Covered Entity Details

RRC360147-40 MARIETTA MEMORIAL HOSPITAL (Active) - information as of 6/26/2025 3:06:01 AM

Main Details

Name

MARIETTA MEMORIAL HOSPITAL

Subdivision Name

Primary Care

Type

Rural Referral Center

Rural

Yes

340B ID

RRC360147-40

Medicare Provider Number

360147

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/1/2014

Participating Start Date

1/1/2015

Participating Approval Date

11/7/2014

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Marietta Memorial Hospital
Doug Full, Director of Finance
(740) 374-1698

Primary Contact

Marietta Memorial Hospital
David Layne, 340B Pharmacy Analyst
(606) 922-3796

Addresses

Street Address

805 Farson Street
SUITE 117
BELPRE, OH 45714-1067

Billing Address
Same as Street Address

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
OH	5511566	1215936927

Shipping Addresses

Same as Street Address

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
RRC360147-01	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	805 FARSON STREET	BELPRE	OH	Active
RRC360147-02	Child	RRC	MARIETTA MEMORIAL HOSPITAL	SPORTS Medicine	802 WAYNE STREET	MARIETTA	OH	Active
RRC360147-03	Child	RRC	MARIETTA MEMORIAL HOSPITAL	EAR, NOSE AND THROAT	807 FARSON ST., SUITE 203	BELPRE	OH	Terminated
RRC360147-04	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	300 E. 8TH STREET, SUITE 121	MARIETTA	OH	Active
RRC360147-05	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	330 EAST EIGHTH STREET	MARIETTA	OH	Terminated
RRC360147-06	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Opthalmology	400 MATTHEW ST STE 100	MARIETTA	OH	Terminated
RRC360147-07	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPARTMENT OF PULMONOLOGY	400 MATTHEW ST	MARIETTA	OH	Active
RRC360147-08	Child	RRC	MARIETTA MEMORIAL HOSPITAL	CARDIOLOGY	400 MATTHEW STREET	MARIETTA	OH	Active
RRC360147-09	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Internal Medicine	807 FARSON STREET	BELPRE	OH	Terminated
RRC360147-10	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	501 HIGHLAND AVENUE	WILLIAMSTOWN	WV	Active
RRC360147-11	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	608 SECOND ST	NEW MATAMORAS	OH	Terminated
RRC360147-12	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	503 5TH ST	BEVERLY	OH	Terminated
RRC360147-13	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	802 WAYNE STREET	MARIETTA	OH	Terminated
RRC360147-14	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	300 E. 8th St.	MARIETTA	OH	Active
RRC360147-15	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Urology	400 MATTHEW STREET	MARIETTA	OH	Active
RRC360147-16	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Medical Oncology	807 FARSON STREET	BELPRE	OH	Active
RRC360147-17	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Allergy and Immunology	410 2ND ST	MARIETTA	OH	Terminated
RRC360147-18	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Endocrinology	803 Farson Street	Belpre	OH	Active
RRC360147-19	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Pain Management	805 FARSON ST	BELPRE	OH	Active
RRC360147-20	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Physical Medicine	400 MATTHEW STREET	MARIETTA	OH	Active
RRC360147-21	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care - Suite 100	210N 7TH ST 100	MARIETTA	OH	Terminated
RRC360147-22	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Internal Medicine	400 MATTHEW STREET	MARIETTA	OH	Terminated
RRC360147-23	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	805 FARSON STREET	BELPRE	OH	Active
RRC360147-24	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Vascular Surgery	400 MATTHEW STREET	MARIETTA	OH	Terminated
RRC360147-25	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	805 FARSON ST	BELPRE	OH	Active
RRC360147-26	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	40 WHITE OAK PROFESSIONAL CTR	VINCENT	OH	Active
RRC360147-27	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Podiatry	400 MATTHEW STREET	MARIETTA	OH	Active
RRC360147-28	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	151 ANDERSON LN	WATERFORD	OH	Active
RRC360147-29	Child	RRC	MARIETTA MEMORIAL HOSPITAL	General and Bariatic Surgery	400 MATTHEW ST	MARIETTA	OH	Active
RRC360147-30	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	320 EAST EIGHTH STREET	MARIETTA	OH	Active
