Covered Entity Details

DSH030064R Banner - University Medical Center Tucson (Terminated) - information as of 6/9/2025 10:56:12 PM

Main Details

Name

Banner - University Medical Center Tucson

Subdivision Name

Banner - AZCC - Radiation Oncology at Orange Grove

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030064R

Medicare Provider Number

030064

Outpatient Facility Provider Number

030064

Additional Details

Current Program Status

Terminated

Registration Date

7/15/2014

Participating Start Date

10/1/2014

Participating Approval Date

8/20/2014

Last Recertification Date

9/4/2022

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Banner University Medical Centers Tucson and South
Brad Hipp, Chief Financial Officer
(520) 694-3446

Primary Contact

Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061

Addresses

Street Address

1891 W. Orange Grove Rd
Tucson, AZ 85704

Billing Address

Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062

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
AZ	005638,988439	1265820179,1508809427

Shipping Addresses

Shipping Address 1

Banner University Medical Center Tucson
Banner UMC Orange Grove
1891 W. Orange Grove Rd
Tucson, AZ 85704

Shipping Address 2

Banner Health
7300 W. Detroit St.
Chandler, AZ 85226

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
DSH030064A	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-PANTANO	7901 EAST 22ND STREET	TUCSON	AZ	Terminated
DSH030064AA	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Orthopedics-clinic	265 West Ina Road	Tucson	AZ	Active
DSH030064AB	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Internal Med Clinic	265 West Ina Road	Tucson	AZ	Terminated
DSH030064AC	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Nephrology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AD	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Internal Med Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AE	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Podiatry-clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AF	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Urology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AG	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Cardiology-clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AH	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC - GV Gynecology Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AJ	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC GV Otolaryngology-Clin	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AK	Child	DSH	Banner - University Medical Center Tucson	Alvernon - Alvernon Orthopedics-Clinic	707 North Alvernon Way	Tucson	AZ	Active
DSH030064AL	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Pediatrics Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AM	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC-Pan Geriatrics-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AN	Child	DSH	Banner - University Medical Center Tucson	Pantano - Pantano Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AP	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Internal Med-Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AQ	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-Pan Gynecology-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AR	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-CardioThoracic-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Urology-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AT	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Vascular-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Support Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064AV	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurosurgery-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AW	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Int Med/Geriatrics-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AX	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Nephrology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AY	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Endo-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AZ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurology Gen-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064B	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-NORTH HILLS	265 WEST INA ROAD	TUCSON	AZ	Active
DSH030064BA	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-ENT-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BB	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Infect Disease-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BC	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Diagnostic Cardiol-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BD	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pacemaker-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BE	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Gastroenterology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BF	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pulmonary Fnct Test-Cli-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BG	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Rheumatology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BH	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Podiatry-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BJ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Radiation Oncology-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BK	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Primary Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BL	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-OB/GYN-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BM	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Ambdom Transplant-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BN	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Trauma/Burn-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BP	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Sleep-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BQ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Allergy-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BR	Child	DSH	Banner - University Medical Center Tucson	Clinic F Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - Surg OP-20PC-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BT	Child	DSH	Banner - University Medical Center Tucson	Clinic H Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Cardiology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BV	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic-Hosp	3838 North Campbell Ave	Tucson	AZ	Terminated
