1:31 PM
Contacts	Authorizing Official	Update		SHAPIRO, ROBERT SR. VP & CFO 5164658162	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	11/30/2017 11:47 AM
Contacts	Signed By	Update		SHAPIRO, ROBERT SR. VP & CFO 5164658162	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	11/30/2017 11:47 AM
Contacts	Primary Contact	Update		Stefas, Onisis VP of Pharmacy Operations 5167195720	Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	10/12/2017 1:11 PM
Contacts	Primary Contact	Update		Briscoe-Dwyer, Leigh A. Chief Pharmacy and Medication Safety Officer 5164723557	Stefas, Onisis VP of Pharmacy Operations 5167195720	7/25/2017 12:32 PM
Contacts	Authorizing Official	Insert			SHAPIRO, ROBERT SR. VP & CFO 5164658162	7/25/2017 12:32 PM
Contacts	Signed By	Insert			SHAPIRO, ROBERT SR. VP & CFO 5164658162	7/25/2017 12:32 PM
Addresses	Main Address	Insert			95-25 Queens Blvd Rego Park, NY 11374	9/30/2016 1:40 PM
Addresses	Billing Address	Insert			LONG ISLAND JEWISH MEDICAL CENTER 270-05 76th Ave New Hyde Park, NY 11040	9/30/2016 1:40 PM
Dates	Last Date That 340B Drugs Purchased	Update			10/1/2016 12:00:00 AM	9/30/2016 1:40 PM
Details	State	Update		Active	Terminated	9/30/2016 1:40 PM
Terminations	Termination Comments	Update			Last patient seen 9/24/16, Rego Park Urgicare Center closes officially on 10/01/16	9/30/2016 1:40 PM
Terminations	Termination Date	Update			10/1/2016 12:00:00 AM	9/30/2016 1:40 PM
Terminations	Termination Effective Date	Update			10/1/2016 12:00:00 AM	9/30/2016 1:40 PM
Terminations	Termination Reason	Update			Site closure	9/30/2016 1:40 PM
Medicaid Billing	Medicaid: Number	Update		243903	00243903	8/31/2016 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/31/2016 3:00 PM
Medicaid Billing	Medicaid: Number	Insert			02998887	8/31/2016 3:00 PM
Medicaid Billing	Medicaid: State	Insert			NY	8/31/2016 3:00 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 3:00 PM
Contacts	Primary Contact	Insert			Briscoe-Dwyer, Leigh A. Chief Pharmacy and Medication Safety Officer 5164723557	8/24/2015 4:38 PM
Details	Last Recertification Date	Update		9/10/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 4:38 PM
Details	Last Recertification Date	Update			9/10/2014 12:00:00 AM	9/10/2014 7:04 AM
Dates	Participating Approval Date	Update			6/11/2014 12:00:00 AM	6/11/2014 5:57 PM
Details	State	Update		Pending	Active	6/11/2014 5:57 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	6/11/2014 5:57 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH330195D	5/29/2014 4:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/15/2014 12:18 PM
Medicaid Billing	Medicaid: Number	Insert			243903	4/15/2014 12:18 PM
Medicaid Billing	Medicaid: State	Insert			NY	4/15/2014 12:18 PM
Medicaid Billing	NPI: Number	Insert			1285641514	4/15/2014 12:18 PM
Details	Last Recertification Date	Insert				4/15/2014 12:18 PM
Details	Grant Number	Insert				4/15/2014 12:18 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/15/2014 12:18 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2014 12:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2014 12:18 PM
Details	Medicare Provider Number	Insert			330195	4/15/2014 12:18 PM
Details	Entity Name	Insert			LONG ISLAND JEWISH MEDICAL CENTER	4/15/2014 12:18 PM
Details	Program Code	Insert			DSH	4/15/2014 12:18 PM
Details	Entity Subname	Insert			North Shore - LIJ Medical Group Urgent Care Center	4/15/2014 12:18 PM
Dates	Participating Approval Date	Insert				4/15/2014 12:18 PM
Details	State	Insert			Pending	4/15/2014 12:18 PM
Dates	Registration Date	Insert			4/15/2014 12:00:00 AM	4/15/2014 12:18 PM
Dates	Signed By Date	Insert			4/15/2014 12:00:00 AM	4/15/2014 12:18 PM
Dates	Start Date	Insert				4/15/2014 12:18 PM
Terminations	Termination Comments	Insert				4/15/2014 12:18 PM
Terminations	Termination Date	Insert				4/15/2014 12:18 PM
Terminations	Termination Effective Date	Insert				4/15/2014 12:18 PM
Terminations	Termination Reason	Insert				4/15/2014 12:18 PM