RRC360147-31	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Pediatrics	310 E. Eighth St.	MARIETTA	OH	Terminated
RRC360147-32	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	802 WAYNE STREET	MARIETTA	OH	Active
RRC360147-33	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Opthalmology	330 EAST EIGHTH STREET	MARIETTA	OH	Active
RRC360147-34	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	330 EAST EIGHTH STREET	MARIETTA	OH	Active
RRC360147-35	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Podiatry	2434 RICHMILLER LN	BELPRE	OH	Active
RRC360147-36	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	304 MAIN STREET	CALDWELL	OH	Active
RRC360147-37	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Psychiatry	210 N. Seventh Street	MARIETTA	OH	Active
RRC360147-38	Child	RRC	MARIETTA MEMORIAL HOSPITAL	ENT	800 WAYNE STREET	MARIETTA	OH	Active
RRC360147-39	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	416 1/2 COLEGATE DR	MARIETTA	OH	Terminated
RRC360147-40	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	805 Farson Street	BELPRE	OH	Active
RRC360147-41	Child	RRC	MARIETTA MEMORIAL HOSPITAL	General Surgery	400 MATTHEW STREET	MARIETTA	OH	Active
RRC360147-42	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Allergy and Immunology	210 North 7th Street	Marietta	OH	Active
RRC360147-43	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Emergency Medicine Belpre	799 Farson Street	Belpre	OH	Active
RRC360147-44	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	424 Highland Avenue	Williamstown	WV	Active
RRC360147-45	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of General and Bariatric Surgery	400 Matthew Street	Marietta	OH	Terminated
RRC360147-46	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Neurology	400 Matthew Street	Marietta	OH	Active
RRC360147-47	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Primary Care	418 Grand Park Drive	Vienna	WV	Active
RRC360147-48	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Obstetrics and Gynecology	320 E. Eighth Street	Marietta	OH	Active
RRC360147-49	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Obstetrics and Gynecology	400 MATTHEW STREET	Marietta	OH	Active
RRC360147-50	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care	807 Farson Street	Belpre	OH	Active
RRC360147-51	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Obstetrics and Gynecology	807 Farson Street	Belpre	OH	Active
RRC360147-52	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Cardiology	803 Farson Street	Belpre	OH	Active
RRC360147-53	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Surgery Belpre	799 Farson Street	Belpre	OH	Active
RRC360147-54	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Gastroentology	400 Matthew Street	Marietta	OH	Active
RRC360147-55	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Strecker Cancer Center	401 Matthew Street	Marietta	OH	Terminated
RRC360147-56	Child	RRC	MARIETTA MEMORIAL HOSPITAL	INTERNAL MEDICINE	807 Farson Street	Belpre	OH	Terminated
RRC360147-57	Child	RRC	MARIETTA MEMORIAL HOSPITAL	OPHTHALMOLOGY	210 7th Street	Marietta	OH	Terminated
RRC360147-58	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	805 Farson Street	Belpre	OH	Terminated
RRC360147-59	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PRIMARY CARE	807 Farson Street	Belpre	OH	Approved
RRC360147-60	Child	RRC	MARIETTA MEMORIAL HOSPITAL	SURGERY HOSPITALIST	401 Matthew Street	Marietta	OH	Active
RRC360147-61	Child	RRC	MARIETTA MEMORIAL HOSPITAL	SURGERY ONCOLOGY	807 Farson Street	Belpre	OH	Active
RRC360147-62	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Pain	799 Farson Street	Belpre	OH	Active
RRC360147-63	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Neurosurgery	400 Matthew Street	Marietta	OH	Active
RRC360147-64	Child	RRC	MARIETTA MEMORIAL HOSPITAL	MARIETTA MEMORIAL HOSPITAL - Primary Care	802 WAYNE ST 200	MARIETTA	OH	Terminated
RRC360147-65	Child	RRC	MARIETTA MEMORIAL HOSPITAL	MARIETTA MEMORIAL HOSPITAL - Specialty Clinic	310 W UNION ST	ATHENS	OH	Active
RRC360147-66	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Pediatrics - Pediatrics	807 Farson Street	Belpre	OH	Terminated
RRC360147-67	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Surgery - Surgery	400 Matthew Street	Marietta	OH	Terminated
RRC360147-68	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Rheumatology - Rheumatology	800 Wayne Street	Marietta	OH	Active
