Covered Entity Details

DSH340023AW ADVENTHEALTH HENDERSONVILLE (Active) - information as of 4/29/2025 11:57:03 PM

Main Details

Name

ADVENTHEALTH HENDERSONVILLE

Subdivision Name

AdventHealth Medical Group Neurology at Hendersonville

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340023AW

Medicare Provider Number

340023

Outpatient Facility Provider Number

340023

Additional Details

Current Program Status

Active

Registration Date

1/13/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/6/2025

Last Recertification Date

Contacts

Authorizing Official

AdventHealth Hendersonville
Steven Burroughs, VP of Finance / CFO
(828) 681-2102

Primary Contact

Adventhealth
Rafael Kirkpatrick, SE Region 340B Coordinator
(956) 466-8487

Addresses

Street Address

50 DOCTORS DRIVE
SUITE 1
HENDERSONVILLE, NC 28792-7209

Billing Address

AdventHealth Hendersonville
c/o AdventHealth
902 Inspiration Ave.
Suite 9100
Altamonte Springs, FL 32714

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 10/1/2014, terminated 7/1/2024. Reinstated 4/1/2025.	01/27/2025

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
NC	3400023S,3400023	1427075027,1265466452

Shipping Addresses

Shipping Address 1

AdventHealth Hendersonville
100 Hospital Drive
Hendersonville, NC 28792

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
DSH340023A	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Hematology Oncology Infusion Services Hendersonville	50 HOSPITAL DRIVE	HENDERSONVILLE	NC	Active
DSH340023AA	Child	DSH	PARK RIDGE HEALTH	Southeastern Sports Medicine of Laurel Park	1881 Pisgah Drive	Hendersonville	NC	Terminated
DSH340023AC	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Urology at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023AD	Child	DSH	PARK RIDGE HEALTH	Southeastern Sports Medicine of Waynesville	35 Valley View Terrace	Waynesville	NC	Terminated
DSH340023AE	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Cardiology at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023AH	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Ear, Nose & Throat at Hendersonville	80 Doctors Drive	Hendersonville	NC	Active
DSH340023AJ	Child	DSH	PARK RIDGE HEALTH	Southeastern Sports Medicine	2315 Asheville Highway	Hendersonville	NC	Terminated
DSH340023AK	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Multispecialty at South Asheville	15 Skyland Inn Drive	Arden	NC	Active
DSH340023AL	Child	DSH	PARK RIDGE HEALTH	Carolinas Center for Advanced Management of Pain	50 Hospital Drive	Hendersonville	NC	Terminated
DSH340023AM	Child	DSH	PARK RIDGE HEALTH	Park Ridge Health Infectious Diseases	50 Hospital Drive	Hendersonville	NC	Terminated
DSH340023AN	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Hematology Oncology Infusion Services Asheville	20 Medical Park Drive	Asheville	NC	Active
DSH340023AP	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Hematology Oncology Infusion Services Haywood	49 Spicewood Drive	Clyde	NC	Active
DSH340023AQ	Child	DSH	PARK RIDGE HEALTH	Park Ridge Health Pediatric Urology	81 Doctors Drive	Hendersonville	NC	Terminated
DSH340023AR	Child	DSH	PARK RIDGE HEALTH	Southeastern Sports Medicine	61 Weaver Boulevard	Weaverville	NC	Terminated
DSH340023AS	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Endocrinology at Hendersonville	81 Doctors Drive	Hendersonville	NC	Active
DSH340023AT	Child	DSH	PARK RIDGE HEALTH	Asheville Sleep Center	333 Gashes Creek Rd.	Asheville	NC	Terminated
DSH340023AU	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Integrative Medicine at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023AV	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Family Medicine at Forge Mountain	127 VANCE HILL DRIVE	MILLS RIVER	NC	Active
DSH340023AW	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Neurology at Hendersonville	50 DOCTORS DRIVE	HENDERSONVILLE	NC	Active
DSH340023AX	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Behavioral Health Medical Office Building	50 HOSPITAL DRIVE	HENDERSONVILLE	NC	Active
DSH340023AZ	Child	DSH	AdventHealth Hendersonville	AdventHealth Medical Group Multispecialty at Parkway	333 GASHES CREEK ROAD	ASHEVILLE	NC	Terminated
DSH340023BA	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Family Medicine at Black Mountain	15 JANE JACOBS ROAD	BLACK MOUNTAIN	NC	Active
DSH340023BB	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Multispecialty at Parkway	333 GASHES CREEK RD.	ASHEVILLE	NC	Active
DSH340023BC	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Rheumatology at Hendersonville	80 Doctors Drive	HENDERSONVILLE	NC	Active
