Covered Entity Details

DSH240006M OLMSTED MEDICAL CENTER (Active) - information as of 4/27/2025 11:34:36 PM

Main Details

Name

OLMSTED MEDICAL CENTER

Subdivision Name

Northwest Clinic / NW Family Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240006M

Medicare Provider Number

240006

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/1/2014

Participating Start Date

1/1/2015

Participating Approval Date

12/4/2014

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Olmsted Medical Center
Kevin Higgins, Chief Financial Officer
(507) 529-6619

Primary Contact

Olmsted Medical Center Hospital Pharmacy
Jennifer King, 340B Program Coordinator
(507) 529-6870

Addresses

Street Address

5067 55th St NW
Rochester, MN 55901

Billing Address

Olmsted Medical Center
1650 4th St SE
Rochester, MN 55904

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
MN	860747800	1538112131

Shipping Addresses

Shipping Address 1

Olmsted Medical Center
1650 4th St SE
Rochester, MN 55904

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
DSH240006A	Child	DSH	OLMSTED MEDICAL CENTER	OMC BYRON CLINIC	846 HIGH POINT DR.	BYRON	MN	Active
DSH240006AA	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Dermatology	210 9th St SE	Rochester	MN	Active
DSH240006AB	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Endocrinology	210 9th St SE	Rochester	MN	Active
DSH240006AC	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Otolaryngology (ENT)	210 9th St SE	Rochester	MN	Active
DSH240006AD	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Internal Medicine	210 9th St SE	Rochester	MN	Active
DSH240006AE	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Neurology	210 9th St SE	Rochester	MN	Active
DSH240006AF	Child	DSH	OLMSTED MEDICAL CENTER	Miracle Mile / Occupational Medicine	132 17th Ave NW	Rochester	MN	Active
DSH240006AG	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Ophthalmology	210 9th St SE	Rochester	MN	Active
DSH240006AH	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Pediatrics	210 9th St SE	Rochester	MN	Active
DSH240006AJ	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Podiatry	210 9th St SE	Rochester	MN	Active
DSH240006AK	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Psychiatry & Psychology	210 9th St SE	Rochester	MN	Active
DSH240006AL	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Family Medicine	210 9th St SE	Rochester	MN	Active
DSH240006AM	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Orthopedics	210 9th St SE	Rochester	MN	Terminated
DSH240006AN	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Travel & Immunization	210 9th St SE	Rochester	MN	Active
DSH240006AP	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Anticoagulation	210 9th St SE	Rochester	MN	Active
DSH240006AQ	Child	DSH	OLMSTED MEDICAL CENTER	Skyway Clinic	318 First Avenue SW	Rochester	MN	Active
DSH240006AR	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Radiology	210 9th St SE	Rochester	MN	Active
DSH240006AS	Child	DSH	OLMSTED MEDICAL CENTER	Rehabilitation Services Elton Hills - Rehabilitation	102 Elton Hills Dr NW	Rochester	MN	Active
DSH240006AT	Child	DSH	OLMSTED MEDICAL CENTER	NW Cardiopulmonary Rehab - Cardiopulmonary Rehab	5067 55th St NW	Rochester	MN	Active
DSH240006AU	Child	DSH	OLMSTED MEDICAL CENTER	SE MAT CLINIC - Medication Assisted Treatment	210 9TH ST SE	Rochester	MN	Active
DSH240006AV	Child	DSH	OLMSTED MEDICAL CENTER	SE Medication Therapy - MTM	210 9TH ST SE	Rochester	MN	Active
DSH240006AW	Child	DSH	OLMSTED MEDICAL CENTER	Miracle Mile - Family Medicine	132 17th Ave NW	Rochester	MN	Active
DSH240006AX	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Rheumatology - Rheumatology	210 9TH ST SE	Rochester	MN	Active
DSH240006AY	Child	DSH	OLMSTED MEDICAL CENTER	OMC Virtual Care - Virtual Care	210 9TH ST SE	Rochester	MN	Active
DSH240006AZ	Child	DSH	OLMSTED MEDICAL CENTER	Miracle Mile / Acute Care - Acute Care	132 17th Ave NW	Rochester	MN	Active
DSH240006B	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic/ Acute Care	210 NINTH ST SE	ROCHESTER	MN	Active
