Covered Entity Details

DSH240019AH SMDC MEDICAL CENTER (Terminated) - information as of 6/28/2025 12:18:05 AM

Main Details

Name

SMDC MEDICAL CENTER

Subdivision Name

Essentia Health Second Street Clinic / Behavioral Health Referral Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH240019AH

Medicare Provider Number

240019

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/29/2014

Participating Start Date

1/1/2015

Participating Approval Date

11/21/2014

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

10/1/2015
Other

Contacts

Authorizing Official

Essentia Health
Bradley Beard, Chief Operating Officer
(218) 786-2652

Primary Contact

Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 828-7143

Addresses

Street Address

502 East 2nd Street
Duluth, MN 55805

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
		1033153895

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
DSH240019A	Child	DSH	SMDC MEDICAL CENTER	Infusion Center	420 E 1ST ST	DULUTH	MN	Active
DSH240019AA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Urology	400 E 3RD ST	DULUTH	MN	Active
DSH240019AB	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Family Practice	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019AC	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / Family Practice	4621 E SUPERIOR ST	DULUTH	MN	Active
DSH240019AD	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / Family Practice	4212 GRAND AVE	DULUTH	MN	Active
DSH240019AE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic / Family Practice	1502 LONDON RD, STE 102	DULUTH	MN	Active
DSH240019AF	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic / Sleep Medicine	1502 LONDON RD, STE 102	DULUTH	MN	Active
DSH240019AG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Proctor Clinic / Family Practice	211 S BOUNDARY AVE	PROCTOR	MN	Active
DSH240019AH	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Behavioral Health Referral Center	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Dermatology	400 E 3RD ST	DULUTH	MN	Active
DSH240019AK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Diabetes Center	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Ear, Nose & Throat	400 E 3RD ST	DULUTH	MN	Active
DSH240019AM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Endocrinology	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Ophthalmology	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Psychiatry	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Second Street Clinic / Skin Renewal Clinic	502 East 2nd Street	Duluth	MN	Terminated
DSH240019AR	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Amberwing / Amberwing	615 PECAN AVE	DULUTH	MN	Active
DSH240019AS	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Amberwing / Integrated Behavior Health	615 Pecan Avenue	Duluth	MN	Terminated
DSH240019AT	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Pulmonary Function Lab	400 E 3RD ST	DULUTH	MN	Terminated
DSH240019AU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Proctor Clinic / Anticoagulation Mgmt - Proc	211 South Boundary Avenue	Proctor	MN	Active
DSH240019AV	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Proctor Clinic / Non Invasive - Proc	211 South Boundary Avenue	Proctor	MN	Terminated
DSH240019AW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic / Anticoagulation Mgmt - Lkwk	1502 London Road STE 102	Duluth	MN	Active
DSH240019AX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic / Non Invasive - Lkwk	1502 London Road	Duluth	MN	Terminated
DSH240019AY	Child	DSH	SMDC Medical Center	Essentia Health Lakewalk Clinic / Physical Therapy - Lkwk	1502 London Road	Duluth	MN	Terminated
DSH240019AZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / Anticoagulation Mgmt	4212 GRAND AVE	DULUTH	MN	Active
DSH240019B	Child	DSH	SMDC Medical Center	Essentia Health First Street Clinic	420 East First Street	Duluth	MN	Terminated
DSH240019BA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / Non Invasive - West	4212 Grand Avenue	Duluth	MN	Terminated
DSH240019BB	Child	DSH	SMDC Medical Center	Essentia Health West Duluth Clinic / Physical Therapy - West	4212 Grand Avenue	Duluth	MN	Terminated
DSH240019BD	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / Anticoagulation Mgmt - Lake	4621 East Superior Street	Duluth	MN	Active
