| Contacts | Authorizing Official | Update | Change Request | Marshall, John P
Chief Medical Officer
Maimonides Medical Center
7182836028 | Marshall, John
EVP MedAffair/Chair MedOfficer
Maimonides Medical Center
7182838313 | 4/10/2025 10:44 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 10:28:53 AM | 8/30/2024 5:20:48 AM | 8/30/2024 5:20 AM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2022 1:57:04 PM | 8/21/2023 10:28:53 AM | 8/21/2023 10:28 AM |
| Contacts | Primary Contact | Update | PC Change Request | Limoncelli, Vito
Associate Director
Maimonides Medical Center
7182836146 | Bukher, Yevgenia
Assistant Director, Pharmacy
Maimonides Medical Center
7182837232 | 7/13/2023 11:05 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Doyle, Declan
SVP, Operations and Clinical Programs
Maimonides Medical Center
7182837106 | Marshall, John P
Chief Medical Officer
Maimonides Medical Center
7182836028 | 7/13/2023 7:17 AM |
| Contacts | Primary Contact | Update | PC Change Request | Caruso, Patricia Ann
Director of Pharmacy
Maimonides Medical Center
7182837207 | Limoncelli, Vito
Associate Director
Maimonides Medical Center
7182836146 | 4/3/2023 6:53 AM |
| Contacts | Authorizing Official | Update | AO Change Request | GIBBS, KENNETH D.
CEO
Maimonides Medical Center
7182836575 | Doyle, Declan
SVP, Operations and Clinical Programs
Maimonides Medical Center
7182837106 | 3/23/2023 4:32 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2021 2:36:16 PM | 9/12/2022 1:57:04 PM | 9/12/2022 1:57 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2020 1:15:32 PM | 9/8/2021 2:36:16 PM | 9/8/2021 2:36 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/2/2020 1:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 4157206 | 9/2/2020 1:15 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NJ | 9/2/2020 1:15 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1093777492 | 9/2/2020 1:15 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NJ | 9/2/2020 1:15 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | NY | 9/2/2020 1:15 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | NY | 9/2/2020 1:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2019 2:46:58 PM | 9/2/2020 1:15:32 PM | 9/2/2020 1:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/4/2018 1:51:41 PM | 9/9/2019 2:46:58 PM | 9/9/2019 2:46 PM |
| Addresses | Billing Address | Insert | Change Request | | Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY 11219 | 4/18/2019 9:51 AM |
| Addresses | Shipping Address | Insert | Change Request | | MAIMONIDES CARDIOLOGY OUTPATIENT C
421 OCEAN PKWY
Brooklyn, NY 11218 | 4/18/2019 9:51 AM |
| Addresses | Shipping Address | Insert | Change Request | | Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY 11219 | 4/18/2019 9:51 AM |
| Contacts | Primary Contact | Update | Change Request | CASSERA, FRED
DIRECTOR OF PHARMACY
Maimonides Medical Center
7182837205 | Caruso, Patricia Ann
Director of Pharmacy
Maimonides Medical Center
7182837207 | 4/18/2019 9:51 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/4/2018 1:51 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 00243641 | 9/4/2018 1:51 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NY | 9/4/2018 1:51 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1083623144 | 9/4/2018 1:51 PM |
| Details | Last Recertification Date | Update | Recertification | 11/20/2017 1:53:07 PM | 9/4/2018 1:51:41 PM | 9/4/2018 1:51 PM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 11/20/2017 1:53:07 PM | 11/20/2017 1:53 PM |
| Contacts | Authorizing Official | Update | | GIBBS, KENNETH D.
CEO
7182836575 | GIBBS, KENNETH D.
CEO
Maimonides Medical Center
7182836575 | 11/17/2017 3:35 PM |
| Contacts | Primary Contact | Update | | CASSERA, FRED
DIRECTOR OF PHARMACY
7182837205 | CASSERA, FRED
DIRECTOR OF PHARMACY
Maimonides Medical Center
7182837205 | 9/26/2017 1:37 PM |
| Contacts | Signed By | Insert | | | BRIER, PAMELA
CEO
7182836009 | 8/11/2017 10:54 AM |
| Contacts | Primary Contact | Insert | | | CASSERA, FRED
DIRECTOR OF PHARMACY
7182837205 | 1/10/2017 11:54 AM |
| Contacts | Authorizing Official | Insert | | | GIBBS, KENNETH D.
CEO
7182836575 | 1/10/2017 11:54 AM |
| Addresses | Main Address | Insert | | |
421 OCEAN PKWY
BROOKLYN, NY 11218-5132 | 8/10/2016 2:24 PM |
| Details | Last Recertification Date | Update | | 8/6/2015 12:00:00 AM | 8/10/2016 12:00:00 AM | 8/10/2016 2:24 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1093777492 | 1/22/2016 4:05 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 12/14/2015 2:41 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 02998736 | 12/14/2015 2:41 PM |
| Medicaid Billing | Medicaid: State | Insert | | | NY | 12/14/2015 2:41 PM |
| Details | Last Recertification Date | Update | | | 8/6/2015 12:00:00 AM | 8/6/2015 1:28 PM |
| Dates | Participating Approval Date | Update | | | 9/4/2014 12:00:00 AM | 9/4/2014 1:28 PM |
| Details | State | Update | | Pending | Active | 9/4/2014 1:28 PM |
| Dates | Start Date | Update | | | 10/1/2014 12:00:00 AM | 9/4/2014 1:28 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_45559 | DSH330194P | 8/29/2014 1:22 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_45559 | 7/14/2014 11:51 AM |
| Details | Last Recertification Date | Insert | | | | 7/14/2014 11:51 AM |
| Details | Grant Number | Insert | | | | 7/14/2014 11:51 AM |
| Details | 340B ID | Insert | | | | 7/14/2014 11:51 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/14/2014 11:51 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/14/2014 11:51 AM |
| Details | Medicare Provider Number | Insert | | | 330194 | 7/14/2014 11:51 AM |
| Details | Entity Name | Insert | | | MAIMONIDES MEDICAL CENTER | 7/14/2014 11:51 AM |
| Details | Program Code | Insert | | | DSH | 7/14/2014 11:51 AM |
| Details | Entity Subname | Insert | | | MAIMONIDES CARDIOLOGY OUTPATIENT C | 7/14/2014 11:51 AM |
| Dates | Participating Approval Date | Insert | | | | 7/14/2014 11:51 AM |
| Details | State | Insert | | | Pending | 7/14/2014 11:51 AM |
| Dates | Registration Date | Insert | | | 7/14/2014 12:00:00 AM | 7/14/2014 11:51 AM |
| Dates | Signed By Date | Insert | | | 7/14/2014 12:00:00 AM | 7/14/2014 11:51 AM |
| Dates | Start Date | Insert | | | | 7/14/2014 11:51 AM |
| Terminations | Termination Comments | Insert | | | | 7/14/2014 11:51 AM |
| Terminations | Termination Date | Insert | | | | 7/14/2014 11:51 AM |
| Terminations | Termination Effective Date | Insert | | | | 7/14/2014 11:51 AM |
| Terminations | Termination Reason | Insert | | | | 7/14/2014 11:51 AM |