Covered Entity Details

PED393302-30 UPMC CHILDREN'S HOSPITAL OF PITTSBURGH (Terminated) - information as of 5/6/2025 12:02:25 AM

Main Details

Name

UPMC CHILDREN'S HOSPITAL OF PITTSBURGH

Subdivision Name

North Satellite/Occupational Therapy

Type

Children's Hospital

Rural

340B ID

PED393302-30

Medicare Provider Number

393302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/28/2014

Participating Start Date

1/1/2015

Participating Approval Date

12/8/2014

Last Recertification Date

8/24/2023

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

UPMC
Mario Edward Wilfong, CFO
(412) 692-8201

Primary Contact

UPMC
Amanda Pell, Manager, 340B Program
(814) 771-8354

Addresses

Street Address

11279 Perry Highway
Wexford, PA 15090

Billing Address

HC PHARMACY CENTRAL – PROCUREMENT
3175 E. CARSON ST
Pittsburgh, PA 15203

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
PA	1007347990017,1007347990012,1007347990004,1007347990059,1007347990089,1007347990060,1007347990069	1164426896,1053476556,1083851968,1619313350,1194889485

Shipping Addresses

Shipping Address 1

HC PHARMACY CENTRAL – PROCUREMENT
3175 E. CARSON ST
Pittsburgh, PA 15203

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
PED393302-01	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	Outpatient Surgery	2599 WEXFORD BAYNE ROAD	SEWICKLEY	PA	Terminated
PED393302-02	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	SOUTH SATELLITE	205 Millers Run Road	BRIDGEVILLE	PA	Terminated
PED393302-03	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	SAME DAY SURGERY-MAIN HOSPITAL (SPU)	4401 PENN AVENUE	PITTSBURGH	PA	Terminated
PED393302-04	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	EAST SATELLITE	4055 MONROEVILLE BLVD.	MONROEVILLE	PA	Terminated
PED393302-05	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	RENAL CLINIC	4401 PENN AVENUE	PITTSBURGH	PA	Terminated
PED393302-06	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Communication Disorders	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-07	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Phlebotomy Services	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-08	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Radiology Diagnostic	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-09	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Occupational Therapy	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-10	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Physical Therapy	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-11	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Pulmonary Function	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-12	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Electroencephalography	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-13	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/EKG / ECHO	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-14	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	South Satellite/Audiology	205 Millers Run Road	Bridgeville	PA	Terminated
PED393302-15	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Electroencephalography	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-16	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Phlebotomy Services	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-17	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Pulmonary Function	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-18	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/EKG / ECHO	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-19	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Occupational Therapy	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-20	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Physical Therapy	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-21	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Radiology Diagnostic	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-22	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Communication Disorders	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-23	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	East Satellite/Audiology	4055 Monroeville Boulevard	Monroeville	PA	Terminated
PED393302-24	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Ronald McDonald Care Mobile	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-25	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Phlebotomy Services	11279 Perry Highway	Wexford	PA	Terminated
PED393302-26	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Electromyography	11279 Perry Highway	Wexford	PA	Terminated
PED393302-27	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Electroencephalography	11279 Perry Highway	Wexford	PA	Terminated
PED393302-28	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Child & Family Counseling	11279 Perry Highway	Wexford	PA	Terminated
PED393302-29	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Communication Disorders	11279 Perry Highway	Wexford	PA	Terminated
PED393302-30	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Occupational Therapy	11279 Perry Highway	Wexford	PA	Terminated
PED393302-31	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Sleep Study Center	2619 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-32	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Pulmonary Function	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-33	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Phlebotomy Services	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-34	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/EKG / ECHO	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-35	Child	PED	CHILDREN'S HOSPITAL OF PITTSBURGH OF UPMC	North Satellite/MRI	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-36	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Radiology Diagnostic	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-37	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Audiology	2559 Wexford-Bayne Road	Sewickley	PA	Terminated
PED393302-38	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Surgery Center	2599 Wexford-Bayne Road	Sewickley	PA	Active
PED393302-39	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	North Satellite/Physical Therapy	11279 Perry Highway	Wexford	PA	Terminated
PED393302-40	Child	PED	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	CHP-Pulmonology North - (31315)	2599 Wexford-Bayne Road	Wexford	PA	Active