DSH340023BD	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Internal Medicine at Hendersonville	50 DOCTORS DRIVE	HENDERSONVILLE	NC	Active
DSH340023BE	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Hematology Oncology Infusion Services Weaverville	179 NORTH BUNCOMBE SCHOOL ROAD	WEAVERVILLE	NC	Active
DSH340023BF	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Cardiac Rehabilitation Hendersonville	50 Hospital Drive	Hendersonville	NC	Active
DSH340023BG	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Multispecialty at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023BH	Child	DSH	PARK RIDGE HEALTH	FLETCHER HOSPITAL INCORPORATED / Park Ridge Health Foundation in Spine Health	333 GASHES CREEK ROAD SUITE 111	ASHEVILLE	NC	Terminated
DSH340023BJ	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Family Medicine at Biltmore Park	1 Town Square	Asheville	NC	Active
DSH340023BK	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AHMG MULTISPECIALTY AT CANDLER - Multispecialty	1388 SAND HILL RD	CANDLER	NC	Active
DSH340023C	Child	DSH	PARK RIDGE HEALTH	SOUTHEASTERN SPORTS MEDICINE	21 TURTLE CREEK DRIVE	ASHEVILLE	NC	Terminated
DSH340023F	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Surgery Specialists at Hendersonville	80 Doctors Drive	Hendersonville	NC	Active
DSH340023H	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Multispecialty at Laurel Park	1881 Pisgah Drive	Hendersonville	NC	Active
DSH340023J	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Breast Center at Hendersonville	80 Doctors Drive	Hendersonville	NC	Active
DSH340023L	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Audiology at Hendersonville	80 Doctors Drive	Hendersonville	NC	Active
DSH340023M	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Family Medicine at Hendersonville	207 Linda Vista Drive	Hendersonville	NC	Active
DSH340023Q	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Obstetrics & Gynecology at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023R	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Dermatology at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023S	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Pediatrics at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023U	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Psychiatry at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023V	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Pulmonology & Sleep Medicine at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023X	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Wound Care & Hyperbaric Medicine at Medical Office Building	50 Hospital Drive	Hendersonville	NC	Active
DSH340023Y	Child	DSH	ADVENTHEALTH HENDERSONVILLE	AdventHealth Medical Group Family Medicine at Mills River	125 Vance Hill Drive	Mills River	NC	Active
DSH340023Z	Child	DSH	PARK RIDGE HEALTH	Southeastern Sports Medicine of Hendersonville	204 South King Street	Hendersonville	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Addresses	Billing Address	Insert	Reinstatement		AdventHealth Hendersonville c/o AdventHealth 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	2/6/2025 6:55 AM
Contacts	Signed By	Update	Reinstatement	Barber, Wendi VP FINANCE, CFO 340023 8286812102	Burroughs, Steven VP of Finance / CFO AdventHealth Hendersonville 8286812102	2/6/2025 6:55 AM
Contacts	Primary Contact	Update	Reinstatement	Phillips, Larry D Director Supply Chain and 340B Pharmacy Adventhealth Hendersonville 8286812720	Kirkpatrick, Rafael SE Region 340B Coordinator Adventhealth 9564668487	2/6/2025 6:55 AM
Details	Last Recertification Date	Update	Reinstatement	8/30/2023 10:51:43 AM		2/6/2025 6:55 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	7/1/2024 12:00:00 AM		2/6/2025 6:55 AM
Details	Entity Name	Update	Reinstatement	AdventHealth Hendersonville	ADVENTHEALTH HENDERSONVILLE	2/6/2025 6:55 AM
Dates	Participating Approval Date	Update	Reinstatement	9/15/2014 12:00:00 AM	2/6/2025 6:55:54 AM	2/6/2025 6:55 AM
Details	State	Update	Reinstatement	Terminated	Approved	2/6/2025 6:55 AM
Dates	Registration Date	Update	Reinstatement	7/9/2014 12:00:00 AM	1/13/2025 10:25:54 AM	2/6/2025 6:55 AM
Dates	Signed By Date	Update	Reinstatement	7/9/2014 12:00:00 AM	1/14/2025 1:50:40 PM	2/6/2025 6:55 AM
Dates	Start Date	Update	Reinstatement	10/1/2014 12:00:00 AM	4/1/2025 12:00:00 AM	2/6/2025 6:55 AM
Terminations	Termination Date	Update	Reinstatement	7/1/2024 12:00:00 AM		2/6/2025 6:55 AM
Terminations	Termination Effective Date	Update	Reinstatement	7/1/2024 12:00:00 AM		2/6/2025 6:55 AM
Terminations	Termination Reason	Update	Reinstatement	Change of covered entity type		2/6/2025 6:55 AM