DSH240006C	Child	DSH	OLMSTED MEDICAL CENTER	OMC PINE ISLAND CLINIC	111 COUNTY ROAD 11 NW	PINE ISLAND	MN	Active
DSH240006D	Child	DSH	OLMSTED MEDICAL CENTER	OMC PRESTON CLINIC	405 KANSAS ST. NW	PRESTON	MN	Active
DSH240006E	Child	DSH	OLMSTED MEDICAL CENTER	OMC SPRING VALLEY CLINIC	802 Memorial Dr.	SPRING VALLEY	MN	Active
DSH240006F	Child	DSH	OLMSTED MEDICAL CENTER	OMC WANAMINGO CLINIC	217 MAIN ST. SUITE B	WANAMINGO	MN	Active
DSH240006G	Child	DSH	OLMSTED MEDICAL CENTER	OMC CHATFIELD CLINIC	207 TWIFORD STREET SW	CHATFIELD	MN	Active
DSH240006H	Child	DSH	OLMSTED MEDICAL CENTER	OMC NORTHWEST OFFICE	5067 55TH ST NW	ROCHESTER	MN	Terminated
DSH240006J	Child	DSH	OLMSTED MEDICAL CENTER	OMC PLAINVIEW CLINIC	20 SECOND AVE. NE	PLAINVIEW	MN	Active
DSH240006K	Child	DSH	OLMSTED MEDICAL CENTER	OMC ST. CHARLES CLINIC	403 WEST FORTH ST.	ST. CHARLES	MN	Active
DSH240006L	Child	DSH	OLMSTED MEDICAL CENTER	OMC STEWARTVILLE CLINIC	208 CENTERTOWN PLAZA	STEWARTVILLE	MN	Active
DSH240006M	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Family Medicine	5067 55th St NW	Rochester	MN	Active
DSH240006N	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Acute Care	5067 55th St NW	Rochester	MN	Active
DSH240006P	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Saturday Walk-in Clinic	5067 55th St NW	Rochester	MN	Terminated
DSH240006Q	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Pediatrics	5067 55th St NW	Rochester	MN	Active
DSH240006R	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Internal Medicine	5067 55th St NW	Rochester	MN	Terminated
DSH240006S	Child	DSH	OLMSTED MEDICAL CENTER	Sports Medicine & Athletic Performance	5155 55th St NW	Rochester	MN	Active
DSH240006T	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Radiology	5067 55th St NW	Rochester	MN	Active
DSH240006U	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / Nuclear Medicine	5067 55th St NW	Rochester	MN	Active
DSH240006V	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / Pain Management	5067 55th St NW	Rochester	MN	Active
DSH240006W	Child	DSH	OLMSTED MEDICAL CENTER	Sleep Medicine Clinic	4303 Highway 52 North	Rochester	MN	Active
DSH240006X	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / NW Rehabilitation Services	5067 55th St NW	Rochester	MN	Active
DSH240006Y	Child	DSH	OLMSTED MEDICAL CENTER	Southeast Clinic / Asthma and Allergy	210 9th St SE	Rochester	MN	Active
DSH240006Z	Child	DSH	OLMSTED MEDICAL CENTER	Northwest Clinic / Cardiology	5067 55th St NW	Rochester	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 3:26:24 PM	8/16/2024 12:08:56 PM	8/16/2024 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 8:59:15 AM	8/21/2023 3:26:24 PM	8/21/2023 3:26 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	860747800 (IA)		7/13/2023 11:24 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	860747800 (WI)		7/13/2023 11:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1538112131 (IA)		7/13/2023 11:24 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1538112131 (WI)		7/13/2023 11:24 AM
Details	Last Recertification Date	Update	Recertification	9/7/2021 9:01:08 AM	9/6/2022 8:59:15 AM	9/6/2022 8:59 AM
Details	Last Recertification Date	Update	Recertification	8/31/2020 5:18:02 PM	9/7/2021 9:01:08 AM	9/7/2021 9:01 AM
Contacts	Primary Contact	Update	Profile Change Request	King, Jennifer 340B Compliance Technician Olmsted Medical Center Hospital Pharmacy 5075296870	King, Jennifer 340B Program Coordinator Olmsted Medical Center Hospital Pharmacy 5075296870	8/19/2021 1:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		860747800	8/31/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	8/31/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		860747800	8/31/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/31/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1538112131	8/31/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/31/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1538112131	8/31/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/31/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1538112131	8/31/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/31/2020 5:18 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1538112131 ( )		8/31/2020 5:18 PM
