Covered Entity Details

DSH200039AJ MAINEGENERAL MEDICAL CENTER (Terminated) - information as of 5/7/2025 10:44:25 PM

Main Details

Name

MAINEGENERAL MEDICAL CENTER

Subdivision Name

Enterprise / MaineGeneral Neurology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH200039AJ

Medicare Provider Number

200039

Outpatient Facility Provider Number

200039

Additional Details

Current Program Status

Terminated

Registration Date

7/15/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/5/2014

Last Recertification Date

8/31/2015

Termination Date
Termination Reason

7/1/2016
Site closure

Contacts

Authorizing Official

MaineGeneral Medical Center
Terrance Brann, Chief Financial Officer
(207) 623-6624

Primary Contact

MaineGeneral Medical Center
Andrea Gimpel-Blanchard, Director of Pharmacy
(207) 626-4133

Addresses

Street Address

15 Enterprise Dr
Augusta, ME 04330

Billing Address

MaineGeneral Medical Center
Accounts Payable
35 Medical Center Parkway
Augusta, ME 04330

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
		1669423380

Shipping Addresses

Shipping Address 1

MaineGeneral Medical Center
Thayer Center for Health
149 North Street
Waterville, ME 04901

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
DSH200039AA	Child	DSH	MAINEGENERAL MEDICAL CENTER	Midwifery Winthrop	Winthrop Commerce Center	Winthrop	ME	Terminated
DSH200039AB	Child	DSH	MAINEGENERAL MEDICAL CENTER	Bariatrics Clinic Augusta	Thayer Center for Health	Waterville	ME	Terminated
DSH200039AC	Child	DSH	MAINEGENERAL MEDICAL CENTER	Diabetes & Nutrition Waterville	325 E Kennedy Memorial Drive	Waterville	ME	Terminated
DSH200039AD	Child	DSH	MAINEGENERAL MEDICAL CENTER	Diabetes & Nutrition Augusta	Ballard Center	Augusta	ME	Active
DSH200039AE	Child	DSH	MAINEGENERAL MEDICAL CENTER	Family Medicine Institute	15 East Chestnut Street	Augusta	ME	Active
DSH200039AF	Child	DSH	MAINEGENERAL MEDICAL CENTER	MDFMR Dermatology	Ballard Center, Third Floor	Augusta	ME	Active
DSH200039AG	Child	DSH	MAINEGENERAL MEDICAL CENTER	Physiatry Augusta	442 Civic Center Dr	Augusta	ME	Active
DSH200039AH	Child	DSH	MAINEGENERAL MEDICAL CENTER	Otolaryngology - A	12 Shuman Ave	Augusta	ME	Terminated
DSH200039AJ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Enterprise / MaineGeneral Neurology	15 Enterprise Dr	Augusta	ME	Terminated
DSH200039AK	Child	DSH	MAINEGENERAL MEDICAL CENTER	Specialty Clinic - Anticoagulation - Ballard Center	Ballard Center	Augusta	ME	Active
DSH200039AL	Child	DSH	MAINEGENERAL MEDICAL CENTER	Specialty Clinic - Anticoagulation	Thayer Center for Health	Waterville	ME	Terminated
DSH200039AM	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Anesthesia - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AN	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / MG Surgery	Thayer Center for Health	Waterville	ME	Active
DSH200039AP	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Cardiology - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AQ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / CAT Scan - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AR	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Emergency Department - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AS	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Endoscopy - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AT	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Imaging - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AU	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Infusion - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AV	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Nuclear Medicine - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AW	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Operating Room - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AX	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Post Anesthesia Care Unit - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039AY	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Medical Center / OP Physical Therapy	107 First Park Drive	Oakland	ME	Active
