Covered Entity Details

DSH330044U Faxton St. Luke's Healthcare (Terminated) - information as of 6/25/2025 12:51:47 AM

Main Details

Name

Faxton St. Luke's Healthcare

Subdivision Name

Recovery Room Faxton

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330044U

Medicare Provider Number

330044

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

5/10/2014

Participating Start Date

7/1/2014

Participating Approval Date

5/22/2014

Last Recertification Date

11/27/2017

Termination Date
Termination Reason

10/1/2018
Site closure

Contacts

Authorizing Official

MVHS Inc, DBA Wynn Hospital
Louis Aiello, Sr. VP Finance/ CFO
(315) 917-8213

Primary Contact

MVHS, Inc. DBA: Wynn Hospital
James Humphrey, AVP Finance/ Controller
(315) 801-4326

Addresses

Street Address

1676 Sunset Ave.
Utica, NY 13502

Billing Address

Faxton St. Luke's Healthcare
PO Box 479
Utica, NY 13503

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	00384309,003193024
		1649350380,1205877172

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
DSH330044A	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Imaging Center	106 Business Park Drive	Utica	NY	Active
DSH330044AA	Child	DSH	Faxton St. Luke's Healthcare	Balance Center	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AB	Child	DSH	Faxton St. Luke's Healthcare	Lymphedema Program	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AC	Child	DSH	Faxton St. Luke's Healthcare	Physical Therapy	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AD	Child	DSH	Faxton St. Luke's Healthcare	Occupational Therapy	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AE	Child	DSH	Faxton St. Luke's Healthcare	Speech Therapy Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AF	Child	DSH	Faxton St. Luke's Healthcare	Home Hemodialysis	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AG	Child	DSH	Faxton St. Luke's Healthcare	Home Peritoneal Dialysis	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AH	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AJ	Child	DSH	Faxton St. Luke's Healthcare	Ambulatory Surgery Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AK	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Audiology	1676 Sunset Ave.	Utica	NY	Active
DSH330044AL	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Ultrasound Faxton	1676 Sunset Ave.	Utica	NY	Active
DSH330044AM	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Outpatient Infusion	1676 Sunset Ave.	Utica	NY	Active
DSH330044AN	Child	DSH	Faxton St. Luke's Healthcare	Endo/ GI Unit Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AP	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Diabetes Education	1676 Sunset Ave.	Utica	NY	Active
DSH330044AQ	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Pet Scan	1676 Sunset Ave.	Utica	NY	Active
DSH330044AR	Child	DSH	Faxton St. Luke's Healthcare	Urgent Care	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044AS	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	ACP Surgeons	1658 Champlin Ave	Utica	NY	Active
DSH330044AT	Child	DSH	Faxton St. Luke's Healthcare	Vascular Surgery	1676 Sunset Avenue	Utica	NY	Terminated
DSH330044AU	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Orthopedic Surgery	1903 Sunset Avenue	Utica	NY	Active
DSH330044AV	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	GI Office	1658 Champlin Ave.	Utica	NY	Active
DSH330044AW	Child	DSH	Faxton St. Luke's Healthcare	SAUQUOIT MEDICAL OFFICE	2888 ONEIDA ST	SAUQUOIT	NY	Terminated
DSH330044AX	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Neuro Interventional	1656 Champlin Ave.	Utica	NY	Terminated
DSH330044AY	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MVHS Pulmonary Group	35 Riverside Drive	Utica	NY	Active
DSH330044AZ	Child	DSH	Faxton St. Luke's Healthcare	WATERVILLE MEDICAL OFFICE	117 W MAIN ST	WATERVILLE	NY	Terminated
DSH330044B	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - Rome	91 Perimeter Road Mohawk Glenn, Suite 140	Rome	NY	Terminated
DSH330044BA	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	CLINTON MEDICAL CENTER	101 COLLEGE ST	CLINTON	NY	Active
DSH330044BB	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Neuro Science Physician Office	1658 Champlin Ave.	Utica	NY	Active
DSH330044BC	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MVHS Surgeons - Faxton Location - Surgery	1676 Sunset Ave.	Utica	NY	Active
DSH330044BD	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Oneida Medical Office - Primary Care	131 Main Street	Oneida	NY	Active
DSH330044BE	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Rome Medical Office - Primary Care	1617 North James Street	Rome	NY	Active
DSH330044BF	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Upstate Urology at MVHS - Urology	1676 Sunset Avenue	Utica	NY	Active