DSH030064BW	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic	3838 North Campbell Ave	Tucson	AZ	Active
DSH030064BX	Child	DSH	Banner - University Medical Center Tucson	C/P-NC Hemonc - Clinic - Hematology / Oncology	3838 N. Campbell Avenue,	Tucson	AZ	Active
DSH030064BY	Child	DSH	Banner - University Medical Center Tucson	PBC UC-NH Pediatrics - Clinic - Pediatrics	265 West Ina Road	Tucson	AZ	Active
DSH030064BZ	Child	DSH	Banner - University Medical Center Tucson	C/P-Imaging-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CA	Child	DSH	Banner - University Medical Center Tucson	ENT Audiology-Clinic-NC - Audiology	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CB	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Gen Surg - Clinic - General Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CC	Child	DSH	Banner - University Medical Center Tucson	PBC UG-GV Vascular Surg Clinic - Vascular Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CD	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Psych-Clinic-NC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064CE	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Cancer Genetics Counsel-Hosp	3838 N Campbell Ave	Tucson	AZ	Active
DSH030064CF	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Pantano Clinic	7901 E 22ND ST	TUCSON	AZ	Active
DSH030064CG	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Green Valley Clinic-Clinic	1141 S LA CANADA DR	GREEN VALLEY	AZ	Active
DSH030064CH	Child	DSH	Banner - University Medical Center Tucson	NORTH HILLS - PBC-UC Pain Mgmt-Clinic	1891 WEST ORANGE GROVE ROAD	Tucson	AZ	Active
DSH030064CJ	Child	DSH	Banner - University Medical Center Tucson	CLINIC - Plastics Surg-Clinic-NC	3838 NORTH CAMPBELL AVE, BUILDING 2, CLINIC H, 3RD FLOOR	Tucson	AZ	Active
DSH030064H	Child	DSH	Banner - University Medical Center Tucson	Outpatient Infusion-Hosp	3838 North Campbell Avenue	Tucson	AZ	Active
DSH030064I	Child	DSH	Banner - University Medical Center Tucson	C/P-OG Hemeonc-Clinic	1891 W. ORANGE GROVE RD	TUCSON	AZ	Active
DSH030064J	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Primary Care-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064K	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon Surgery Center	750 North Alvernon Way	Tucson	AZ	Terminated
DSH030064L	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon	707 North Alvernon Way	Tucson	AZ	Terminated
DSH030064M	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC La Cholla Clinic	6261 North La Cholla	Tucson	AZ	Terminated
DSH030064N	Child	DSH	Banner - University Medical Center Tucson	Banner - University Medical Imaging (UMI)	4291 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064P	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Urology	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064Q	Child	DSH	Banner - University Medical Center Tucson	C/P-Mohs Dermatology Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064R	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Radiation Oncology at Orange Grove	1891 W. Orange Grove Rd	Tucson	AZ	Terminated
DSH030064S	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Bone Marrow Transplant Adult	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064T	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - North Campus Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064U	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC Bone Marrow Transplant (BMT)	1625 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064V	Child	DSH	Banner - University Medical Center Tucson	Banner - Arizona Cancer Center - Lab - North Campus	3838 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064W	Child	DSH	Banner - University Medical Center Tucson	Surgery 6OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064X	Child	DSH	Banner - University Medical Center Tucson	Surgery 5OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Y	Child	DSH	Banner - University Medical Center Tucson	Surgery 4OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Z	Child	DSH	Banner - University Medical Center Tucson	Medicine 2OPC	3838 N Campbell Ave	Tucson	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		12/31/2022 12:00:00 AM	8/24/2023 5:06 PM
Details	State	Update	Recertification	Active	To Be Terminated	8/24/2023 5:06 PM
Terminations	Termination Date	Update	Recertification		10/1/2023 12:00:00 AM	8/24/2023 5:06 PM
Terminations	Termination Effective Date	Update	Recertification		12/31/2022 12:00:00 AM	8/24/2023 5:06 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	8/24/2023 5:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 6:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		005638	3/14/2023 6:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AZ	3/14/2023 6:23 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1508809427	3/14/2023 6:23 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AZ	3/14/2023 6:23 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	020470-01 (AZ)		11/28/2022 4:20 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9000142345 (CO)		11/28/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1508809427 (AZ)		11/28/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649668450 (AZ)		11/28/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1265820179 (CO)		11/28/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1508809427 (CO)		11/28/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649668450 (CO)		11/28/2022 4:20 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 8:12:20 PM	9/4/2022 7:21:41 PM	9/4/2022 7:21 PM