DSH200039AZ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Prevention Center - Thayer	149 North Street	Waterville	ME	Terminated
DSH200039BA	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Same Day Surgery - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BB	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Pulmonary Function Lab - Thayer	149 North Street	Waterville	ME	Active
DSH200039BC	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Ultrasound - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BD	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Vascular Lab - Thayer	149 North Street	Waterville	ME	Terminated
DSH200039BE	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Maine Dartmouth Family Medicine	149 North Street	Waterville	ME	Active
DSH200039BF	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Maine Dartmouth Collaborative Care	Thayer Center for Health	Waterville	ME	Active
DSH200039BG	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Neurology - Thayer	149 North Street	Waterville	ME	Terminated
DSH200039BH	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Wound Healing Clinic - Thayer	149 North Street	Waterville	ME	Terminated
DSH200039BJ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Pulmonology - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BK	Child	DSH	MAINEGENERAL MEDICAL CENTER	Harold Alfond Center for Cancer Care / Laboratory - CC	361 Old Belgrade Road	Augusta	ME	Active
DSH200039BL	Child	DSH	MAINEGENERAL MEDICAL CENTER	Harold Alfond Center for Cancer Care / Radiation Oncology - CC	361 Old Belgrade Road	Augusta	ME	Active
DSH200039BM	Child	DSH	MAINEGENERAL MEDICAL CENTER	Harold Alfond Center for Cancer Care / Medical Oncology - CC	361 Old Belgrade Road	Augusta	ME	Active
DSH200039BN	Child	DSH	MAINEGENERAL MEDICAL CENTER	Harold Alfond Center for Cancer Care / Imaging - CC	361 Old Belgrade Road	Augusta	ME	Active
DSH200039BP	Child	DSH	MAINEGENERAL MEDICAL CENTER	Harold Alfond Center for Cancer Care / MaineGeneral Surgery	361 Old Belgrade Road	Augusta	ME	Terminated
DSH200039BQ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / EEG - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BR	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Laboratory - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BS	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Cardiac Rehab Service - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BT	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / Nephrology - MaineGeneral Kidney Care	Thayer Center for Health	Waterville	ME	Active
DSH200039BU	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Center for Health / MRI - Thayer	Thayer Center for Health	Waterville	ME	Active
DSH200039BV	Child	DSH	MAINEGENERAL MEDICAL CENTER	Enterprise Drive / Physical Therapy	15 Enterprise Drive	Augusta	ME	Active
DSH200039BW	Child	DSH	MAINEGENERAL MEDICAL CENTER	First Park / Physical Therapy - First Park	2 Evergreen Drive	Oakland	ME	Terminated
DSH200039BX	Child	DSH	MAINEGENERAL MEDICAL CENTER	Physical Therapy	40 Granite Hill Road	Manchester	ME	Terminated
DSH200039BY	Child	DSH	MAINEGENERAL MEDICAL CENTER	Obstetrics and Gynecology	Winthrop Commerce Center	Winthrop	ME	Terminated