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	Termination Request		10/1/2023 12:00:00 AM	9/12/2023 12:23 PM
Details	State	Update	Termination Request	Active	To Be Terminated	9/12/2023 12:23 PM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	9/12/2023 12:23 PM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2023 12:00:00 AM	9/12/2023 12:23 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	9/12/2023 12:23 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 11:29:46 AM	8/24/2023 4:24:35 PM	8/24/2023 4:24 PM
Contacts	Primary Contact	Update	Group Change Request	Lynch, Jennifer Director, Pharmacy 340B Program UPMC 7406067463	Pell, Amanda Manager, 340B Program UPMC 8147718354	7/24/2023 1:06 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 3:28:30 PM	8/31/2022 11:29:46 AM	8/31/2022 11:29 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0010928 (OH)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0001649000 (WV)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	00429603 (NY)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4201515 (NJ)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	304681340 (MI)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100034940A (IN)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	092432600 (FL)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1743267 (LA)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	00220429 (MS)		8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990059	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990089	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990060	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990069	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/23/2022 2:17 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1194889485	8/23/2022 2:17 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/23/2022 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0010928	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990017	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990012	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007347990004	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0001649000	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		00429603	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		4201515	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NJ	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		304681340	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MI	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		100034940A	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IN	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		092432600	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1743267	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		00220429	8/22/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MS	8/22/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1164426896	8/22/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1053476556	8/22/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1083851968	8/22/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619313350	8/22/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 10:19 AM
Contacts	Primary Contact	Update	Group Change Request	Patterson, Anthony Director of Pharmacy Children's Hospital of Pittsburgh of UPMC 4126926242	Lynch, Jennifer Director, Pharmacy 340B Program UPMC 7406067463	2/2/2022 8:20 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 10:21:06 AM	9/9/2021 3:28:30 PM	9/9/2021 3:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007347990004 (PA)		11/30/2020 3:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1053476556 (PA)		11/30/2020 3:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1083851968 (PA)		11/30/2020 3:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164426896 (PA)		11/30/2020 3:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1194889485 (PA)		11/30/2020 3:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053476556	9/1/2020 10:21 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 10:21 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1083851968	9/1/2020 10:21 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 10:21 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164426896	9/1/2020 10:21 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 10:21 AM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/1/2020 10:21 AM