Details	Comments Public	Insert	Reinstatement		Participated starting 10/1/2014, terminated 7/1/2024. Reinstated 4/1/2025.	1/27/2025 12:47 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/22/2024 2:49 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	4/22/2024 2:49 PM
Terminations	Termination Date	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/22/2024 2:49 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/22/2024 2:49 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	4/22/2024 2:49 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 8:21:14 AM	8/30/2023 10:51:43 AM	8/30/2023 10:51 AM
Contacts	Authorizing Official	Update	AO Change Request	Nudd, Brandon M President & CEO AdventHealth Hendersonville 8286812102	Burroughs, Steven VP of Finance / CFO AdventHealth Hendersonville 8286812102	4/3/2023 10:28 AM
Contacts	Primary Contact	Update	PC Change Request	Horn, Jonathan 340B Coordinator AdventHealth 7708784891	Phillips, Larry D Director Supply Chain and 340B Pharmacy Adventhealth Hendersonville 8286812720	3/28/2023 8:33 AM
Contacts	Authorizing Official	Update	AO Change Request	Stenstrom, Ella CFO Park Ridge Health 8286812102	Nudd, Brandon M President & CEO AdventHealth Hendersonville 8286812102	12/13/2022 3:49 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3407195 (NC)		10/14/2022 10:43 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992740468 (NC)		10/14/2022 10:43 AM
Contacts	Primary Contact	Update	Recertification	Roselli, Jessica 340B Coordinator AdventHealth Hendersonville 8286812168	Horn, Jonathan 340B Coordinator AdventHealth 7708784891	9/8/2022 8:21 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 8:36:10 AM	9/8/2022 8:21:14 AM	9/8/2022 8:21 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 12:48:49 PM	9/9/2021 8:36:10 AM	9/9/2021 8:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:48 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3400023S	9/3/2020 12:48 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/3/2020 12:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:48 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3407195	9/3/2020 12:48 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/3/2020 12:48 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1427075027 ( )		9/3/2020 12:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1427075027	9/3/2020 12:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/3/2020 12:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265466452	9/3/2020 12:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/3/2020 12:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992740468	9/3/2020 12:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/3/2020 12:48 PM
Details	Last Recertification Date	Update	Recertification	8/23/2019 4:14:30 PM	9/3/2020 12:48:49 PM	9/3/2020 12:48 PM
Contacts	Primary Contact	Update	Change Request	Bayne, Christina Interim 340B Regional Mgr Southeast Region 8286508298	Roselli, Jessica 340B Coordinator AdventHealth Hendersonville 8286812168	11/21/2019 9:33 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 9:17:34 AM	8/23/2019 4:14:30 PM	8/23/2019 4:14 PM
Addresses	Billing Address	Update	Change Request	AdventHealth Hendersonville c/o Adventist Health System 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	AdventHealth Hendersonville c/o AdventHealth 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	8/14/2019 4:40 PM
Contacts	Authorizing Official	Update	Profile Change Request	Stenstrom, Ella Interim CFO Park Ridge Health 8286812102	Stenstrom, Ella CFO Park Ridge Health 8286812102	7/25/2019 11:45 AM
Contacts	Authorizing Official	Update	Profile Change Request	Stenstrom, Ella Interim CFO Park Ridge Health 6123902075	Stenstrom, Ella Interim CFO Park Ridge Health 8286812102	7/25/2019 11:45 AM
Addresses	Shipping Address	Insert	Change Request		AdventHealth Hendersonville 100 Hospital Drive Hendersonville, NC 28792	4/26/2019 1:54 PM
Addresses	Billing Address	Update	Change Request	Park Ridge Health c/o Adventist Health System 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	AdventHealth Hendersonville c/o Adventist Health System 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	4/26/2019 1:54 PM
Addresses	Shipping Address	Delete	Change Request	Park Ridge Health 100 Hospital Drive Hendersonville, NC 28792		4/26/2019 1:54 PM
Details	Entity Subname	Update	Change Request	Park Ridge Health Neurology	AdventHealth Medical Group Neurology at Hendersonville	4/26/2019 1:54 PM
Details	Entity Name	Update	Change Request	PARK RIDGE HEALTH	AdventHealth Hendersonville	4/26/2019 1:48 PM
