| Details | Entity Name | Update | Change Request | Mercy Health-Marcum & Wallace Hospital, LLC. | Marcum & Wallace Memorial Hospital | 11/5/2024 8:54 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 11/5/2024 8:42 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 7100244280 | 11/5/2024 8:42 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 11/5/2024 8:42 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1609151471 | 11/5/2024 8:42 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | KY | 11/5/2024 8:42 AM |
| Details | Entity Subname | Update | Change Request | Mercy Medical Clinic of Lee County | MH - Lee County Primary Care | 11/5/2024 8:42 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 2:56:19 PM | 8/29/2024 12:39:12 PM | 8/29/2024 12:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 3:14:59 PM | 8/21/2023 2:56:19 PM | 8/21/2023 2:56 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Seminaro, Anthony
CFO, Markets
Bon Secours Mercy Health
9415871220 | Warren, Daniel Thomas
Market CFO
Bon Secours Mercy Health
2704442553 | 5/10/2023 12:34 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Archbold, Alan
Chief Financial Officer Kentucky Region
Lourdes Hospital
2704442553 | Seminaro, Anthony
CFO, Markets
Bon Secours Mercy Health
9415871220 | 11/16/2022 7:09 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2021 10:02:26 AM | 8/30/2022 3:14:59 PM | 8/30/2022 3:14 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Patton, Lisa
Director of Pharmacy Services
Mercy Health-Marcum & Wallace Hospital, LLC
6067262146 | Patton, Lisa
Manager of Pharmacy
Mercy Health-Marcum & Wallace Hospital, LLC
6067262146 | 8/17/2022 1:56 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2020 2:12:58 PM | 8/24/2021 10:02:26 AM | 8/24/2021 10:02 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1487643821 ( ) | | 9/3/2020 2:12 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1487643821 | 9/3/2020 2:12 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | KY | 9/3/2020 2:12 PM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2019 8:37:44 AM | 9/3/2020 2:12:58 PM | 9/3/2020 2:12 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Witt, Lori
CFO
Mercy Health - Marcum & Wallace Hospital
6067266507 | Archbold, Alan
Chief Financial Officer Kentucky Region
Lourdes Hospital
2704442553 | 4/30/2020 6:47 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/11/2020 3:39 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 7100124510 | 3/11/2020 3:39 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 3/11/2020 3:39 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1487643821 | 3/11/2020 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2018 4:05:01 PM | 9/6/2019 8:37:44 AM | 9/6/2019 8:37 AM |
| Addresses | Billing Address | Update | Change Request | Mercy Health-Marcum & Wallace Hospital, LLC.
60 Mercy Court
Irvine, KY 40336 | Mercy Health-Marcum and Wallace Hospital, LLC.
60 Mercy Court
Irvine, KY 40336 | 3/12/2019 9:09 AM |
| Addresses | Shipping Address | Insert | Change Request | | Mercy Health-Marcum and Wallace Hospital, LLC.
60 Mercy Court
Irvine, KY 40336 | 3/12/2019 9:09 AM |
| Addresses | Billing Address | Insert | Change Request | | Mercy Health-Marcum & Wallace Hospital, LLC.
60 Mercy Court
Irvine, KY 40336 | 9/25/2018 11:13 AM |
| Details | Last Recertification Date | Update | Recertification | 11/20/2017 11:30:37 AM | 8/24/2018 4:05:01 PM | 8/24/2018 4:05 PM |
| Addresses | Main Address | Update | Recertification |
1025 Grand Avenue
Beattyville, KY 41311 |
1049 HWY 11 N
Beattyville, KY 41311 | 11/20/2017 11:30 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2016 12:00:00 AM | 11/20/2017 11:30:37 AM | 11/20/2017 11:30 AM |
| Details | Entity Name | Update | Recertification | Mercy Health-Marcum & Wallace Hospital LLC | Mercy Health-Marcum & Wallace Hospital, LLC. | 11/20/2017 10:53 AM |
| Contacts | Authorizing Official | Update | | Witt, Lori
CFO
6067266507 | Witt, Lori
CFO
Mercy Health - Marcum & Wallace Hospital
6067266507 | 10/12/2017 1:50 PM |
| Contacts | Primary Contact | Update | | Patton, Lisa
Director of Pharmacy Services
6067262146 | Patton, Lisa
Director of Pharmacy Services
Mercy Health-Marcum & Wallace Hospital, LLC
6067262146 | 10/9/2017 1:11 PM |
| Contacts | Authorizing Official | Update | | Witt, Lori
CFO
6067266507 | Witt, Lori
CFO
6067266507 | 9/11/2017 3:29 PM |
| Addresses | Main Address | Insert | | |
1025 Grand Avenue
Beattyville, KY 41311 | 3/14/2017 1:37 PM |
| Contacts | Primary Contact | Insert | | | Patton, Lisa
Director of Pharmacy Services
6067262146 | 3/14/2017 1:37 PM |
| Contacts | Authorizing Official | Insert | | | Witt, Lori
CFO
6067266507 | 3/14/2017 1:37 PM |
| Contacts | Signed By | Insert | | | Witt, Lori
CFO
6067266507 | 3/14/2017 1:37 PM |
| Details | Entity Name | Update | | Marcum & Wallace Memorial Hospital, Inc. | Mercy Health-Marcum & Wallace Hospital LLC | 3/14/2017 1:36 PM |
| Details | Last Recertification Date | Update | | 8/31/2015 12:00:00 AM | 8/24/2016 12:00:00 AM | 8/24/2016 1:59 PM |
| Details | Last Recertification Date | Update | | | 8/31/2015 12:00:00 AM | 8/31/2015 11:24 AM |
| Dates | Participating Approval Date | Update | | | 9/5/2014 12:00:00 AM | 9/5/2014 11:09 AM |
| Details | State | Update | | Pending | Active | 9/5/2014 11:09 AM |
| Dates | Start Date | Update | | | 10/1/2014 12:00:00 AM | 9/5/2014 11:09 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_45957 | CAH181301-04 | 9/4/2014 12:40 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_45957 | 7/15/2014 1:03 PM |
| Details | Last Recertification Date | Insert | | | | 7/15/2014 1:03 PM |
| Details | Grant Number | Insert | | | | 7/15/2014 1:03 PM |
| Details | 340B ID | Insert | | | | 7/15/2014 1:03 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/15/2014 1:03 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/15/2014 1:03 PM |
| Details | Medicare Provider Number | Insert | | | 181301 | 7/15/2014 1:03 PM |
| Details | Entity Name | Insert | | | Marcum & Wallace Memorial Hospital, Inc. | 7/15/2014 1:03 PM |
| Details | Program Code | Insert | | | CAH | 7/15/2014 1:03 PM |
| Details | Entity Subname | Insert | | | Mercy Medical Clinic of Lee County | 7/15/2014 1:03 PM |
| Dates | Participating Approval Date | Insert | | | | 7/15/2014 1:03 PM |
| Details | State | Insert | | | Pending | 7/15/2014 1:03 PM |
| Dates | Registration Date | Insert | | | 7/15/2014 12:00:00 AM | 7/15/2014 1:03 PM |
| Dates | Signed By Date | Insert | | | 7/15/2014 12:00:00 AM | 7/15/2014 1:03 PM |
| Dates | Start Date | Insert | | | | 7/15/2014 1:03 PM |
| Terminations | Termination Comments | Insert | | | | 7/15/2014 1:03 PM |
| Terminations | Termination Date | Insert | | | | 7/15/2014 1:03 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/15/2014 1:03 PM |
| Terminations | Termination Reason | Insert | | | | 7/15/2014 1:03 PM |