Details	Last Recertification Date	Update	Recertification	9/4/2020 11:33:55 AM	9/8/2021 8:12:20 PM	9/8/2021 8:12 PM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1625 North Campbell Avenue Tucson, AZ 85719	Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	6/14/2021 10:39 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100542115 (NV)		6/14/2021 10:39 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10026590500 (NE)		6/14/2021 10:39 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	145728400 (WY)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NE)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NE)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NE)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WY)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WY)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WY)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NV)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NV)		6/14/2021 10:39 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NV)		6/14/2021 10:39 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	425805300 (MD)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MI)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200784450A (OK)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100564160 (KY)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500707030 (OR)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387902 (TX)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387901 (TX)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0635921 (MT)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1657501 (AK)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (CT)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003189644A (GA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (IA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (ID)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2432435 (LA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MN)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00096009 (MS)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (NC)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	19852088 (NM)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1031106620001 (PA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11566A (SC)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q028631 (TN)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (UT)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2017276884 (VA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2060663 (WA)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100063007 (WI)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0596345 (NJ)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TX)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TX)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TX)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MS)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MS)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MS)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (GA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (GA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (GA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NJ)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NJ)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NJ)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (PA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (PA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (PA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (SC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (SC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (SC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (CT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (CT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (CT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (IA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (IA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (IA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (ID)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (ID)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (ID)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MN)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MN)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MN)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NC)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (UT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (UT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (UT)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MI)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (AK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (AK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (AK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NM)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NM)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NM)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OK)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (VA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (VA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (VA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (LA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (LA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (LA)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MD)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MD)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MD)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OR)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OR)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OR)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (KY)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (KY)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (KY)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TN)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TN)		2/3/2021 10:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TN)		2/3/2021 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2020 1:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100542115	12/14/2020 1:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		395387901	9/4/2020 11:33 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/4/2020 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0635921	9/4/2020 11:33 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:33 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265820179 ( )		9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1508809427 ( )		9/4/2020 11:33 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649668450 ( )		9/4/2020 11:33 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 2:21:12 PM	9/4/2020 11:33:55 AM	9/4/2020 11:33 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Tucson Banner UMC Orange Grove 1891 W. Orange Grove Rd Tucson, AZ 85704	2/3/2020 2:56 PM
Addresses	Shipping Address	Insert	Change Request		Banner Health 7300 W. Detroit St. Chandler, AZ 85226	2/3/2020 2:56 PM
