Covered Entity Details

DSH360051AH MIAMI VALLEY HOSPITAL (Active) - information as of 4/29/2025 1:43:08 AM

Main Details

Name

MIAMI VALLEY HOSPITAL

Subdivision Name

Miami Valley Hospital South- Surgery Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360051AH

Medicare Provider Number

360051

Outpatient Facility Provider Number

360051

Additional Details

Current Program Status

Active

Registration Date

7/3/2014

Participating Start Date

10/1/2014

Participating Approval Date

8/29/2014

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Premier Health
Craig Allen Ganger, Chief Financial Officer
(937) 499-9988

Primary Contact

Premier Health
SHELLY STIDHAM, 340B Coordinator
(937) 838-5767

Addresses

Street Address

2400 Miami Valley Drive
Dayton, OH 45459

Billing Address

Premier Health
110 N Main Street
Attn Accounts Payable
Dayton, OH 45402

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
KY		1073688354
IN		1073688354
OH		1073688354
AZ		1073688354
CO		1073688354
FL		1073688354
MI		1073688354
MO		1073688354
NM		1073688354
NY		1073688354
TX		1073688354
VA		1073688354
WV		1073688354
TN		1073688354
WI		1073688354

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
DSH360051A	Child	DSH	MIAMI VALLEY HOSPITAL	MIAMI VALLEY HOSPITAL SOUTH	2400 MIAMI VALLEY DRIVE	DAYTON	OH	Terminated
DSH360051AA	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Maternal Fetal Medicine	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AB	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Breast Center	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AC	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Womens Center	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AD	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Nuclear Medicine	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AE	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Medical Imaging	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AF	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Anesthesia	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AG	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South-PACU	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AH	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Surgery Center	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AJ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- ATA	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051AK	Child	DSH	MIAMI VALLEY HOSPITAL	CARDIOLOGY	122 WYOMING STREET	Dayton	OH	Terminated
DSH360051AL	Child	DSH	MIAMI VALLEY HOSPITAL	Cardiac Imaging	122 WYOMING STREET	Dayton	OH	Terminated
DSH360051AM	Child	DSH	MIAMI VALLEY HOSPITAL	Maternal Fetal Medicine North	900 South Dixie Drive	Vandalia	OH	Active
DSH360051AN	Child	DSH	MIAMI VALLEY HOSPITAL	BEAVERCREEK SATELLITE / Medical Imaging	1244 MEADOW BRIDGE DR	BEAVERCREEK	OH	Active
DSH360051AP	Child	DSH	MIAMI VALLEY HOSPITAL	SPRINGBORO SATELLITE / Medical Imaging	630N MAIN ST	SPRINGBORO	OH	Active
DSH360051AQ	Child	DSH	MIAMI VALLEY HOSPITAL	FAIRBORN SATELLITE	725 UNIVERSITY BLVD	FAIRBORN	OH	Terminated
DSH360051AR	Child	DSH	MIAMI VALLEY HOSPITAL	BEAVERCREEK SATELLITE / Cardiac Testing	1244 MEADOW BRIDGE DR	BEAVERCREEK	OH	Active
DSH360051AS	Child	DSH	MIAMI VALLEY HOSPITAL	JAMESTOWN SATELLITE / Cardiac Testing	4940 COTTONVILLE RD	JAMESTOWN	OH	Terminated
DSH360051AT	Child	DSH	MIAMI VALLEY HOSPITAL	PAIN CENTER	30 E APPLE ST	DAYTON	OH	Active
DSH360051AU	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Wound Care Center	2400 Miami Valley Drive	Centerville	OH	Active
DSH360051AV	Child	DSH	MIAMI VALLEY HOSPITAL	TURNING POINT OUTPATIENT	627 Edwin C Moses Boulevard	Dayton	OH	Terminated
DSH360051AW	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South / Endoscopy	2400 Miami Valley Drive	Centerville	OH	Active
DSH360051AX	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South / Pain Center	2400 Miami Valley Drive	Centerville	OH	Active
DSH360051AY	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South / Admission/PreOp	2400 Miami Valley Drive, Suite 2000	Centerville	OH	Terminated
DSH360051AZ	Child	DSH	MIAMI VALLEY HOSPITAL	MVH OUTPATIENT PT AND SPORTS MED - Physical Therapy	1525 E Stroop Rd	Dayton	OH	Active
DSH360051BA	Child	DSH	MIAMI VALLEY HOSPITAL	Huber Heights Satellite - Medical Imaging - Medical Imaging	6251 Good Samaritan Way	Dayton	OH	Active
DSH360051BB	Child	DSH	MIAMI VALLEY HOSPITAL	Huber Heights Satellite - Nuclear Medicine - Nuclear Medicine	6251 Good Samaritan Way	Huber Heights	OH	Active