DSH240019BE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / Non Invasive - Lake	4621 East Superior Street	Duluth	MN	Terminated
DSH240019BF	Child	DSH	SMDC Medical Center	Essentia Health Lakeside Clinic / Physical Therapy - Lake	4621 East Superior Street	Duluth	MN	Terminated
DSH240019BG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Non Invasive - Herm	4855 West Arrowhead Road	Hermantown	MN	Terminated
DSH240019BH	Child	DSH	SMDC Medical Center	Essentia Health Hermantown Clinic / Physical Therapy - Herm	4855 West Arrowhead Road	Hermantown	MN	Terminated
DSH240019BJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Anticoagulation Mgmt	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019BK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Skin Renewal Clinic	400 E 3RD ST	DULUTH	MN	Active
DSH240019BL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / MSK Ultrasound Program	400 E 3RD ST	DULUTH	MN	Active
DSH240019BM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Plastic Surgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Orthopedic Surgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Pain Management	400 E 3RD ST	DULUTH	MN	Active
DSH240019BQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Physical Medicine & Rehab	400 E 3RD ST	DULUTH	MN	Active
DSH240019BR	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Cardiovascular & Thoracic Surg	400 E 3RD ST	DULUTH	MN	Active
DSH240019BS	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Neurosurgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BT	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Trauma Surgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Vascular Surgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BV	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / General Surgery	400 E 3RD ST	DULUTH	MN	Active
DSH240019BW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Pulmonary Disease	400 E 3RD ST	DULUTH	MN	Active
DSH240019BX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Integrated Behavioral Health	420 East First Street	Duluth	MN	Terminated
DSH240019BY	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Breast Health Program	420 E 1ST ST	DULUTH	MN	Active
DSH240019BZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Genetic Counseling	420 E 1ST ST	DULUTH	MN	Active
DSH240019C	Child	DSH	SMDC Medical Center	Essentia Health Duluth Clinic	400 East Third Street	Duluth	MN	Terminated
DSH240019CA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Pediatric Oncology	420 E 1ST ST	DULUTH	MN	Active
DSH240019CB	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Cardiology	420 E 1ST ST	DULUTH	MN	Active
DSH240019CC	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Gynecology/Oncology	420 E 1ST ST	DULUTH	MN	Active
DSH240019CD	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Gastroenterology	420 E 1ST ST	DULUTH	MN	Active
DSH240019CE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Vascular Diagnostics	400 E 3RD ST	DULUTH	MN	Active
DSH240019CF	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Rad Oncology Ancillary	420 E 1ST ST	DULUTH	MN	Active
DSH240019CG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Med Physics	420 E 1ST ST	DULUTH	MN	Active
DSH240019CH	Child	DSH	SMDC Medical Center	Essentia Health Lakewalk Clinic / Breast Center - Lkwk	1502 London Road	Duluth	MN	Terminated
DSH240019CJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Nuclear Medicine	420 E 1ST ST	DULUTH	MN	Active
DSH240019CK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Breast Center	420 E 1ST ST	DULUTH	MN	Active
DSH240019CL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Ultrasound	420 E 1ST ST	DULUTH	MN	Active
DSH240019CM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Neurodiagnostics / EEG	400 E 3RD ST	DULUTH	MN	Active
DSH240019CN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / MRI	420 E 1ST ST	DULUTH	MN	Active
DSH240019CP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / CAT Scan	420 E 1ST ST	DULUTH	MN	Active
DSH240019CQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / PET/CT	420 E 1ST ST	DULUTH	MN	Active
DSH240019CR	Child	DSH	SMDC Medical Center	Essentia Health West Duluth Clinic / General Surgery	4212 Grand Avenue	Duluth	MN	Terminated
DSH240019CS	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / Psychiatry	4212 GRAND AVE	DULUTH	MN	Active