Details	Last Recertification Date	Update	Recertification	9/4/2019 2:34:36 PM	9/1/2020 10:21:06 AM	9/1/2020 10:21 AM
Contacts	Authorizing Official	Update	Change Request	BARCELLONA, NICHOLAS CFO Children's Hospital of Pittsburgh of UPMC 4126927331	Wilfong, Mario Edward CFO UPMC 4126928201	6/15/2020 1:11 PM
Addresses	Shipping Address	Insert	Recertification		HC PHARMACY CENTRAL – PROCUREMENT 3175 E. CARSON ST Pittsburgh, PA 15203	9/4/2019 2:34 PM
Addresses	Billing Address	Update	Recertification	CHILDREN'S HOSPITAL OF PITTSBURGH OF UPMC 4401 PENN AVENUE Pittsburgh, PA 15224	HC PHARMACY CENTRAL – PROCUREMENT 3175 E. CARSON ST Pittsburgh, PA 15203	9/4/2019 2:34 PM
Details	Last Recertification Date	Update	Recertification	8/31/2018 11:46:50 AM	9/4/2019 2:34:36 PM	9/4/2019 2:34 PM
Details	Entity Name	Update	Recertification	CHILDREN'S HOSPITAL OF PITTSBURGH OF UPMC	UPMC CHILDREN'S HOSPITAL OF PITTSBURGH	9/7/2018 12:33 PM
Details	Last Recertification Date	Update	Recertification	11/27/2017 2:07:21 PM	8/31/2018 11:46:50 AM	8/31/2018 11:46 AM
Contacts	Primary Contact	Insert	Recertification		Patterson, Anthony Director of Pharmacy Children's Hospital of Pittsburgh of UPMC 4126926242	11/27/2017 2:07 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/27/2017 2:07:21 PM	11/27/2017 2:07 PM
Contacts	Authorizing Official	Update		BARCELLONA, NICHOLAS CFO 4126927331	BARCELLONA, NICHOLAS CFO Children's Hospital of Pittsburgh of UPMC 4126927331	10/10/2017 1:02 PM
Contacts	Signed By	Update		BARCELLONA, NICHOLAS CFO 4126927331	BARCELLONA, NICHOLAS CFO Children's Hospital of Pittsburgh of UPMC 4126927331	10/10/2017 1:02 PM
Contacts	Authorizing Official	Insert			BARCELLONA, NICHOLAS CFO 4126927331	7/13/2017 2:06 PM
Contacts	Signed By	Insert			BARCELLONA, NICHOLAS CFO 4126927331	7/13/2017 2:06 PM
Details	Last Recertification Date	Update		8/21/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 8:22 AM
Addresses	Main Address	Insert			11279 Perry Highway Wexford, PA 15090	8/30/2016 8:22 AM
Details	Last Recertification Date	Update			8/21/2015 12:00:00 AM	8/21/2015 10:11 AM
Addresses	Billing Address	Insert			CHILDREN'S HOSPITAL OF PITTSBURGH OF UPMC 4401 PENN AVENUE Pittsburgh, PA 15224	12/8/2014 7:08 PM
Details	Entity Subname	Update		North Satellite	North Satellite/Occupational Therapy	12/8/2014 6:57 PM
Dates	Participating Approval Date	Update			12/8/2014 12:00:00 AM	12/8/2014 6:57 PM
Details	State	Update		Pending	Active	12/8/2014 6:57 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	12/8/2014 6:57 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47789	PED393302-30	11/3/2014 8:33 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47789	10/28/2014 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/28/2014 2:07 PM
Medicaid Billing	Medicaid: Number	Insert			1007347990004	10/28/2014 2:07 PM
Medicaid Billing	Medicaid: State	Insert			PA	10/28/2014 2:07 PM
Medicaid Billing	NPI: Number	Insert			1194889485	10/28/2014 2:07 PM
Details	Last Recertification Date	Insert				10/28/2014 2:07 PM
Details	Grant Number	Insert				10/28/2014 2:07 PM
Details	340B ID	Insert				10/28/2014 2:07 PM
Details	Is Authorizing Official EHB Data	Insert				10/28/2014 2:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/28/2014 2:07 PM
Details	Medicare Provider Number	Insert			393302	10/28/2014 2:07 PM
Details	Entity Name	Insert			CHILDREN'S HOSPITAL OF PITTSBURGH OF UPMC	10/28/2014 2:07 PM
Details	Program Code	Insert			PED	10/28/2014 2:07 PM
Details	Entity Subname	Insert			North Satellite	10/28/2014 2:07 PM
Dates	Participating Approval Date	Insert				10/28/2014 2:07 PM
Details	State	Insert			Pending	10/28/2014 2:07 PM
Dates	Registration Date	Insert			10/28/2014 12:00:00 AM	10/28/2014 2:07 PM
Dates	Signed By Date	Insert			10/28/2014 12:00:00 AM	10/28/2014 2:07 PM
Dates	Start Date	Insert				10/28/2014 2:07 PM
Terminations	Termination Comments	Insert				10/28/2014 2:07 PM
Terminations	Termination Date	Insert				10/28/2014 2:07 PM
Terminations	Termination Effective Date	Insert				10/28/2014 2:07 PM
Terminations	Termination Reason	Insert				10/28/2014 2:07 PM