Contacts	Primary Contact	Update	Change Request	Molnar, Diane 340B Regional Manager Southeast Region 8286812168	Bayne, Christina Interim 340B Regional Mgr Southeast Region 8286508298	12/21/2018 10:44 AM
Contacts	Authorizing Official	Update	Change Request	Barber, Wendi VP FINANCE, CFO 340023 8286812102	Stenstrom, Ella Interim CFO Park Ridge Health 6123902075	11/26/2018 7:12 AM
Details	Last Recertification Date	Update	Recertification	11/16/2017 4:47:15 PM	9/4/2018 9:17:34 AM	9/4/2018 9:17 AM
Addresses	Billing Address	Update	Recertification	Park Ridge Health 50 Doctors Dr. Suite G-A Hendersonville, NC 28792	Park Ridge Health c/o Adventist Health System 902 Inspiration Ave. Suite 9100 Altamonte Springs, FL 32714	11/16/2017 4:47 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/16/2017 4:47:15 PM	11/16/2017 4:47 PM
Contacts	Authorizing Official	Update		Barber, Wendi VP FINANCE, CFO 8286812102	Barber, Wendi VP FINANCE, CFO 340023 8286812102	9/24/2017 7:57 AM
Contacts	Signed By	Update		Barber, Wendi VP FINANCE, CFO 8286812102	Barber, Wendi VP FINANCE, CFO 340023 8286812102	9/24/2017 7:57 AM
Contacts	Primary Contact	Update	Profile Change Request	Molnar, Diane 340B Regional Manager Park Ridge Health 8286812168	Molnar, Diane 340B Regional Manager Southeast Region 8286812168	9/22/2017 10:04 AM
Contacts	Primary Contact	Update		Molnar, Diane 340B Regional Manager 8286812168	Molnar, Diane 340B Regional Manager Park Ridge Health 8286812168	9/18/2017 3:08 PM
Contacts	Primary Contact	Insert			Molnar, Diane 340B Regional Manager 8286812168	8/10/2017 5:14 PM
Contacts	Authorizing Official	Insert			Barber, Wendi VP FINANCE, CFO 8286812102	7/14/2017 10:59 AM
Contacts	Signed By	Insert			Barber, Wendi VP FINANCE, CFO 8286812102	7/14/2017 10:59 AM
Addresses	Main Address	Insert			50 DOCTORS DRIVE SUITE 1 HENDERSONVILLE, NC 28792-7209	2/22/2017 1:18 PM
Addresses	Billing Address	Insert			Park Ridge Health 50 Doctors Dr. Suite G-A Hendersonville, NC 28792	2/22/2017 1:18 PM
Addresses	Shipping Address	Insert			Park Ridge Health 100 Hospital Drive Hendersonville, NC 28792	2/22/2017 1:18 PM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 2:18 PM
Details	Last Recertification Date	Update			8/11/2015 12:00:00 AM	8/11/2015 1:31 PM
Details	Entity Subname	Update		PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology	Park Ridge Health Neurology	1/23/2015 8:41 AM
Details	Entity Subname	Update		PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology / Park Ridge Health Neurology	PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology	12/31/2014 3:51 PM
Details	Entity Subname	Update		PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology	PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology / Park Ridge Health Neurology	12/19/2014 2:16 PM
Dates	Participating Approval Date	Update			9/15/2014 12:00:00 AM	9/15/2014 12:44 PM
Details	State	Update		Pending	Active	9/15/2014 12:44 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/15/2014 12:44 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_44932	DSH340023AW	9/12/2014 11:07 AM
Details	Entity Subname	Update		PARK RIDGE MEDICAL ASSOCIATES	PARK RIDGE MEDICAL ASSOCIATES-Park Ridge Health Neurology	9/12/2014 11:07 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_44932	7/9/2014 10:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/9/2014 10:49 PM
Medicaid Billing	Medicaid: Number	Insert			3400023	7/9/2014 10:49 PM
Medicaid Billing	Medicaid: State	Insert			NC	7/9/2014 10:49 PM
Medicaid Billing	NPI: Number	Insert			1427075027	7/9/2014 10:49 PM
Details	Last Recertification Date	Insert				7/9/2014 10:49 PM
Details	Grant Number	Insert				7/9/2014 10:49 PM
Details	340B ID	Insert				7/9/2014 10:49 PM
Details	Is Authorizing Official EHB Data	Insert				7/9/2014 10:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/9/2014 10:49 PM
Details	Medicare Provider Number	Insert			340023	7/9/2014 10:49 PM
Details	Entity Name	Insert			PARK RIDGE HEALTH	7/9/2014 10:49 PM
Details	Program Code	Insert			DSH	7/9/2014 10:49 PM
Details	Entity Subname	Insert			PARK RIDGE MEDICAL ASSOCIATES	7/9/2014 10:49 PM
Dates	Participating Approval Date	Insert				7/9/2014 10:49 PM
Details	State	Insert			Pending	7/9/2014 10:49 PM
Dates	Registration Date	Insert			7/9/2014 12:00:00 AM	7/9/2014 10:49 PM
Dates	Signed By Date	Insert			7/9/2014 12:00:00 AM	7/9/2014 10:49 PM
Dates	Start Date	Insert				7/9/2014 10:49 PM
Terminations	Termination Comments	Insert				7/9/2014 10:49 PM
Terminations	Termination Date	Insert				7/9/2014 10:49 PM
Terminations	Termination Effective Date	Insert				7/9/2014 10:49 PM
Terminations	Termination Reason	Insert				7/9/2014 10:49 PM