DSH240019CT	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Diabetes Center	4855 W ARROWHEAD RD	HERMANTOWN	MN	Terminated
DSH240019CU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Urgent Care	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019CV	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Psychiatry	4855 W ARROWHEAD RD	HERMANTOWN	MN	Terminated
DSH240019CW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Spine Center	400 E 3RD ST	DULUTH	MN	Active
DSH240019CX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Occupational Medicine	400 E 3RD ST	DULUTH	MN	Terminated
DSH240019CY	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Pediatric Cardiology	420 E 1ST ST	DULUTH	MN	Active
DSH240019CZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Maternal Fetal Medicine	420 E 1ST ST	DULUTH	MN	Active
DSH240019D	Child	DSH	SMDC Medical Center	Essentia Health Hermantown Clinic	4855 West Arrowhead Road	Hermantown	MN	Terminated
DSH240019DA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Weight Management	400 E 3RD ST	DULUTH	MN	Active
DSH240019DB	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Pediatric Gastroenterology	420 E 1ST ST	DULUTH	MN	Active
DSH240019DC	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Integrated Health	420 E 1ST ST	DULUTH	MN	Active
DSH240019DD	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Rheumatology Osteo	400 E 3RD ST	DULUTH	MN	Active
DSH240019DE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / Urgent Care	4212 GRAND AVE	DULUTH	MN	Active
DSH240019DF	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Amberwing / Psychiatry	615 PECAN AVE	DULUTH	MN	Active
DSH240019DG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / First Rad Ancillary	420 E 1ST ST	DULUTH	MN	Active
DSH240019DH	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Medication Therapy Management	420 E 1ST ST	DULUTH	MN	Active
DSH240019DJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Podiatry - SUPR	400 E 3RD ST	DULUTH	MN	Terminated
DSH240019DK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Psychiatry – HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019DL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Ophthalmology	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019DM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Orthopedic Medicine	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019DN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Anticoagulation Management	420 E 1ST ST	DULUTH	MN	Terminated
DSH240019DP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Family Practice	420 E 1ST ST	DULUTH	MN	Active
DSH240019DQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / Diabetes Center	4621 E SUPERIOR ST	DULUTH	MN	Terminated
DSH240019DR	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic - Essentia Health Hermantown Clinic / General Pediatrics - HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019DS	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic - Essentia Health Hermantown Clinic / OB & Gynecology - HERM	4855 W ARROWHEAD RD	Hermantown	MN	Active
DSH240019DT	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic - Essentia Health Lakeside Clinic / Orthopedic Medicine - LAKE	4621 E SUPERIOR ST	Duluth	MN	Active
DSH240019DU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic - Essentia Health Lakeside Clinic / Integrative Health - LAKE	4621 E Superior St	Duluth	MN	Active
DSH240019DV	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic - Essentia Health West Duluth Clinic / Orthopedic Medicine - WEST	4212 Grand Ave	Duluth	MN	Active
DSH240019DW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Proctor Clinic - Essentia Health Proctor Clinic / Orthopedic Medicine - PROC	211 S BOUNDARY AVE	PROCTOR	MN	Active
DSH240019DX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic - Essentia Health Duluth Clinic / Audiology	400 E 3RD ST	DULUTH	MN	Terminated
DSH240019DY	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Pediatric Pulmonology - Pediatric Pulmonology	420 E 1ST STREET	Duluth	MN	Active
DSH240019DZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic - Cardiology - LKWK	1502 LONDON ROAD	DULUTH	MN	Active
DSH240019E	Child	DSH	SMDC Medical Center	Essentia Health Lakeside Clinic	4621 East Superior Street	Duluth	MN	Terminated