Addresses	Main Address	Update	Change Request	1891 W. Orange Grove Road Tucson, AZ 85704	1891 W. Orange Grove Rd Tucson, AZ 85704	2/3/2020 2:56 PM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1625 N Campbell Ave Tucson, AZ 85719	Banner University Medical Center Tucson 1625 North Campbell Avenue Tucson, AZ 85719	2/3/2020 2:56 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 2:15:47 PM	8/28/2019 2:21:12 PM	8/28/2019 2:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		425805300	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200784450A	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100564160	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500707030	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		395387902	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	8/28/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	020470	020470-01	8/28/2019 1:54 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1588614911 ( )		8/28/2019 1:54 PM
Contacts	Authorizing Official	Update	Change Request	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	7/29/2019 3:24 PM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724	Banner University Medical Center Tucson 1625 N Campbell Ave Tucson, AZ 85719	5/3/2019 6:20 PM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	9/27/2018 7:35 AM
Addresses	Billing Address	Update	Recertification	Banner - University Medical Center Tucson 3838 NORTH CAMPBELL AVENUE Tucson, AZ 85719	Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724	8/30/2018 2:15 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 7:09:43 PM	8/30/2018 2:15:47 PM	8/30/2018 2:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/20/2018 9:01 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0596345	7/20/2018 9:01 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	7/20/2018 9:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1154384899 ( )		7/20/2018 9:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1306908355 ( )		7/20/2018 9:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1275921082 ( )		7/20/2018 9:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1657501	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000142345	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003189644A	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2432435	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00096009	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026590500	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		19852088	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1031106620001	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11566A	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q028631	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2017276884	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2060663	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100063007	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		145728400	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	3/16/2018 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/4/2017 7:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		988439	12/4/2017 7:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	12/4/2017 7:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	12/4/2017 7:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	12/4/2017 7:09 PM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	12/4/2017 7:09:43 PM	12/4/2017 7:09 PM
Contacts	Primary Contact	Update		Weibel, Kurt Director of Pharmacy Services 5206946061	Weibel, Kurt Director of Pharmacy Services Banner University Medical Center Tucson 5206946061	10/13/2017 4:14 PM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance 5206943446	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	10/10/2017 3:53 PM
Contacts	Authorizing Official	Update		Mohesky, Debra CFO 6028393620	Polashek, Maurene Sr Dir Finance 5206943446	9/11/2017 3:29 PM
Contacts	Signed By	Insert			Hansen, Misty CFO 5206944091	6/23/2017 11:11 AM
Contacts	Primary Contact	Update		Diaz, Rafael AVP, Pharmacy and Supply Chain 5206946127	Weibel, Kurt Director of Pharmacy Services 5206946061	6/22/2017 10:57 AM
Contacts	Authorizing Official	Insert			Mohesky, Debra CFO 6028393620	4/28/2017 6:03 PM
Addresses	Main Address	Insert			1891 W. Orange Grove Road Tucson, AZ 85704	4/28/2017 6:03 PM
Addresses	Billing Address	Insert			Banner - University Medical Center Tucson 3838 NORTH CAMPBELL AVENUE Tucson, AZ 85719	4/28/2017 6:03 PM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 2:20 AM
Details	Last Recertification Date	Update			8/26/2015 12:00:00 AM	8/26/2015 6:40 AM
Contacts	Primary Contact	Insert			Diaz, Rafael AVP, Pharmacy and Supply Chain 5206946127	6/9/2015 11:42 AM
Medicaid Billing	NPI: Number	Insert			1265820179	5/12/2015 4:27 PM
Medicaid Billing	NPI: Number	Insert			1275921082	5/12/2015 4:27 PM
Details	Entity Subname	Update		Radiation Oncology at Orange Grove	Banner - AZCC - Radiation Oncology at Orange Grove	5/12/2015 4:27 PM
Details	Entity Name	Update		UNIVERSITY MEDICAL CENTER	Banner - University Medical Center Tucson	4/14/2015 3:09 PM
Medicaid Billing	NPI: Number	Insert			1154384899	1/12/2015 8:32 PM
Medicaid Billing	NPI: Number	Insert			1306908355	1/12/2015 8:32 PM
Medicaid Billing	NPI: Number	Insert			1588614911	1/12/2015 8:32 PM
Dates	Participating Approval Date	Update			8/20/2014 12:00:00 AM	8/20/2014 5:35 PM
Details	State	Update		Pending	Active	8/20/2014 5:35 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	8/20/2014 5:35 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_46148	DSH030064R	7/24/2014 12:24 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_46148	7/15/2014 7:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2014 7:04 PM
Medicaid Billing	Medicaid: Number	Insert			020470	7/15/2014 7:04 PM
Medicaid Billing	Medicaid: State	Insert			AZ	7/15/2014 7:04 PM
Details	Last Recertification Date	Insert				7/15/2014 7:04 PM
Details	Grant Number	Insert				7/15/2014 7:04 PM
Details	340B ID	Insert				7/15/2014 7:04 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2014 7:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2014 7:04 PM
Details	Medicare Provider Number	Insert			030064	7/15/2014 7:04 PM
Details	Entity Name	Insert			UNIVERSITY MEDICAL CENTER	7/15/2014 7:04 PM
Details	Program Code	Insert			DSH	7/15/2014 7:04 PM
Details	Entity Subname	Insert			Radiation Oncology at Orange Grove	7/15/2014 7:04 PM
Dates	Participating Approval Date	Insert				7/15/2014 7:04 PM
Details	State	Insert			Pending	7/15/2014 7:04 PM
Dates	Registration Date	Insert			7/15/2014 12:00:00 AM	7/15/2014 7:04 PM
Dates	Signed By Date	Insert			7/15/2014 12:00:00 AM	7/15/2014 7:04 PM
Dates	Start Date	Insert				7/15/2014 7:04 PM
Terminations	Termination Comments	Insert				7/15/2014 7:04 PM
Terminations	Termination Date	Insert				7/15/2014 7:04 PM
Terminations	Termination Effective Date	Insert				7/15/2014 7:04 PM
Terminations	Termination Reason	Insert				7/15/2014 7:04 PM