Covered Entity Details

DSH180013A THE MEDICAL CENTER - BOWLING GREEN (Active) - information as of 5/2/2025 10:34:09 PM

Main Details

Name

THE MEDICAL CENTER - BOWLING GREEN

Subdivision Name

Western Kentucky Diagnostic Imaging

Type

Disproportionate Share Hospital

Rural

340B ID

DSH180013A

Medicare Provider Number

180013

Outpatient Facility Provider Number

180013

Additional Details

Current Program Status

Active

Registration Date

7/11/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/15/2014

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Med Center Health
Wade R. Stone, Executive Vice President
(270) 745-1504

Primary Contact

Commonwealth Health Corporation
Caleb Benningfield, Pharmacist
(270) 745-1640

Addresses

Street Address

1635 Scottsville Rd
Bowling Green, KY 42104

Billing Address

The Medical Center
250 Park St
Bowling Green, KY 42101

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	01011154	1043293608

Shipping Addresses

Shipping Address 1

The Medical Center
250 Park St
Bowling Green, KY 42101

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
DSH180013A	Child	DSH	THE MEDICAL CENTER - BOWLING GREEN	Western Kentucky Diagnostic Imaging	1635 Scottsville Rd	Bowling Green	KY	Active
DSH180013B	Child	DSH	THE MEDICAL CENTER - BOWLING GREEN	MEDICAL CENTER PSYCHIATRY - Psychiatry	350 PARK ST	BOWLING GREEN	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 11:30:18 AM	9/5/2024 11:34:45 AM	9/5/2024 11:34 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 3:53:40 PM	9/6/2023 11:30:18 AM	9/6/2023 11:30 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 12:29:20 PM	9/12/2022 3:53:40 PM	9/12/2022 3:53 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 2:16:19 PM	9/9/2021 12:29:20 PM	9/9/2021 12:29 PM
Contacts	Authorizing Official	Update	AO Change Request	Joyce, Melinda C Vice-President, Corporate Support Services Med Center Health 2707451599	Stone, Wade R. Executive Vice President Med Center Health 2707451504	8/30/2021 8:11 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/8/2020 2:16 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 6:46:49 AM	9/8/2020 2:16:19 PM	9/8/2020 2:16 PM
Contacts	Primary Contact	Update	Recertification	Polston, Aric Corporate Director of Pharmacy The Medical Center - Bowling Green 2707451640	Benningfield, Caleb Pharmacist Commonwealth Health Corporation 2707451640	9/13/2019 6:46 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 11:21:59 AM	9/13/2019 6:46:49 AM	9/13/2019 6:46 AM
Details	Last Recertification Date	Update	Recertification	11/20/2017 2:12:58 PM	9/6/2018 11:21:59 AM	9/6/2018 11:21 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/20/2017 2:12:58 PM	11/20/2017 2:12 PM
Contacts	Primary Contact	Update		Polston, Aric Corporate Director of Pharmacy 2707451640	Polston, Aric Corporate Director of Pharmacy The Medical Center - Bowling Green 2707451640	10/12/2017 4:45 PM
Contacts	Authorizing Official	Update	AO Change Request	HAGAN, ERIC EVP 2707451257	Joyce, Melinda C Vice-President, Corporate Support Services Med Center Health 2707451599	9/29/2017 2:43 PM
Addresses	Main Address	Insert			1635 Scottsville Rd Bowling Green, KY 42104	8/24/2016 7:12 AM
Contacts	Authorizing Official	Update		MOORE, SARAH EVP 2707451257	HAGAN, ERIC EVP 2707451257	8/24/2016 7:12 AM
Contacts	Primary Contact	Insert			Polston, Aric Corporate Director of Pharmacy 2707451640	8/24/2016 7:12 AM
Contacts	Signed By	Insert			SMITH, CONNIE CEO 2707451262	8/24/2016 7:12 AM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 7:12 AM
Addresses	Billing Address	Insert			The Medical Center 250 Park St Bowling Green, KY 42101	8/9/2016 9:22 AM
Addresses	Shipping Address	Insert			The Medical Center 250 Park St Bowling Green, KY 42101	8/9/2016 9:22 AM
Contacts	Authorizing Official	Insert			MOORE, SARAH EVP 2707451257	5/2/2016 10:51 AM
Details	Last Recertification Date	Update			8/6/2015 12:00:00 AM	8/6/2015 9:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/22/2015 1:40 PM
Medicaid Billing	Medicaid: Number	Insert			01011154	7/22/2015 1:40 PM
Medicaid Billing	Medicaid: State	Insert			KY	7/22/2015 1:40 PM
Dates	Participating Approval Date	Update			9/15/2014 12:00:00 AM	9/15/2014 3:50 PM
Details	State	Update		Pending	Active	9/15/2014 3:50 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/15/2014 3:50 PM
Details	Entity Subname	Update		Radiology	Western Kentucky Diagnostic Imaging	9/12/2014 11:11 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45326	DSH180013A	9/12/2014 9:06 AM
Details	Entity Subname	Update			Radiology	9/12/2014 9:06 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45326	7/11/2014 1:57 PM
Medicaid Billing	NPI: Number	Insert			1043293608	7/11/2014 1:57 PM
Details	Last Recertification Date	Insert				7/11/2014 1:57 PM
Details	Grant Number	Insert				7/11/2014 1:57 PM
Details	340B ID	Insert				7/11/2014 1:57 PM
Details	Is Authorizing Official EHB Data	Insert				7/11/2014 1:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2014 1:57 PM
Details	Medicare Provider Number	Insert			180013	7/11/2014 1:57 PM
Details	Entity Name	Insert			THE MEDICAL CENTER - BOWLING GREEN	7/11/2014 1:57 PM
Details	Program Code	Insert			DSH	7/11/2014 1:57 PM
Details	Entity Subname	Insert				7/11/2014 1:57 PM
Dates	Participating Approval Date	Insert				7/11/2014 1:57 PM
Details	State	Insert			Pending	7/11/2014 1:57 PM
Dates	Registration Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 1:57 PM
Dates	Signed By Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 1:57 PM
Dates	Start Date	Insert				7/11/2014 1:57 PM
Terminations	Termination Comments	Insert				7/11/2014 1:57 PM
Terminations	Termination Date	Insert				7/11/2014 1:57 PM
Terminations	Termination Effective Date	Insert				7/11/2014 1:57 PM
Terminations	Termination Reason	Insert				7/11/2014 1:57 PM