DSH240019EA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / 24/7 Virtual Telecare - Essentia Health First Street Clinic / 24/7 Virtual Telecare	420 E 1ST STREET	Duluth	MN	Active
DSH240019EB	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / Urgent Care - Essentia Health Cloquet Clinic / Urgent Care	1413 HWY 33 S	Cloquet	MN	Active
DSH240019EC	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / Family Practice - Essentia Health Cloquet Clinic / Family Practice	1413 HWY 33 S	Cloquet	MN	Active
DSH240019ED	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / Pediatrics - Essentia Health Lakeside Clinic / Pediatrics	4621 E SUPERIOR ST	Duluth	MN	Active
DSH240019EE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Cardiac Rehab - Cardiac Rehabilitation - HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019EF	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / Orthopedic Med - Orthopedic Medicine - CLOQ	1413 HWY 33 SOUTH	CLOQUET	MN	Active
DSH240019EG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Cardiology - Cardiology - HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019EH	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / OBGYN - OB and Gynecology - CLOQ	1413 HWY 33 SOUTH	CLOQUET	MN	Active
DSH240019EJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / Cardiology - Cardiology - CLOQ	1413 HWY 33 SOUTH	CLOQUET	MN	Active
DSH240019EK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / General Internal Med - Gen Internal Medicine - HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019EL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / Echocardiography - Echocardiography - HERM	4855 W ARROWHEAD RD	HERMANTOWN	MN	Active
DSH240019EM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / General Pediatrics - General Pediatrics - CLOQ	1413 HWY 33 SOUTH	CLOQUET	MN	Active
DSH240019EN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Cloquet Clinic / - General Radiology - CLOQ	1413 HWY 33 S	CLOQUET	MN	Active
DSH240019EP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic - Medication Therapy Mgmt	1502 LONDON ROAD	DULUTH	MN	Active
DSH240019EQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic - General Radiology - LKWK	1502 LONDON ROAD	DULUTH	MN	Active
DSH240019ER	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - General Radiology - MHC	1600 MILLER TRUNK HIGHWAY; STE 1300	HERMANTOWN	MN	Active
DSH240019ES	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Proctor Clinic / - General Radiology - PROC	211 S BOUNDARY AVE	PROCTOR	MN	Active
DSH240019ET	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic - Family Practice	400 EAST THIRD STREET	DULUTH	MN	Active
DSH240019EU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic - Hematology/Oncology	400 EAST THIRD STREET	DULUTH	MN	Active
DSH240019EV	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic - General Radiology	400 EAST THIRD STREET	DULUTH	MN	Active
DSH240019EW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic - OB & Gynecology	400 EAST THIRD STREET	DULUTH	MN	Active
DSH240019EX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic - Pulmonary Disease	420 EAST FIRST STREET	DULUTH	MN	Active
DSH240019EY	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic - Radiation Oncology	420 EAST FIRST STREET	DULUTH	MN	Active
DSH240019EZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic - Interventional Radiology	420 EAST FIRST STREET	DULUTH	MN	Active
DSH240019F	Child	DSH	SMDC Medical Center	Essentia Health West Duluth Clinic	4212 Grand Avenue	Duluth	MN	Terminated
DSH240019FA	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic - Radiology	420 EAST FIRST STREET	DULUTH	MN	Active
DSH240019FB	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / - General Radiology - WEST	4212 GRAND AVENUE	DULUTH	MN	Active
DSH240019FC	Child	DSH	SMDC MEDICAL CENTER	Essentia Health West Duluth Clinic / - Diabetes Center - WEST	4212 GRAND AVENUE	DULUTH	MN	Active
DSH240019FD	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / - General Radiology - LAKE	4621 EAST SUPERIOR STREET	DULUTH	MN	Active