DSH200039BZ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Rapid Evaluation Program	15 Enterprise Drive	Augusta	ME	Terminated
DSH200039CA	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Child Behavioral Clinic	15 Enterprise Drive	Augusta	ME	Terminated
DSH200039CB	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Rapid Evaluation Program	149 North Street	Waterville	ME	Terminated
DSH200039CC	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Rapid Evaluation Program	Ballard Center	Augusta	ME	Active
DSH200039CD	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Child Behavioral Clinic	149 North St	Waterville	ME	Terminated
DSH200039CE	Child	DSH	MAINEGENERAL MEDICAL CENTER	Pediatric Child Behavioral Clinic	Ballard Center	Augusta	ME	Active
DSH200039CF	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Physical Therapy - Winthrop	Winthrop Commerce Center	Winthrop	ME	Active
DSH200039CG	Child	DSH	MAINEGENERAL MEDICAL CENTER	Oakland Family Medicine	25 First Park Drive	Oakland	ME	Active
DSH200039CH	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Gastroenterology	Thayer Center for Health	Waterville	ME	Active
DSH200039CJ	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Ear, Nose & Throat	Thayer Center for Health	Waterville	ME	Active
DSH200039CK	Child	DSH	MAINEGENERAL MEDICAL CENTER	Outpatient Counceling Services	9 Green Street	Augusta	ME	Active
DSH200039CL	Child	DSH	MAINEGENERAL MEDICAL CENTER	Intensive Outpatient Services	24 Chase Avenue	Waterville	ME	Active
DSH200039CM	Child	DSH	MAINEGENERAL MEDICAL CENTER	Outpatient Counseling Services	24 Chase Avenue	Waterville	ME	Active
DSH200039CP	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Orthopaedics	Winthrop Commerce Center	Winthrop	ME	Terminated
DSH200039CQ	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral / Urology	442 Civic Center Drive	Augusta	ME	Active
DSH200039CR	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral / Neurology	361 Old Belgrade Road	Augusta	ME	Terminated
DSH200039CS	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral / Ear, Nose and Throat	Harold Alfond Center for Cancer Care	Augusta	ME	Active
DSH200039CT	Child	DSH	MAINEGENERAL MEDICAL CENTER	Intensive Outpatient Services	9 Green Street	Augusta	ME	Active
DSH200039CU	Child	DSH	MAINEGENERAL MEDICAL CENTER	Outpatient Psychiatry / PSYCHIATRIC/PSYCHOLOGICAL SERVICES	24 Chase Avenue	Waterville	ME	Active
DSH200039CV	Child	DSH	MAINEGENERAL MEDICAL CENTER	Maine Dartmouth Collaborative Care / Neuromuscular Clinic	6 East Chestnut St	Augusta	ME	Active
DSH200039CW	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Eye Center - Ophthalmology	4 Sheridan Drive	Fairfield	ME	Active
DSH200039CX	Child	DSH	MAINEGENERAL MEDICAL CENTER	MDFMR Dermatology - Dermatology	Thayer Center for Health	Waterville	ME	Active
DSH200039CY	Child	DSH	MAINEGENERAL MEDICAL CENTER	Maine Dartmouth Geriatric Medicine - Geriatrics	Ballard Center	Augusta	ME	Active
DSH200039CZ	Child	DSH	MAINEGENERAL MEDICAL CENTER	Thayer Internal Medicine - Internal Medicine	Thayer Center for Health	Waterville	ME	Active
DSH200039D	Child	DSH	MAINEGENERAL MEDICAL CENTER	Gardiner Family Medicine	5 Central Maine Crossing	Gardiner	ME	Active
DSH200039DA	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Rheumatology - Rheumatology	15 Enterprise Drive	Augusta	ME	Active
DSH200039DB	Child	DSH	MAINEGENERAL MEDICAL CENTER	Imaging Gardiner - Radiology	5 Central Maine Crossing	Gardiner	ME	Active
DSH200039DC	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Urology - Urology	Thayer Center for Health	Waterville	ME	Terminated
DSH200039DD	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Orthopaedics - Orthopaedics	5 Central Maine Crossing	Gardiner	ME	Active