RRC360147-69	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Infectious Disease - Infectious Disease	400 Matthew Street	Marietta	OH	Active
RRC360147-70	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Neurosurgery - Neurosurgery	807 Farson Street	Belpre	OH	Active
RRC360147-72	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Primary Care - Primary Care	206 Columbus Road	Athens	OH	Active
RRC360147-73	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Belpre Dept Specialty Care - Belpre Dept Specialty Care	807 Farson Street	Belpre	OH	Active
RRC360147-74	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF SLEEP MEDICINE - SLEEP MEDICINE	210 N 7TH ST	MARIETTA	OH	Active
RRC360147-75	Child	RRC	MARIETTA MEMORIAL HOSPITAL	PLASTIC, HAND & RECONSTRUCTIVE SURG - Plastic Surgery	400 MATTHEW ST	MARIETTA	OH	Active
RRC360147-76	Child	RRC	MARIETTA MEMORIAL HOSPITAL	WOUND CARE CENTER - WOUND CENTER	805 FARSON ST	BELPRE	OH	Active
RRC360147-77	Child	RRC	MARIETTA MEMORIAL HOSPITAL	OSTEOPATHIC MANIPULATIVE MED DEPT - Manipulative Medicine	26 East Park Drive	ATHENS	OH	Active
RRC360147-78	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF GASTROENTEROLOGY - GASTROENTEROLOGY	799 FARSON ST	BELPRE	OH	Active
RRC360147-79	Child	RRC	MARIETTA MEMORIAL HOSPITAL	MARIETTA MEMORIAL HOSPITAL - PRIMARY CARE	800 PIKE ST	MARIETTA	OH	Active
RRC360147-80	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF BEHAVORIAL HEALTH - BEHAVIORAL HEALTH	807 FARSON ST	BELPRE	OH	Active
RRC360147-81	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF DERMATOLOGY - DERMATOLOGY	1818 Washington Blvd	BELPRE	OH	Active
RRC360147-82	Child	RRC	MARIETTA MEMORIAL HOSPITAL	MARIETTA MEMORIAL HOSPITAL - PRIMARY CARE	1006 WASHINGTON BLVD	BELPRE	OH	Active
RRC360147-83	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF PRIMARY CARE - PRIMARY CARE	127 S MAIN ST	WOODSFIELD	OH	Active
RRC360147-84	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF RADIATION ONCOLOGY - RADIATION ONCOLOGY BELPRE	807 FARSON ST	BELPRE	OH	Active
RRC360147-85	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Obstetrics and Gynecology Athens - OBGYN Athens	206 Columbus Road	Athens	OH	Active
RRC360147-86	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF ORTHOPEDICS - ORTHOPEDICS ATHENS	20 UNIVERSITY ESTATES BLVD	ATHENS	OH	Active
RRC360147-87	Child	RRC	MARIETTA MEMORIAL HOSPITAL	Department of Rheumatology Belpre - Rheumatology Belpre	807 Farson Street Suite 204 C	Belpre	OH	Active
RRC360147-88	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF ORTHOPAEDICS - ORTHOPEDICS	611 2ND ST	MARIETTA	OH	Active
RRC360147-89	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF ORTHOPAEDICS - ORTHOPEDICS	2434 RICHMILLER LN	BELPRE	OH	Active
RRC360147-90	Child	RRC	MARIETTA MEMORIAL HOSPITAL	DEPT OF PRIMARY CARE - FAMILY SERVICES	807 FARSON ST	BELPRE	OH	Active
RRC360147-91	Child	RRC	MARIETTA MEMORIAL HOSPITAL	ATHENS DEPT OF OPHTHALMOLOGY - OPHTHALMOLOGY	206 COLUMBUS RD	ATHENS	OH	Approved
RRC360147-92	Child	RRC	MARIETTA MEMORIAL HOSPITAL	OBGYN - OBGYN	400 Matthew Street	Marietta	OH	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 11:23:59 AM	8/21/2024 12:19:40 PM	8/21/2024 12:19 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 11:12:46 AM	8/30/2023 11:23:59 AM	8/30/2023 11:23 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 11:31:08 AM	9/9/2022 11:12:46 AM	9/9/2022 11:12 AM
Details	Last Recertification Date	Update	Recertification	8/19/2020 11:51:41 AM	8/27/2021 11:31:08 AM	8/27/2021 11:31 AM
Contacts	Primary Contact	Update	Change Request	Full, Doug Director of Finance Marietta Memorial Hospital 7403741698	Layne, David 340B Pharmacy Analyst Marietta Memorial Hospital 6069223796	1/28/2021 8:02 AM
Contacts	Authorizing Official	Update	Change Request	Hupp, Joseph SR Director of Finance / Interim CFO Marietta Memorial Hospital 7403741546	Full, Doug Director of Finance Marietta Memorial Hospital 7403741698	1/26/2021 3:53 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0001529000 (WV)		12/23/2020 4:32 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1215936927 (WV)		12/23/2020 4:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1215936927 ( )		8/19/2020 11:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1215936927	8/19/2020 11:51 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/19/2020 11:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1215936927	8/19/2020 11:51 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/19/2020 11:51 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 4:19:32 PM	8/19/2020 11:51:41 AM	8/19/2020 11:51 AM