DSH240019FE	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / - Elder Care - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FF	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / - Pulmonary Disease - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FG	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / - General Radiology - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FH	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / - Sleep Medicine - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FJ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic - / Rheumatology - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FK	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic Building E / - MH Adult Partial	530 EAST 2ND STREET	DULUTH	MN	Active
DSH240019FL	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic Building E / - Psychiatry	530 EAST 2ND STREET	DULUTH	MN	Active
DSH240019FM	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / - Psychiatry	420 E 1ST ST	DULUTH	MN	Active
DSH240019FN	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakewalk Clinic / - Psychiatry - LKWK	1502 LONDON ROAD	DULUTH	MN	Active
DSH240019FP	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - Psychiatry - MHC	1600 MILLER TRUNK HIGHWAY	DULUTH	MN	Active
DSH240019FQ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - Peds Occupational Therapy - MHC	1600 MILLER TRUNK HIGHWAY	DULUTH	MN	Active
DSH240019FR	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - Neonatology - MHC	1600 MILLER TRUNK HIGHWAY	DULUTH	MN	Active
DSH240019FS	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / - General Pediatrics	400 E 3RD ST	DULUTH	MN	Active
DSH240019FT	Child	DSH	SMDC MEDICAL CENTER	Medication Therapy Mgmt - MAIN CLINICAL	400 E 3RD ST	DULUTH	MN	Active
DSH240019FU	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - Neurology - MHC	1600 MILLER TRUNK HWY	DULUTH	MN	Active
DSH240019FV	Child	DSH	SMDC MEDICAL CENTER	MRI - MAIN MRI	407 E 3RD ST	DULUTH	MN	Active
DSH240019FW	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Hermantown Clinic / - Nephrology - HERM	4855 WEST ARROWHEAD ROAD	HERMANTOWN	MN	Active
DSH240019FX	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Lakeside Clinic / - Cardiology - LAKE	4621 SUPERIOR STREET	DULUTH	MN	Active
DSH240019FY	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / - Travel Vaccinations	400 E 3RD ST	DULUTH	MN	Active
DSH240019FZ	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Miller Hill Clinic / - Occupational Medicine - MHC	1600 MILLER TRUNK HIGHWAY	DULUTH	MN	Active
DSH240019G	Child	DSH	SMDC Medical Center	Essentia Health Lakewalk Clinic	1502 London Road	Duluth	MN	Terminated
DSH240019GA	Child	DSH	SMDC MEDICAL CENTER	Toxicology - MAIN TOXICOLOGY / ADDICTION MEDICINE	407 E 3RD ST	DULUTH	MN	Active
DSH240019H	Child	DSH	SMDC Medical Center	Essentia Health Proctor Clinic	211 South Boundary Avenue	Proctor	MN	Terminated
DSH240019J	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Cardiology	420 East First Street	Duluth	MN	Terminated
DSH240019K	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / General Internal Medicine	420 E 1ST ST	DULUTH	MN	Active
DSH240019L	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / General Pediatrics	420 E 1ST ST	DULUTH	MN	Active
DSH240019M	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Hematology/Oncology	420 E 1ST ST	DULUTH	MN	Active
DSH240019N	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / OB & Gynecology	420 E 1ST ST	DULUTH	MN	Active
DSH240019P	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Palliative Care	420 East First Street	Duluth	MN	Terminated
DSH240019Q	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Allergy	400 E 3RD ST	DULUTH	MN	Active
DSH240019R	Child	DSH	SMDC MEDICAL CENTER	Essentia Health First Street Clinic / Elder Care	420 East First Street	Duluth	MN	Active
DSH240019S	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Infectious Disease	400 E 3RD ST	DULUTH	MN	Active
DSH240019T	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Med Ortho	400 E 3RD ST	DULUTH	MN	Active
DSH240019U	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Nephrology	400 E 3RD ST	DULUTH	MN	Active
DSH240019V	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Neurology	400 E 3RD ST	DULUTH	MN	Active
DSH240019W	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Podiatry	400 E 3RD ST	DULUTH	MN	Active
DSH240019X	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Rheumatology	400 E 3RD ST	DULUTH	MN	Active
DSH240019Y	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Travel Medicine	400 E 3RD ST	DULUTH	MN	Terminated
DSH240019Z	Child	DSH	SMDC MEDICAL CENTER	Essentia Health Duluth Clinic / Urgent Care	400 E 3RD ST	DULUTH	MN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2188287143	10/9/2020 9:19 AM
