Covered Entity Details

DSH330009Y BronxCare Health System (Active) - information as of 5/26/2025 12:45:51 AM

Main Details

Name

BronxCare Health System

Subdivision Name

BronxCare Pediatric Practice

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330009Y

Medicare Provider Number

330009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/6/2015

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Bronx Lebanon Hospital Center
VICTOR DEMARCO, CFO
(718) 901-8600

Primary Contact

BronxCare Health System
Kyoung-Sil Kang, Director of Pharmacy
(718) 518-5021

Addresses

Street Address

1650 Grand Concourse, 3rd Floor
Bronx, NY 10457

Billing Address

BronxCare Health System
1276 Fulton Avenue
Bronx, NY 10456

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
NY	00476022	1417027558

Shipping Addresses

Shipping Address 1

BronxCare Health System
1276 Fulton Avenue
Bronx, NY 10456

Shipping Address 2

Pharmacy Department
1650 Grand Concourse
Bronx, NY 10457

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
DSH330009AA	Child	DSH	BronxCare Health System	Health and Wellness Center - Endocrinology	199 Mt. Eden Parkway, 8th Floor	Bronx	NY	Active
DSH330009AB	Child	DSH	BronxCare Health System	Health and Wellness Center - Breast Care Center	199 Mt. Eden Parkway, 9th Floor	Bronx	NY	Active
DSH330009AC	Child	DSH	BronxCare Health System	Health and Wellness Center - Center for Gynecologic Care	199 Mt Eden Parkway, 3rd Floor	Bronx	NY	Active
DSH330009AD	Child	DSH	BronxCare Health System	Health and Wellness Center - Adult Surgery	199 Mt. Eden Parkway, 5th Floor	Bronx	NY	Active
DSH330009AE	Child	DSH	BronxCare Health System	Health and Wellness Center - Adult Medicine	199 Mt. Eden Parkway, 7th Floor	Bronx	NY	Active
DSH330009AF	Child	DSH	BronxCare Health System	Health and Wellness Center - Neurology	199 Mt. Eden Parkway, 6th Floor	Bronx	NY	Terminated
DSH330009AG	Child	DSH	BronxCare Health System	Health and Wellness Center - Center for Orthopedic Services	199 Mt. Eden Parkway, 4th Floor	Bronx	NY	Active
DSH330009AH	Child	DSH	BronxCare Health System	Health and Wellness Center - Vascular	199 Mt. Eden Parkway, 5th Floor	Bronx	NY	Active
DSH330009AJ	Child	DSH	BronxCare Health System	Health and Wellness Center - Rheumotology	199 Mt Eden Parkway, 6th Floor	Bronx	NY	Active
DSH330009AK	Child	DSH	BronxCare Health System	Health and Wellness Center - Urology	199 Mt. Eden Parkway, 9th Floor	Bronx	NY	Active
DSH330009AL	Child	DSH	BronxCare Health System	Health and Wellness Center - Dermatology	199 Mt. Eden Parkway, 8th Floor	Bronx	NY	Active
DSH330009AM	Child	DSH	BronxCare Health System	Health and Wellness Center - Advanced Wound Care	199 Mt. Eden Parkway, 5th Floor	Bronx	NY	Active
DSH330009AN	Child	DSH	BronxCare Health System	BronxCare Oncology Outpatient Program	1650 Selwyn Avenue, 1st Floor	Bronx	NY	Terminated
DSH330009AP	Child	DSH	BronxCare Health System	BronxCare Life Recovery Center	1285 Fulton Ave, 2nd Floor	Bronx	NY	Terminated
DSH330009AQ	Child	DSH	BronxCare Health System	BronxCare Life Recovery Center	1285 Fulton Ave, 1st and 2nd Floor	Bronx	NY	Active
DSH330009AR	Child	DSH	BronxCare Health System	BronxCare Pediatric Surgery - BronxCare Pediatric Surgery	1650 Grand Concourse, 3rd Floor	Bronx	NY	Active
DSH330009AS	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - ACN Pediatric Infectious Disease - BronxCare Center for Comprehensive Care - ACN Pediatric Infectious Disease	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009AT	Child	DSH	BronxCare Health System	Health and Wellness Center - Renal - Health and Wellness Center - Renal	199 Mt. Eden Parkway, 8th Floor	Bronx	NY	Active