DSH330044BG	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Herkimer Oncology - Oncology	201 East State Street	Herkimer	NY	Active
DSH330044BH	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Oncology Clinic - Oncology	807 Newell Street	Utica	NY	Active
DSH330044BJ	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Rome Oncology Office - Oncology	91 Perimeter Road	Rome	NY	Active
DSH330044BK	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Surburban OB - OB/GYN	1656 Champlin Ave.	Utica	NY	Active
DSH330044BL	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	OP Psychiatry - Psychiatry	1676 Sunset Ave.	New Hartford	NY	Active
DSH330044BM	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Pulmonary Function Testing - Respiratory Therapy	4401 Middle Settlement Road	New Hartford	NY	Active
DSH330044BN	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MVHS Podiatry - Podiatry	120 Hobart Street	Utica	NY	Active
DSH330044BP	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Sleep Laboratroy - Sleep Studies	2215 Genesee Street	Utica	NY	Active
DSH330044BQ	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Wound Care - Wound Care	Medical Arts Building	New Hartford	NY	Active
DSH330044BR	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Sr. Rose Vincent Family Med Ctr - Primary Care	120 Hobart Street	Utica	NY	Active
DSH330044BS	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Prim - Town of Webb - Primary Care	114 South Shore Road	Old Forge	NY	Active
DSH330044BT	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Little Falls Primary Care - Primary Care	500 East Main Street	Little Falls	NY	Active
DSH330044BU	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Prim - East Utica - Primary Care	1256 Culver Ave.	Utica	NY	Active
DSH330044BV	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Prim - Children's Health - Pediatric	2212 Genesee Street	Utica	NY	Active
DSH330044BW	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Spec - Bariatric Surgery - Bariatric Surgery	1676 Sunset Ave.	Utica	NY	Active
DSH330044BX	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Comm Med - Infectious Disease - Infectious Disease	6 Hampden Place	Utica	NY	Active
DSH330044BY	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Endo / GI Unit MVEC - Endoscopy	116 Business Park Drive	Utica	NY	Active
DSH330044BZ	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Medical Group Trauma Surgeons - Trauma Surgeons	601 State Street	Utica	NY	Active
DSH330044C	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - Oneida	131 Main Street, Suite 201	Oneida	NY	Terminated
DSH330044CA	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Vascular Surgery - Vascular Surgery	601 State Street	Utica	NY	Active
DSH330044CB	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	MG - Spec - CT Surgery - Cardio Thoracic Surgeons	MG - Spec - CT Surgery	Utica	NY	Active
DSH330044CC	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Medical Group - Cardiology - Cardiology	Medical Arts Building	New Hartford	NY	Terminated
DSH330044D	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - Masonic	Soldiers & Sailors Building, 1st Floor	Utica	NY	Terminated
DSH330044E	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - Hamilton	10 Eaton Street	Hamilton	NY	Terminated
DSH330044F	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Dental Health Center	1714 Burrstone Road	New Hartford	NY	Terminated
DSH330044G	Child	DSH	Faxton St. Luke's Healthcare	Genesee Urgent Care	1904 Genesee Street	Utica	NY	Terminated
DSH330044H	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Whitesboro Medical Office	37 Main Street	Whitesboro	NY	Active
DSH330044J	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Waterville Medical Office	358 Madison Street	Waterville	NY	Active
DSH330044K	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Washington Mills Medical Office	3946 Oneida Street	New Hartford	NY	Active
DSH330044L	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	North Utica Medical Office	417 Trenton Road	Utica	NY	Active
DSH330044M	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	New Hartford Medical Office	8411 Seneca Turnpike	New Hartford	NY	Active
DSH330044N	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Mohawk Valley Medical Office	201 East State Street	Herkimer	NY	Active
DSH330044P	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Boonville Medical Office	13460 State Route 12	Boonville	NY	Active
DSH330044Q	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Barneveld Medical Office	7980 State Route 12	Barneveld	NY	Active
DSH330044R	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - SLH	1650 Champlin Ave.	Utica	NY	Terminated
DSH330044S	Child	DSH	Faxton St. Luke's Healthcare	Renal Dialysis - Herkimer	201 East State Street	Herkimer	NY	Terminated