DSH200039DE	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Neurology - Neurology	15 Enterprise Drive	Augusta	ME	Active
DSH200039DF	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Expresscare-Gardiner - Expresscare	5 Central Maine Crossing	Gardiner	ME	Active
DSH200039DG	Child	DSH	MAINEGENERAL MEDICAL CENTER	Respiratory Care - Respiratory	Thayer Center for Health	Waterville	ME	Active
DSH200039DH	Child	DSH	MAINEGENERAL MEDICAL CENTER	Sleep Lab-Waterville - Sleep Lab	Thayer Center for Health	Waterville	ME	Active
DSH200039DJ	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Addiction Medicine - Addiction Medicine	Thayer Center for Health	Waterville	ME	Active
DSH200039DK	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Addiction Medicine - Addiction Medicine	9 Green Street	Augusta	ME	Active
DSH200039DL	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Express Care-Winthrop - Express Care	Winthrop Commerce Center	Winthrop	ME	Terminated
DSH200039DM	Child	DSH	MAINEGENERAL MEDICAL CENTER	Great Oak Family Medicine - Primary Care	3 Evergreen Drive	Oakland	ME	ToBeTerminated
DSH200039DN	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Obstetrics & Gynecology - OBGYN	Thayer Center for Health	Waterville	ME	Active
DSH200039DP	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Vascular Surgery - Surgery	Thayer Center for Health	Waterville	ME	Active
DSH200039DQ	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral MOHS Surgery - Dermatology	Ballard Center	Augusta	ME	Active
DSH200039DR	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Medical Center Sleep Disorders Clinic - Sleep Disorders	Thayer Center for Health	Waterville	ME	Active
DSH200039DS	Child	DSH	MAINEGENERAL MEDICAL CENTER	Waterville Pediatrics - Pediatrics	MaineGeneral Medical Center	Waterville	ME	Active
DSH200039DT	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Vascular Surgery - Surgery	MaineGeneral Medical Center	Winthrop	ME	Approved
DSH200039DU	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral College Health - College Health	Thayer Center for Health	Waterville	ME	Approved
DSH200039E	Child	DSH	MAINEGENERAL MEDICAL CENTER	Elmwood Primary Care	211 Main Street	Waterville	ME	Active
DSH200039F	Child	DSH	MAINEGENERAL MEDICAL CENTER	Augusta Family Medicine	15 Enterprise Drive	Augusta	ME	Active
DSH200039G	Child	DSH	MAINEGENERAL MEDICAL CENTER	Winthrop Family Medicine	Winthrop Commerce Center	Winthrop	ME	Active
DSH200039H	Child	DSH	MAINEGENERAL MEDICAL CENTER	Kennebec Pediatrics	Ballard Center	Augusta	ME	Active
DSH200039K	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Orthopaedics	107 First Park Drive	Oakland	ME	Active
DSH200039M	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Allergy & Asthma	12 Shuman Drive	Augusta	ME	Terminated
DSH200039N	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Urology	Thayer Center for Health	Waterville	ME	Active
DSH200039Q	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Internal Medicine	211 Main Street	Waterville	ME	ToBeTerminated
DSH200039S	Child	DSH	MAINEGENERAL MEDICAL CENTER	Four Seasons Family Practice	4 Sheridan Drive	Fairfield	ME	Active
DSH200039T	Child	DSH	MAINEGENERAL MEDICAL CENTER	Winthrop Pediatrics & Adolescent Medicine	Winthrop Commerce Center	Winthrop	ME	Active
DSH200039V	Child	DSH	MAINEGENERAL MEDICAL CENTER	MaineGeneral Orthopaedics	15 Enterprise Drive	Augusta	ME	Active
DSH200039W	Child	DSH	MAINEGENERAL MEDICAL CENTER	Nephrology Augusta	15 Enterprise Drive	Augusta	ME	Terminated
DSH200039Y	Child	DSH	MAINEGENERAL MEDICAL CENTER	MGMC Express Care Waterville	211 Main Street	Waterville	ME	Active