Contacts	Primary Contact	Update	Profile Change Request	Lundberg, Bryan 340b Program Manager Essentia 2185760745	Lundberg, Bryan 340b Program Manager Essentia Health 2185760745	4/1/2020 10:07 AM
Contacts	Authorizing Official	Update	Change Request	Garvey, James M. SVP Hospital Operations East Region Essentia Health 2187864878	Beard, Bradley Chief Operating Officer Essentia Health 2187862652	8/5/2019 4:03 PM
Contacts	Authorizing Official	Update		Garvey, James M. SVP Hospital Operations East Region 2187864878	Garvey, James M. SVP Hospital Operations East Region Essentia Health 2187864878	10/3/2017 10:42 AM
Contacts	Primary Contact	Update		Lundberg, Bryan 340b Program Manager 2185760745	Lundberg, Bryan 340b Program Manager Essentia 2185760745	9/20/2017 3:06 PM
Contacts	Primary Contact	Insert			Lundberg, Bryan 340b Program Manager 2185760745	8/14/2017 1:06 PM
Contacts	Authorizing Official	Insert			Garvey, James M. SVP Hospital Operations East Region 2187864878	8/11/2017 9:47 AM
Contacts	Signed By	Insert			Wessberg, Barbara R. Administrator/VP 2187862646	3/13/2017 12:34 PM
Details	Last Recertification Date	Update			9/8/2015 12:00:00 AM	9/8/2015 8:58 AM
Dates	Last Date That 340B Drugs Purchased	Update			9/4/2015 12:00:00 AM	9/8/2015 8:58 AM
Details	State	Update		Active	Terminated	9/8/2015 8:58 AM
Terminations	Termination Comments	Update			I am terminating the Child Site due to it having the same physical address as Parent Site. According to Apexus/HRSA we do not need it registered on the database. This Child Site would remain eligible as it is considered within the 4 walls of the hospital.	9/8/2015 8:58 AM
Terminations	Termination Date	Update			10/1/2015 12:00:00 AM	9/8/2015 8:58 AM
Terminations	Termination Effective Date	Update			9/4/2015 12:00:00 AM	9/8/2015 8:58 AM
Terminations	Termination Reason	Update			Other	9/8/2015 8:58 AM
Addresses	Main Address	Insert			502 East 2nd Street Duluth, MN 55805	9/8/2015 8:58 AM
Details	Entity Subname	Update		Essentia Health Second Street Clinic / Behavioral Health Referral Center / Behavioral Health Referral Center	Essentia Health Second Street Clinic / Behavioral Health Referral Center	12/12/2014 11:21 AM
Details	Entity Subname	Update		Essentia Health Second Street Clinic / Behavioral Health Referral Center	Essentia Health Second Street Clinic / Behavioral Health Referral Center / Behavioral Health Referral Center	11/21/2014 3:23 PM
Dates	Participating Approval Date	Update			11/21/2014 12:00:00 AM	11/21/2014 3:23 PM
Details	State	Update		Pending	Active	11/21/2014 3:23 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	11/21/2014 3:23 PM
Details	Entity Subname	Update		Essentia Health Second Street Clinic	Essentia Health Second Street Clinic / Behavioral Health Referral Center	11/14/2014 10:09 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47887	DSH240019AH	11/14/2014 10:09 AM
Details	Entity Subname	Update		Essentia Health Third Street Clinic	Essentia Health Second Street Clinic	11/14/2014 10:09 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47887	10/29/2014 10:08 PM
Medicaid Billing	NPI: Number	Insert			1033153895	10/29/2014 10:08 PM
Details	Last Recertification Date	Insert				10/29/2014 10:08 PM
Details	Grant Number	Insert				10/29/2014 10:08 PM
Details	340B ID	Insert				10/29/2014 10:08 PM
Details	Is Authorizing Official EHB Data	Insert				10/29/2014 10:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/29/2014 10:08 PM
Details	Medicare Provider Number	Insert			240019	10/29/2014 10:08 PM
Details	Entity Name	Insert			SMDC MEDICAL CENTER	10/29/2014 10:08 PM
Details	Program Code	Insert			DSH	10/29/2014 10:08 PM
Details	Entity Subname	Insert			Essentia Health Third Street Clinic	10/29/2014 10:08 PM
Dates	Participating Approval Date	Insert				10/29/2014 10:08 PM
Details	State	Insert			Pending	10/29/2014 10:08 PM
Dates	Registration Date	Insert			10/29/2014 12:00:00 AM	10/29/2014 10:08 PM
Dates	Signed By Date	Insert			10/29/2014 12:00:00 AM	10/29/2014 10:08 PM
Dates	Start Date	Insert				10/29/2014 10:08 PM
Terminations	Termination Comments	Insert				10/29/2014 10:08 PM
Terminations	Termination Date	Insert				10/29/2014 10:08 PM
Terminations	Termination Effective Date	Insert				10/29/2014 10:08 PM
Terminations	Termination Reason	Insert				10/29/2014 10:08 PM