DSH360051BC	Child	DSH	MIAMI VALLEY HOSPITAL	Huber Heights Satellite - Physical Therapy - Physical Therapy	6251 Good Samaritan Way	Huber Heights	OH	Active
DSH360051BD	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital Austin - CT Scan - CT Scan	300 Austin West Blvd	Miamisburg	OH	Active
DSH360051BE	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital Austin - Medical Imaging - Medical Imaging	300 Austin West Blvd	Miamisburg	OH	Active
DSH360051BF	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital Austin - Respiratory - Respiratory	300 Austin West Blvd	Miamisburg	OH	Active
DSH360051BG	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital Austin - Ultrasound - Ultrasound	300 Austin West Blvd	Miamisburg	OH	Active
DSH360051BH	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Anesthesia - Anesthesia	9000 N Main Street	Dayton	OH	Active
DSH360051BJ	Child	DSH	MIAMI VALLEY HOSPITAL	MVH AUSTIN BOULEVARD EMERGENCY CTR - Emergency Center	300 AUSTIN WEST BLVD	MIAMISBURG	OH	Active
DSH360051BK	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Physicial Therapy - Physical Therapy	9000 N Main Street	Dayton	OH	Active
DSH360051BL	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - EEG - EEG	9000 N Main Street	Dayton	OH	Active
DSH360051BM	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Women's Center OBRR - Womens Center OBRR	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051BN	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Nuclear Medicine - Nuclear Medicine	9000 N Main Street	Dayton	OH	Active
DSH360051BP	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Periop - Periop	9000 N Main Street	Dayton	OH	Active
DSH360051BQ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Hemodialysis - Hemodialysis	9000 N Main Street	Dayton	OH	Terminated
DSH360051BR	Child	DSH	MIAMI VALLEY HOSPITAL	Needmore Satellite- Medical Imaging - Medical Imaging	1530 Needmore Road	Dayton	OH	Active
DSH360051BS	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Women's Center LDR - Womens Cener LDR	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051BT	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - PT Rehab - PT Rehab	9000 N Main Street	Dayton	OH	Active
DSH360051BU	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Pulmonary Function - Pulmonary Function	9000 N Main Street	Dayton	OH	Active
DSH360051BV	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Ultrasound - Ultrasound	9000 N Main Street	Dayton	OH	Active
DSH360051BW	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - CT Scan - CT Scan	9000 N Main Street	Dayton	OH	Active
DSH360051BX	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Women's Center LDN - Womens Center	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051BY	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Respiratory - Respiratory	9000 N Main Street	Dayton	OH	Active
DSH360051BZ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - PACU - PACU	9000 N Main Street	Dayton	OH	Active
DSH360051C	Child	DSH	MIAMI VALLEY HOSPITAL	Jamestown- Emergency Department	4940 Cottonville Road	Jamestown	OH	Active
DSH360051CA	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - EMG - EMG	9000 N Main Street	Dayton	OH	Active
DSH360051CB	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Speech Therapy - Speech Therapy	9000 N Main Street	Dayton	OH	Active
DSH360051CC	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Occupational Hand Therapy - Occupational Hand Therapy	9000 N Main Street	Dayton	OH	Active
DSH360051CE	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Medical Imaging - Medical Imaging	9000 N Main Street	Dayton	OH	Active
DSH360051CF	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Pre-Admission Testing - Pre-Admission Testing	9000 N Main Street	Dayton	OH	Active
DSH360051CG	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - OT Rehab - OT Rehab	9000 N Main Street	Dayton	OH	Active
DSH360051CH	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Heart Wellness - Heart Wellness	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051CJ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - MRI - MRI	9000 N Main Street	Dayton	OH	Active
DSH360051CK	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Emergency Department - Emergency Department	9000 N Main Street	Dayton	OH	Active
DSH360051CL	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Operating Room - Operating Room	9000 N Main Street	Dayton	OH	Active
DSH360051CM	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Cardiac Rehabilitation - Cardiac Rehabilitation	9000 N Main Street	Dayton	OH	Active