DSH200039Z	Child	DSH	MAINEGENERAL MEDICAL CENTER	MGMC Express Care Augusta	15 Enterprise Drive	Augusta	ME	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update		Gimpel-Blanchard, Andrea Director of Pharmacy 2076264133	Gimpel-Blanchard, Andrea Director of Pharmacy MaineGeneral Medical Center 2076264133	11/17/2017 7:17 AM
Contacts	Authorizing Official	Update	Change Request	Brann, Terrance Chief Financial Officer 2076236624	Brann, Terrance Chief Financial Officer MaineGeneral Medical Center 2076236624	10/13/2017 10:22 AM
Contacts	Primary Contact	Insert			Gimpel-Blanchard, Andrea Director of Pharmacy 2076264133	7/25/2017 10:57 AM
Contacts	Authorizing Official	Insert			Brann, Terrance Chief Financial Officer 2076236624	7/25/2017 10:57 AM
Contacts	Signed By	Insert			KOZIOL, MICHAEL SR VP/CHIEF FINANCIAL OFFICER 2076261212	7/25/2017 10:56 AM
Addresses	Main Address	Insert			15 Enterprise Dr Augusta, ME 04330	6/30/2016 3:55 PM
Addresses	Billing Address	Insert			MaineGeneral Medical Center Accounts Payable 35 Medical Center Parkway Augusta, ME 04330	6/30/2016 3:55 PM
Addresses	Shipping Address	Insert			MaineGeneral Medical Center Thayer Center for Health 149 North Street Waterville, ME 04901	6/30/2016 3:55 PM
Dates	Last Date That 340B Drugs Purchased	Update			6/23/2016 12:00:00 AM	6/30/2016 3:55 PM
Details	State	Update		Active	Terminated	6/30/2016 3:55 PM
Terminations	Termination Comments	Update			Child site moving to within the 4 walls of the parent hospital.	6/30/2016 3:55 PM
Terminations	Termination Date	Update			7/1/2016 12:00:00 AM	6/30/2016 3:55 PM
Terminations	Termination Effective Date	Update			6/23/2016 12:00:00 AM	6/30/2016 3:55 PM
Terminations	Termination Reason	Update			Site closure	6/30/2016 3:55 PM
Details	Last Recertification Date	Update			8/31/2015 12:00:00 AM	8/31/2015 1:21 PM
Medicaid Billing	NPI: Number	Insert			1669423380	1/17/2015 5:15 PM
Details	Entity Subname	Update		Neurology - Enterprise / MaineGeneral Neurology	Enterprise / MaineGeneral Neurology	12/31/2014 3:51 PM
Details	Entity Subname	Update		Neurology - Enterprise	Neurology - Enterprise / MaineGeneral Neurology	12/19/2014 2:16 PM
Dates	Participating Approval Date	Update			9/5/2014 12:00:00 AM	9/5/2014 11:42 AM
Details	State	Update		Pending	Active	9/5/2014 11:42 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/5/2014 11:42 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45900	DSH200039AJ	9/1/2014 7:23 AM
Details	Entity Subname	Update			Neurology - Enterprise	9/1/2014 7:23 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45900	7/15/2014 12:15 PM
Details	Last Recertification Date	Insert				7/15/2014 12:15 PM
Details	Grant Number	Insert				7/15/2014 12:15 PM
Details	340B ID	Insert				7/15/2014 12:15 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2014 12:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2014 12:15 PM
Details	Medicare Provider Number	Insert			200039	7/15/2014 12:15 PM
Details	Entity Name	Insert			MAINEGENERAL MEDICAL CENTER	7/15/2014 12:15 PM
Details	Program Code	Insert			DSH	7/15/2014 12:15 PM
Details	Entity Subname	Insert				7/15/2014 12:15 PM
Dates	Participating Approval Date	Insert				7/15/2014 12:15 PM
Details	State	Insert			Pending	7/15/2014 12:15 PM
Dates	Registration Date	Insert			7/15/2014 12:00:00 AM	7/15/2014 12:15 PM
Dates	Signed By Date	Insert			7/15/2014 12:00:00 AM	7/15/2014 12:15 PM
Dates	Start Date	Insert				7/15/2014 12:15 PM
Terminations	Termination Comments	Insert				7/15/2014 12:15 PM
Terminations	Termination Date	Insert				7/15/2014 12:15 PM
Terminations	Termination Effective Date	Insert				7/15/2014 12:15 PM
Terminations	Termination Reason	Insert				7/15/2014 12:15 PM