DSH330044T	Child	DSH	Faxton St. Luke's Healthcare	Operating Room Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044U	Child	DSH	Faxton St. Luke's Healthcare	Recovery Room Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044V	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Radiology Diagnostic Faxton	1676 Sunset Ave	Utica	NY	Active
DSH330044W	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Cancer Care Program	1676 Sunset Avenue	Utica	NY	Active
DSH330044X	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Radiation Medicine	1676 Sunset Ave.	Utica	NY	Active
DSH330044Y	Child	DSH	Faxton St. Luke's Healthcare	Nuclear Medicine Faxton	1676 Sunset Ave.	Utica	NY	Terminated
DSH330044Z	Child	DSH	MVHS, Inc. DBA: Wynn Hospital	Cat Scan Faxton	1676 Sunset Ave.	Utica	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Aiello, Louis Sr. VP Finance/ CFO Faxton St. Luke's Healthcare 3156246143	Aiello, Louis Sr. VP Finance/ CFO MVHS Inc, DBA Wynn Hospital 3159178213	5/31/2024 8:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Humphrey, James AVP Finance/ Controller Faxton St. Luke's Healthcare 3158014326	Humphrey, James AVP Finance/ Controller MVHS, Inc. DBA: Wynn Hospital 3158014326	5/28/2024 7:29 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/30/2018 12:00:00 AM	8/27/2018 1:33 PM
Details	State	Update	Recertification	Active	To Be Terminated	8/27/2018 1:33 PM
Terminations	Termination Date	Update	Recertification		10/1/2018 12:00:00 AM	8/27/2018 1:33 PM
Terminations	Termination Effective Date	Update	Recertification		6/30/2018 12:00:00 AM	8/27/2018 1:33 PM
Terminations	Termination Reason	Update	Recertification		Site closure	8/27/2018 1:33 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/27/2017 12:53:40 PM	11/27/2017 12:53 PM
Contacts	Primary Contact	Update		Humphrey, James AVP Finance/ Controller 3158014326	Humphrey, James AVP Finance/ Controller Faxton St. Luke's Healthcare 3158014326	10/18/2017 2:48 PM
Contacts	Authorizing Official	Update		Aiello, Louis Sr. VP Finance/ CFO 3156246143	Aiello, Louis Sr. VP Finance/ CFO Faxton St. Luke's Healthcare 3156246143	10/18/2017 10:19 AM
Contacts	Primary Contact	Insert			Humphrey, James AVP Finance/ Controller 3158014326	8/2/2017 1:51 PM
Contacts	Authorizing Official	Insert			Aiello, Louis Sr. VP Finance/ CFO 3156246143	8/2/2017 1:51 PM
Contacts	Signed By	Insert			Aiello, Louis Sr. VP Finance/ CFO 3156246143	7/14/2017 9:04 AM
Addresses	Main Address	Insert			1676 Sunset Ave. Utica, NY 13502	4/26/2017 12:53 PM
Addresses	Billing Address	Insert			Faxton St. Luke's Healthcare PO Box 479 Utica, NY 13503	4/26/2017 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/16/2017 9:18 AM
Medicaid Billing	Medicaid: Number	Insert			003193024	3/16/2017 9:18 AM
Medicaid Billing	Medicaid: State	Insert			NY	3/16/2017 9:18 AM
Medicaid Billing	NPI: Number	Insert			1205877172	3/16/2017 9:18 AM
Details	Last Recertification Date	Update		8/21/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 10:40 AM
Details	Last Recertification Date	Update		8/25/2014 12:00:00 AM	8/21/2015 12:00:00 AM	8/21/2015 1:38 PM
Details	Last Recertification Date	Update			8/25/2014 12:00:00 AM	8/25/2014 7:24 AM
Dates	Participating Approval Date	Update			5/22/2014 12:00:00 AM	5/22/2014 5:01 PM
Details	State	Update		Pending	Active	5/22/2014 5:01 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	5/22/2014 5:01 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH330044U	5/14/2014 9:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/10/2014 8:06 AM
Medicaid Billing	Medicaid: Number	Insert			00384309	5/10/2014 8:06 AM
Medicaid Billing	Medicaid: State	Insert			NY	5/10/2014 8:06 AM
Medicaid Billing	NPI: Number	Insert			1649350380	5/10/2014 8:06 AM
Details	Last Recertification Date	Insert				5/10/2014 8:06 AM
Details	Grant Number	Insert				5/10/2014 8:06 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	5/10/2014 8:06 AM
Details	Is Authorizing Official EHB Data	Insert				5/10/2014 8:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert				5/10/2014 8:06 AM
Details	Medicare Provider Number	Insert			330044	5/10/2014 8:06 AM
Details	Entity Name	Insert			Faxton St. Luke's Healthcare	5/10/2014 8:06 AM
Details	Program Code	Insert			DSH	5/10/2014 8:06 AM
Details	Entity Subname	Insert			Recovery Room Faxton	5/10/2014 8:06 AM
Dates	Participating Approval Date	Insert				5/10/2014 8:06 AM
Details	State	Insert			Pending	5/10/2014 8:06 AM
Dates	Registration Date	Insert			5/10/2014 12:00:00 AM	5/10/2014 8:06 AM
Dates	Signed By Date	Insert			5/10/2014 12:00:00 AM	5/10/2014 8:06 AM
Dates	Start Date	Insert				5/10/2014 8:06 AM
Terminations	Termination Comments	Insert				5/10/2014 8:06 AM
Terminations	Termination Date	Insert				5/10/2014 8:06 AM
Terminations	Termination Effective Date	Insert				5/10/2014 8:06 AM
Terminations	Termination Reason	Insert				5/10/2014 8:06 AM