DSH330009AU	Child	DSH	BronxCare Health System	BronxCare Pediatric Emergency Room - BronxCare Pediatric Emergency Room	1650 Grand Concourse, 1st Floor	Bronx	NY	Active
DSH330009AV	Child	DSH	BronxCare Health System	BronxCare Ear, Nose and Throat Practice - Speech Therapy Ref - BronxCare Ear, Nose and Throat Practice - Speech Therapy Ref	1650 Grand Concourse, 6th Floor	Bronx	NY	Active
DSH330009AW	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - CHAPS Infectious Disease - BronxCare Center for Comprehensive Care - CHAPS Infectious Disease	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009AX	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - CHAPS Psychiatry - BronxCare Center for Comprehensive Care - CHAPS Psychiatry	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009AY	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - Pediatric Infectious Disease - BronxCare Center for Comprehensive Care - Pediatric Infectious Disease	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009AZ	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - Adult Infectious Disease - BronxCare Center for Comprehensive Care - Adult Infectious Disease	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009B	Child	DSH	BRONX-LEBANON HOSPITAL CENTER	Life Recovery Center	1285 FULTON AVE.	BRONX	NY	Terminated
DSH330009BA	Child	DSH	BronxCare Health System	BronxCare Women's Health Center - Initial Prenatal - BronxCare Women's Health Center - Initial Prenatal	1650 Grand Concourse, 14th Floor	Bronx	NY	Active
DSH330009BB	Child	DSH	BronxCare Health System	BronxCare Women's Health Center - Gynecology - BronxCare Women's Health Center - Gynecology	1650 Grand Concourse, 14th Floor	Bronx	NY	Active
DSH330009BC	Child	DSH	BronxCare Health System	BronxCare Ear, Nose and Throat Practice - Audiology - BronxCare Ear, Nose and Throat Practice - Audiology	1650 Grand Concourse, 6th Floor	Bronx	NY	Active
DSH330009BD	Child	DSH	BronxCare Health System	BronxCare Grand Concourse GI Lab - BronxCare Grand Concourse GI Lab	1650 Grand Concourse, 3rd Floor	Bronx	NY	Active
DSH330009BE	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care - Infectious Disease PAC - BronxCare Center for Comprehensive Care - Infectious Disease PAC	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009BF	Child	DSH	BronxCare Health System	BronxCare Cardiology - BronxCare Cardiology	1650 Grand Concourse, 12th Floor	Bronx	NY	Active
DSH330009BG	Child	DSH	BronxCare Health System	BronxCare Women's Health Center - OBS PCAP - BronxCare Women's Health Center - OBS PCAP	1650 Grand Concourse, 14th Floor	Bronx	NY	Active
DSH330009BH	Child	DSH	BronxCare Health System	BronxCare Emergency Room - BronxCare Emergency Room	1650 Grand Concourse, 1st Floor	Bronx	NY	Active
DSH330009BJ	Child	DSH	BronxCare Health System	BronxCare Women's Health Center - Infectious Disease Counseling - BronxCare Women's Health Center - Infectious Disease Counseling	1650 Grand Concourse, 14th Floor	Bronx	NY	Active
DSH330009BK	Child	DSH	BronxCare Health System	Health and Wellness Center - Plastic Surgery - Health and Wellness Center - Plastic Surgery	199 Mt. Eden Parkway, 9th Floor	Bronx	NY	Active
DSH330009BL	Child	DSH	BronxCare Health System	Health and Wellness Center - Pulmonary Clinic - Asthma - Health and Wellness Center - Pulmonary Clinic - Asthma	199 Mt. Eden Parkway, 6th Floor	Bronx	NY	Active
DSH330009BM	Child	DSH	BronxCare Health System	BronxCare Coumadin Clinic - BronxCare Coumadin Clinic	1650 Grand Concourse, 12th Floor	Bronx	NY	Active