Addresses	Main Address	Update	Change Request	805 Farson Street 117 BELPRE, OH 45714-1067	805 Farson Street SUITE 117 BELPRE, OH 45714-1067	4/9/2020 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/8/2020 11:17 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		5511566	1/8/2020 11:17 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	1/8/2020 11:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/8/2020 11:17 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0001529000	1/8/2020 11:17 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	1/8/2020 11:17 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1215936927	1/8/2020 11:17 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 8:38:19 AM	8/21/2019 4:19:32 PM	8/21/2019 4:19 PM
Contacts	Authorizing Official	Update	Change Request	YOUNG, ERIC CFO Marietta Memorial Hospital 7403741641	Hupp, Joseph SR Director of Finance / Interim CFO Marietta Memorial Hospital 7403741546	10/3/2018 3:10 PM
Addresses	Main Address	Update	Change Request	809 FARSON AVE, SUITE 101 BELPRE, OH 45714-1067	805 Farson Street 117 BELPRE, OH 45714-1067	8/23/2018 9:43 AM
Details	Entity Subname	Update	Change Request	BELPRE DIAGNOSTICS	Primary Care	8/23/2018 9:43 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 1:07:21 PM	8/20/2018 8:38:19 AM	8/20/2018 8:38 AM
Contacts	Primary Contact	Insert	Recertification		Full, Doug Director of Finance Marietta Memorial Hospital 7403741698	11/9/2017 1:07 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/9/2017 1:07:21 PM	11/9/2017 1:07 PM
Contacts	Authorizing Official	Update		YOUNG, ERIC CFO 7403741641	YOUNG, ERIC CFO Marietta Memorial Hospital 7403741641	9/28/2017 10:37 AM
Contacts	Signed By	Update		YOUNG, ERIC CFO 7403741641	YOUNG, ERIC CFO Marietta Memorial Hospital 7403741641	9/28/2017 10:37 AM
Contacts	Authorizing Official	Insert			YOUNG, ERIC CFO 7403741641	7/14/2017 3:03 PM
Contacts	Signed By	Insert			YOUNG, ERIC CFO 7403741641	7/14/2017 3:03 PM
Addresses	Main Address	Insert			809 FARSON AVE, SUITE 101 BELPRE, OH 45714-1067	4/20/2017 4:24 PM
Details	Last Recertification Date	Update		8/18/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 1:44 PM
Details	Entity Subname	Update			BELPRE DIAGNOSTICS	4/28/2016 10:41 AM
Details	Medicare Provider Number	Update			360147	4/22/2016 6:14 PM
Details	Medicare Provider Number	Update		360147		4/22/2016 3:01 PM
Details	Entity Subname	Update		BELPRE DIAGNOSTICS		4/22/2016 3:01 PM
Details	Last Recertification Date	Update			8/18/2015 12:00:00 AM	8/18/2015 2:30 PM
Dates	Participating Approval Date	Update			11/7/2014 12:00:00 AM	11/7/2014 10:40 AM
Details	State	Update		Pending	Active	11/7/2014 10:40 AM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	11/7/2014 10:40 AM
Details	340B ID	Update		RRC360147-41	RRC360147-40	10/29/2014 5:47 PM
Details	340B ID	Update		RRC360147-38	RRC360147-41	10/29/2014 5:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_46364	RRC360147-38	10/29/2014 5:27 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_46364	10/1/2014 10:34 AM
Details	Last Recertification Date	Insert				10/1/2014 10:34 AM
Details	Grant Number	Insert				10/1/2014 10:34 AM
Details	340B ID	Insert				10/1/2014 10:34 AM
Details	Is Authorizing Official EHB Data	Insert				10/1/2014 10:34 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/1/2014 10:34 AM
Details	Medicare Provider Number	Insert			360147	10/1/2014 10:34 AM
Details	Entity Name	Insert			MARIETTA MEMORIAL HOSPITAL	10/1/2014 10:34 AM
Details	Program Code	Insert			RRC	10/1/2014 10:34 AM
Details	Entity Subname	Insert			BELPRE DIAGNOSTICS	10/1/2014 10:34 AM
Dates	Participating Approval Date	Insert				10/1/2014 10:34 AM
Details	State	Insert			Pending	10/1/2014 10:34 AM
Dates	Registration Date	Insert			10/1/2014 12:00:00 AM	10/1/2014 10:34 AM
Dates	Signed By Date	Insert			10/1/2014 12:00:00 AM	10/1/2014 10:34 AM
Dates	Start Date	Insert				10/1/2014 10:34 AM
Terminations	Termination Comments	Insert				10/1/2014 10:34 AM
Terminations	Termination Date	Insert				10/1/2014 10:34 AM
Terminations	Termination Effective Date	Insert				10/1/2014 10:34 AM
Terminations	Termination Reason	Insert				10/1/2014 10:34 AM