DSH360051CN	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Breast Center - Breast Center	9000 N Main Street	Dayton	OH	Active
DSH360051CP	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Heart Failure Clinic - Clinic	9000 North Main Street	Dayton	OH	Active
DSH360051CQ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Infusion Therapy - Infusion Center	9000 N Main Street	Dayton	OH	Active
DSH360051CR	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Ambulatory Surgery Center - Surgery	9000 North Main Street	Dayton	OH	Terminated
DSH360051CS	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Cathlab - MVHS Cathlab	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051CT	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Cathlab - MVHN Cathlab	9000 North Main Street	Dayton	OH	Terminated
DSH360051CU	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Cathlab and ATA - MVHS Cathlab and ATA	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051CV	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Surecare Imaging - MVH Surecare Imaging	360 West Central Avenue	Springboro	OH	Active
DSH360051CW	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Beavercreek Radiology - MVH Beavercreek Radiology	1244 Meadow Bridge Drive	Beavercreek	OH	Terminated
DSH360051CX	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Greenville Radiology - MVH Greenville Radiology	742 Sweitzer Street	Greenville	OH	Active
DSH360051CY	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Springboro Physical Therapy - MVH Springboro Physical Therapy	90 Remick Blvd	Springboro	OH	Active
DSH360051CZ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Rio Beavercreek - MVH Rio Beavercreek	1244 Meadow Bridge Drive	Beavercreek	OH	Active
DSH360051D	Child	DSH	MIAMI VALLEY HOSPITAL	Jamestown- Physical Therapy	4940 Cottonville Road	Jamestown	OH	Active
DSH360051DA	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Sleep Center Clyo - MVH Sleep Center Clyo	6611 Clyo Road	Dayton	OH	Active
DSH360051DB	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - SNSC Surgery and Recovery - Ambulatory Surgery	9000 North Main Street	Dayton	OH	Active
DSH360051DC	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Womens Unit - MVHS Womens Unit	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051DD	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Echo Wyoming - MVH Echo Wyoming	122 Wyoming Street	Dayton	OH	Terminated
DSH360051DE	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Center for Sleep and Wake Disorders - Sleep and Wake Disorders	30 E Apple Street	Dayton	OH	Active
DSH360051DF	Child	DSH	MIAMI VALLEY HOSPITAL	MVB EMERGECY ROOM - EMERGENCY ROOM	2400 LAKEVIEW DRIVE	BEAVERCREEK	OH	Active
DSH360051DG	Child	DSH	MIAMI VALLEY HOSPITAL	MVB MEDICAL IMAGING - MEDICAL IMAGING	2400 LAKEVIEW DRIVE	BEAVERCREEK	OH	Active
DSH360051DH	Child	DSH	MIAMI VALLEY HOSPITAL	MVB RESPIRATORY CARE - RESPIRATORY	400 LAKEVIEW DRIVE	BEAVERCREEK	OH	Active
DSH360051DJ	Child	DSH	MIAMI VALLEY HOSPITAL	MVS INFUSION THERAPY - INFUSION	2300 MIAMI VALLEY DRIVE	CENTERVILLE	OH	Active
DSH360051DK	Child	DSH	MIAMI VALLEY HOSPITAL	MVHM INFUSION MIDDLETOWN - INFUSION	501 ATRIUM DRIVE	MIDDLETOWN	OH	Active
DSH360051DL	Child	DSH	MIAMI VALLEY HOSPITAL	MVHT INFUSION TROY - INFUSION	3130 N COUNTY ROAD 25A	TROY	OH	Active
DSH360051DM	Child	DSH	MIAMI VALLEY HOSPITAL	MVS PULMONARY REHAB - PULMONARY	2400 MIAMI VALLEY DRIVE	CENTERVILLE	OH	Active
DSH360051DN	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - OP Heart Clinic - Cardiology	30 E Apple St	Dayton	OH	Active
DSH360051DP	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Echo - Echo	9000 N Main St	Dayton	OH	Active
DSH360051DQ	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Cancer Genetics - Cancer Genetics	9000 N Main St	Dayton	OH	Active
DSH360051DR	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Neuro Infusion - Infusion	2300 Miami Valley Drive	Centerville	OH	Active
DSH360051DS	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Radiation Oncology - Radiation Oncology	9000 N Main St	Dayton	OH	Active
DSH360051DT	Child	DSH	MIAMI VALLEY HOSPITAL	MIAMI VALLEY HOSPITAL- GREENVILLE - Clinic Greenville	742 SWEITZER ST	GREENVILLE	OH	Active
DSH360051DU	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital North - Med Therapy Management - Med Therapy	9000 N Main St	Dayton	OH	Active
DSH360051DV	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital - Infusion Center Greenville - Infusion	1111 Sweitzer St	Greenville	OH	Active