DSH330009BN	Child	DSH	BronxCare Health System	BronxCare Grand Concourse Operating Rooms - BronxCare Grand Concourse Operating Rooms	1650 Grand Concourse, 3rd and 4th Floors	Bronx	NY	Active
DSH330009E	Child	DSH	BronxCare Health System	Adult Outpatient Treatment Clinic #2	1265 Franklin Ave.	BRONX	NY	Active
DSH330009G	Child	DSH	BronxCare Health System	BronxCare Child Study Center	406 EAST 176TH ST.	BRONX	NY	Terminated
DSH330009H	Child	DSH	BronxCare Health System	BronxCare Comprehensive Psychiatric Emergency Program	1265 FRANKLIN AVE.	BRONX	NY	Active
DSH330009J	Child	DSH	BRONX-LEBANON HOSPITAL CENTER	ASSERTIVE COMMUNITY TREATMENT (ACT)	1276 FULTON AVE.	BRONX	NY	Terminated
DSH330009K	Child	DSH	BronxCare Health System	BronxCare Oncology Outpatient Program	1775 Grand Concourse	BRONX	NY	Active
DSH330009L	Child	DSH	BRONX-LEBANON HOSPITAL CENTER	Bronxcare at Morris Avenue	1650 Grand Concourse	Bronx	NY	Terminated
DSH330009M	Child	DSH	BronxCare Health System	BronxCare Ear, Nose and Throat Practice	1650 Grand Concourse, 6th Floor	Bronx	NY	Active
DSH330009N	Child	DSH	BronxCare Health System	BronxCare Orthopedic Practice and Medicine Clinic	1650 Grand Concourse, 7th Floor	Bronx	NY	Active
DSH330009P	Child	DSH	BronxCare Health System	BronxCare Center for Comprehensive Care	1650 Selwyn Ave, 9th Floor	Bronx	NY	Active
DSH330009Q	Child	DSH	BRONX-LEBANON HOSPITAL CENTER	HIV Healthcare & Support Services	1650 Selwyn Ave, 9th Floor	Bronx	NY	Terminated
DSH330009R	Child	DSH	BRONX-LEBANON HOSPITAL CENTER	Pain Management Clinic	1276 Fulton Ave	Bronx	NY	Terminated
DSH330009S	Child	DSH	BronxCare Health System	BronxCare Eye Center	1650 Grand Concourse, Ground Floor	Bronx	NY	Active
DSH330009U	Child	DSH	BronxCare Health System	BronxCare Center for Physical Rehabilitation	1775 Grand Concourse	Bronx	NY	Active
DSH330009V	Child	DSH	BronxCare Health System	Health and Wellness Center - GI Clinic	199 Mt Eden Parkway, 8th Floor	Bronx	NY	Active
DSH330009W	Child	DSH	BronxCare Health System	Health and Wellness Center - Pulmonary Clinic	199 Mt. Eden Parkway, 6th Floor	Bronx	NY	Active
DSH330009X	Child	DSH	BronxCare Health System	BronxCare Women's Health Center	1650 Grand Concourse, 14th Floor	Bronx	NY	Active
DSH330009Y	Child	DSH	BronxCare Health System	BronxCare Pediatric Practice	1650 Grand Concourse, 3rd Floor	Bronx	NY	Active
DSH330009Z	Child	DSH	BronxCare Health System	Neuro Science Center	1650 Selwyn Ave, 2nd Floor	Bronx	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:04:17 PM	8/20/2024 2:14:34 PM	8/20/2024 2:14 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:28:38 PM	8/23/2023 4:04:17 PM	8/23/2023 4:04 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 2:19:44 PM	8/30/2022 1:28:38 PM	8/30/2022 1:28 PM
Details	Last Recertification Date	Update	Recertification	9/1/2020 10:45:39 AM	8/27/2021 2:19:44 PM	8/27/2021 2:19 PM
Contacts	Primary Contact	Update	Group Change Request	Schiller, Lawrence Director of Pharmacy Bronx-Lebanon Hospital Center 7185185021	Kang, Kyoung-Sil Director of Pharmacy BronxCare Health System 7185185021	7/29/2021 2:53 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/1/2020 10:45 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 4:11:19 PM	9/1/2020 10:45:39 AM	9/1/2020 10:45 AM
Addresses	Shipping Address	Insert	Change Request		Pharmacy Department 1650 Grand Concourse Bronx, NY 10457	9/30/2019 2:18 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 2:06:04 PM	8/20/2019 4:11:19 PM	8/20/2019 4:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1417027558	7/9/2019 5:05 PM
Details	Entity Name	Update	Change Request	BRONX-LEBANON HOSPITAL CENTER	BronxCare Health System	11/14/2018 8:49 AM