Details	Last Recertification Date	Update	Recertification	8/19/2019 10:05:25 AM	8/31/2020 5:18:02 PM	8/31/2020 5:18 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 12:59:14 PM	8/19/2019 10:05:25 AM	8/19/2019 10:05 AM
Addresses	Billing Address	Insert	Recertification		Olmsted Medical Center 1650 4th St SE Rochester, MN 55904	8/22/2018 12:59 PM
Addresses	Shipping Address	Insert	Recertification		Olmsted Medical Center 1650 4th St SE Rochester, MN 55904	8/22/2018 12:59 PM
Details	Last Recertification Date	Update	Recertification	11/20/2017 10:36:00 AM	8/22/2018 12:59:14 PM	8/22/2018 12:59 PM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/20/2017 10:36:00 AM	11/20/2017 10:36 AM
Contacts	Authorizing Official	Update		Higgins, Kevin Chief Financial Officer 5075296619	Higgins, Kevin Chief Financial Officer Olmsted Medical Center 5075296619	10/23/2017 9:25 AM
Contacts	Signed By	Update		Higgins, Kevin Chief Financial Officer 5075296619	Higgins, Kevin Chief Financial Officer Olmsted Medical Center 5075296619	10/23/2017 9:25 AM
Contacts	Primary Contact	Update		King, Jennifer 340B Compliance Technician 5075296870	King, Jennifer 340B Compliance Technician Olmsted Medical Center Hospital Pharmacy 5075296870	9/20/2017 1:28 PM
Contacts	Authorizing Official	Insert			Higgins, Kevin Chief Financial Officer 5075296619	7/21/2017 3:39 PM
Contacts	Signed By	Insert			Higgins, Kevin Chief Financial Officer 5075296619	7/21/2017 3:39 PM
Contacts	Primary Contact	Update		Ellenbaum, Dan Senior Financial Analyst 5075296631	King, Jennifer 340B Compliance Technician 5075296870	6/28/2017 12:45 PM
Addresses	Main Address	Insert			5067 55th St NW Rochester, MN 55901	6/27/2017 5:47 PM
Contacts	Primary Contact	Insert			Ellenbaum, Dan Senior Financial Analyst 5075296631	4/27/2017 7:56 AM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/19/2016 12:00:00 AM	8/19/2016 3:17 PM
Details	Last Recertification Date	Update			8/19/2015 12:00:00 AM	8/19/2015 4:01 PM
Dates	Participating Approval Date	Update			12/4/2014 12:00:00 AM	12/4/2014 11:24 AM
Details	State	Update		Pending	Active	12/4/2014 11:24 AM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	12/4/2014 11:24 AM
Details	Entity Subname	Update		Northwest Clinic	Northwest Clinic / NW Family Medicine	11/12/2014 2:15 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_46338	DSH240006M	11/12/2014 2:14 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_46338	10/1/2014 9:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/1/2014 9:08 AM
Medicaid Billing	Medicaid: Number	Insert			860747800	10/1/2014 9:08 AM
Medicaid Billing	Medicaid: State	Insert			MN	10/1/2014 9:08 AM
Medicaid Billing	NPI: Number	Insert			1538112131	10/1/2014 9:08 AM
Details	Last Recertification Date	Insert				10/1/2014 9:08 AM
Details	Grant Number	Insert				10/1/2014 9:08 AM
Details	340B ID	Insert				10/1/2014 9:08 AM
Details	Is Authorizing Official EHB Data	Insert				10/1/2014 9:08 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/1/2014 9:08 AM
Details	Medicare Provider Number	Insert			240006	10/1/2014 9:08 AM
Details	Entity Name	Insert			OLMSTED MEDICAL CENTER	10/1/2014 9:08 AM
Details	Program Code	Insert			DSH	10/1/2014 9:08 AM
Details	Entity Subname	Insert			Northwest Clinic	10/1/2014 9:08 AM
Dates	Participating Approval Date	Insert				10/1/2014 9:08 AM
Details	State	Insert			Pending	10/1/2014 9:08 AM
Dates	Registration Date	Insert			10/1/2014 12:00:00 AM	10/1/2014 9:08 AM
Dates	Signed By Date	Insert			10/1/2014 12:00:00 AM	10/1/2014 9:08 AM
Dates	Start Date	Insert				10/1/2014 9:08 AM
Terminations	Termination Comments	Insert				10/1/2014 9:08 AM
Terminations	Termination Date	Insert				10/1/2014 9:08 AM
Terminations	Termination Effective Date	Insert				10/1/2014 9:08 AM
Terminations	Termination Reason	Insert				10/1/2014 9:08 AM