DSH360051DW	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Med Therapy Management - Med Therapy	2400 Miami Valley Drive	Centerville	OH	Active
DSH360051E	Child	DSH	MIAMI VALLEY HOSPITAL	Jamestown- Respiratory	4940 Cottonville Road	Jamestown	OH	Active
DSH360051F	Child	DSH	MIAMI VALLEY HOSPITAL	Jamestown-Medical Imaging	4940 Cottonville Road	Jamestown	OH	Active
DSH360051G	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Women's Unit	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051H	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Orthopedic Unit	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051J	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South -Patient Care Unit 1	2400 Miami Valley Drive	Dayton	OH	Terminated
DSH360051K	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Emergency Department	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051L	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital -South Echo	2400 Miami Valley Drive	Centerville	OH	Active
DSH360051M	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South -Noninvasive Cardiology	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051N	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Acute Speech Therapy	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051P	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Acute Occupational Therapy	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051Q	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Occupational Hand Therapy	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051R	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Acute Physical Therapy	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051S	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital -South Sports Medicine	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051T	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South - Respiratory	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051U	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South -Hyperbaric Center	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051V	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South -Vascular Ultrasound	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051W	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South -MRI	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051X	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- CT Scan	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051Y	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital- South Gyn Oncology	2400 Miami Valley Drive	Dayton	OH	Active
DSH360051Z	Child	DSH	MIAMI VALLEY HOSPITAL	Miami Valley Hospital South- Ultrasound	2400 Miami Valley Drive	Dayton	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/1/2023 2:56:29 PM	8/23/2024 8:09:21 AM	8/23/2024 8:09 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 9:38:37 AM	9/1/2023 2:56:29 PM	9/1/2023 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	2/15/2023 7:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	2/15/2023 7:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	2/15/2023 7:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	2/15/2023 7:07 PM
Details	Last Recertification Date	Update	Recertification	8/20/2021 9:31:43 AM	9/7/2022 9:38:37 AM	9/7/2022 9:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01540012 (KY)		1/14/2022 9:57 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300013423 (IN)		1/14/2022 9:57 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	5935608 (OH)		1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	1/14/2022 9:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073688354	1/14/2022 9:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/14/2022 9:57 AM
Details	Last Recertification Date	Update	Recertification	8/25/2020 3:02:20 PM	8/20/2021 9:31:43 AM	8/20/2021 9:31 AM
Contacts	Primary Contact	Update	Change Request	Ranly, Jennifer Marie Director, Reimbursement Premier Health 9374995529	STIDHAM, SHELLY 340B Coordinator Premier Health 9378385767	3/10/2021 12:53 PM
Contacts	Authorizing Official	Update	AO Change Request	Shelton, Scott Andrew VP CFO Premier Health 9374999989	Ganger, Craig Allen Chief Financial Officer Premier Health 9374999988	12/21/2020 7:16 AM