Addresses	Billing Address	Insert	Change Request		BronxCare Health System 1276 Fulton Avenue Bronx, NY 10456	11/14/2018 8:47 AM
Addresses	Shipping Address	Insert	Change Request		BronxCare Health System 1276 Fulton Avenue Bronx, NY 10456	11/14/2018 8:47 AM
Details	Entity Subname	Update	Change Request	BronxCare Pediatric Practice at Concourse	BronxCare Pediatric Practice	11/14/2018 8:47 AM
Details	Last Recertification Date	Update	Recertification	11/16/2017 3:17:47 PM	8/21/2018 2:06:04 PM	8/21/2018 2:06 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/16/2017 3:17:47 PM	11/16/2017 3:17 PM
Contacts	Authorizing Official	Update		DEMARCO, VICTOR CFO 7189018600	DEMARCO, VICTOR CFO Bronx Lebanon Hospital Center 7189018600	11/16/2017 3:10 PM
Contacts	Signed By	Update		DEMARCO, VICTOR CFO 7189018600	DEMARCO, VICTOR CFO Bronx Lebanon Hospital Center 7189018600	11/16/2017 3:10 PM
Contacts	Primary Contact	Update		Schiller, Lawrence Director of Pharmacy 7185185021	Schiller, Lawrence Director of Pharmacy Bronx-Lebanon Hospital Center 7185185021	11/16/2017 11:20 AM
Contacts	Authorizing Official	Insert			DEMARCO, VICTOR CFO 7189018600	8/8/2017 2:04 PM
Contacts	Signed By	Insert			DEMARCO, VICTOR CFO 7189018600	8/8/2017 2:04 PM
Contacts	Primary Contact	Insert			Schiller, Lawrence Director of Pharmacy 7185185021	2/3/2017 4:24 PM
Addresses	Main Address	Insert			1650 Grand Concourse, 3rd Floor Bronx, NY 10457	11/15/2016 11:06 AM
Details	Entity Subname	Update		Ambulatory Care Network	BronxCare Pediatric Practice at Concourse	11/15/2016 11:06 AM
Details	Last Recertification Date	Update		8/17/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 4:54 PM
Details	Last Recertification Date	Update			8/17/2015 12:00:00 AM	8/17/2015 10:43 AM
Dates	Participating Approval Date	Update			3/6/2015 12:00:00 AM	3/6/2015 8:08 PM
Details	State	Update		Pending	Active	3/6/2015 8:08 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/6/2015 8:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49094	DSH330009Y	2/24/2015 10:18 AM
Details	Entity Subname	Update		Ambulatory Care Network / Ambulatory Care Network	Ambulatory Care Network	2/24/2015 10:18 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49094	1/14/2015 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/14/2015 10:17 AM
Medicaid Billing	Medicaid: Number	Insert			00476022	1/14/2015 10:17 AM
Medicaid Billing	Medicaid: State	Insert			NY	1/14/2015 10:17 AM
Details	Last Recertification Date	Insert				1/14/2015 10:17 AM
Details	Grant Number	Insert				1/14/2015 10:17 AM
Details	340B ID	Insert				1/14/2015 10:17 AM
Details	Is Authorizing Official EHB Data	Insert				1/14/2015 10:17 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2015 10:17 AM
Details	Medicare Provider Number	Insert			330009	1/14/2015 10:17 AM
Details	Entity Name	Insert			BRONX-LEBANON HOSPITAL CENTER	1/14/2015 10:17 AM
Details	Program Code	Insert			DSH	1/14/2015 10:17 AM
Details	Entity Subname	Insert			Ambulatory Care Network / Ambulatory Care Network	1/14/2015 10:17 AM
Dates	Participating Approval Date	Insert				1/14/2015 10:17 AM
Details	State	Insert			Pending	1/14/2015 10:17 AM
Dates	Registration Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 10:17 AM
Dates	Signed By Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 10:17 AM
Dates	Start Date	Insert				1/14/2015 10:17 AM
Terminations	Termination Comments	Insert				1/14/2015 10:17 AM
Terminations	Termination Date	Insert				1/14/2015 10:17 AM
Terminations	Termination Effective Date	Insert				1/14/2015 10:17 AM
Terminations	Termination Reason	Insert				1/14/2015 10:17 AM