Addresses	Billing Address	Insert	Change Request		Premier Health 110 N Main Street Attn Accounts Payable Dayton, OH 45402	10/13/2020 8:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073688354	8/25/2020 3:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	8/25/2020 3:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073688354	8/25/2020 3:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/25/2020 3:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073688354	8/25/2020 3:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/25/2020 3:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1073688354 ( )		8/25/2020 3:02 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 1:06:57 PM	8/25/2020 3:02:20 PM	8/25/2020 3:02 PM
Details	Last Recertification Date	Update	Recertification	8/31/2018 2:26:17 PM	8/20/2019 1:06:57 PM	8/20/2019 1:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2019 5:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01540012	4/10/2019 5:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	4/10/2019 5:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2019 5:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300013423	4/10/2019 5:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/10/2019 5:11 PM
Contacts	Primary Contact	Update	Change Request	Aylor, Melany C. Reimbursement Analyst Premier Health 9374995662	Ranly, Jennifer Marie Director, Reimbursement Premier Health 9374995529	12/17/2018 3:16 PM
Details	Last Recertification Date	Update	Recertification	11/17/2017 10:36:15 AM	8/31/2018 2:26:17 PM	8/31/2018 2:26 PM
Contacts	Primary Contact	Update	Change Request	Johnson, Renee Director Premier Health 9374995519	Aylor, Melany C. Reimbursement Analyst Premier Health 9374995662	7/16/2018 12:20 PM
Contacts	Authorizing Official	Update	AO Change Request	DUNCAN, THOMAS CFO Premier Health 9374999988	Shelton, Scott Andrew VP CFO Premier Health 9374999989	6/14/2018 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/17/2017 10:36:15 AM	11/17/2017 10:36 AM
Contacts	Authorizing Official	Update		DUNCAN, THOMAS CFO 9374999988	DUNCAN, THOMAS CFO Premier Health 9374999988	10/2/2017 11:14 AM
Contacts	Primary Contact	Update		Johnson, Renee Director 9374995519	Johnson, Renee Director Premier Health 9374995519	9/27/2017 9:52 AM
Contacts	Primary Contact	Insert			Johnson, Renee Director 9374995519	7/12/2017 6:04 PM
Contacts	Authorizing Official	Insert			DUNCAN, THOMAS CFO 9374999988	7/12/2017 3:44 PM
Contacts	Signed By	Insert			SHELTON, SCOTT CFO 9372084026	7/12/2017 3:44 PM
Addresses	Main Address	Insert			2400 Miami Valley Drive Dayton, OH 45459	7/12/2017 3:44 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 3:07 PM
Medicaid Billing	NPI: Number	Insert			1073688354	10/21/2015 2:59 PM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 9:35 AM
Details	Entity Subname	Update		Miami Valley Hospital South- Surgery Center / Surgery Center	Miami Valley Hospital South- Surgery Center	12/31/2014 3:51 PM
Details	Entity Subname	Update		Miami Valley Hospital South- Surgery Center	Miami Valley Hospital South- Surgery Center / Surgery Center	12/19/2014 2:16 PM
Dates	Participating Approval Date	Update			8/29/2014 12:00:00 AM	8/29/2014 4:55 PM
Details	State	Update		Pending	Active	8/29/2014 4:55 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	8/29/2014 4:55 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_44291	DSH360051AH	8/26/2014 9:36 AM
Details	Entity Subname	Update		Miami Valley Hospital South Surgery Center	Miami Valley Hospital South- Surgery Center	8/26/2014 9:36 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_44291	7/3/2014 9:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/3/2014 9:13 AM
Medicaid Billing	Medicaid: Number	Insert			5935608	7/3/2014 9:13 AM
Medicaid Billing	Medicaid: State	Insert			OH	7/3/2014 9:13 AM
Details	Last Recertification Date	Insert				7/3/2014 9:13 AM
Details	Grant Number	Insert				7/3/2014 9:13 AM
Details	340B ID	Insert				7/3/2014 9:13 AM
Details	Is Authorizing Official EHB Data	Insert				7/3/2014 9:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/3/2014 9:13 AM
Details	Medicare Provider Number	Insert			360051	7/3/2014 9:13 AM
Details	Entity Name	Insert			MIAMI VALLEY HOSPITAL	7/3/2014 9:13 AM
Details	Program Code	Insert			DSH	7/3/2014 9:13 AM
Details	Entity Subname	Insert			Miami Valley Hospital South Surgery Center	7/3/2014 9:13 AM
Dates	Participating Approval Date	Insert				7/3/2014 9:13 AM
Details	State	Insert			Pending	7/3/2014 9:13 AM
Dates	Registration Date	Insert			7/3/2014 12:00:00 AM	7/3/2014 9:13 AM
Dates	Signed By Date	Insert			7/3/2014 12:00:00 AM	7/3/2014 9:13 AM
Dates	Start Date	Insert				7/3/2014 9:13 AM
Terminations	Termination Comments	Insert				7/3/2014 9:13 AM
Terminations	Termination Date	Insert				7/3/2014 9:13 AM
Terminations	Termination Effective Date	Insert				7/3/2014 9:13 AM
Terminations	Termination Reason	Insert				7/3/2014 9:13 AM