Covered Entity Details

DSH330128N ELMHURST HOSPITAL CENTER (NYCHHC) (Active) - information as of 4/29/2025 10:33:15 PM

Main Details

Name

ELMHURST HOSPITAL CENTER (NYCHHC)

Subdivision Name

Elmhurst Hospital: Hope Pavilion / BReast Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330128N

Medicare Provider Number

330128

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

2/9/2015

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

NYC Health + Hospitals
Deborah Alyse Brown, Senior Vice President, Chief External Affairs Officer
(347) 947-0446

Primary Contact

NYC Health + Hospitals
Mark Capuano, Senior Director, Corporate Pharmacy 340B Program
(347) 835-9198

Addresses

Street Address

77-11 Broadway
Elmhurst, NY 11373

Billing Address

Elmhurst Hospital
79-01 Broadway
Elmhurst, NY 11373

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	00246075	1063426377

Shipping Addresses

Shipping Address 1

Elmhurst Hospital
79-01 Broadway
Elmhurst, NY 11373

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
DSH330128A	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Women's Medical Center at Corona	59-17 Junction Blvd	Corona	NY	Terminated
DSH330128B	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Ridgewood Communicare Clinic	769 Onderdonk Ave	Ridgewood	NY	Terminated
DSH330128C	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Woodside Houses Child Health Clinic	50-53 Newtown Road	Woodside	NY	Terminated
DSH330128D	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	School Based Hospital Extension Clinic: Long Island City HS	1430 Broadway	Long Island City	NY	Terminated
DSH330128E	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	School Based Hospital Extension Clinic: IS 145	33-34 80th Street	Jackson Heights	NY	Terminated
DSH330128F	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Corona District Health Center - Junction Medical	34-33 Junction Blvd	Corona	NY	Terminated
DSH330128G	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Corona Child Health Clinic	104-04 Corona Ave	Corona	NY	Terminated
DSH330128H	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Cancer Treatment	77-11 Broadway	Elmhurst	NY	Active
DSH330128J	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Chemotherapy Treatment Center	77-11 Broadway	Elmhurst	NY	Active
DSH330128K	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Endocrine	77-11 Broadway	Elmhurst	NY	Active
DSH330128L	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion World Trade Center Clinic (WTC) / World Trade Center	77-11 Broadway	Elmhurst	NY	Active
DSH330128M	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Breast Procedures	77-11 Broadway	Elmhurst	NY	Active
DSH330128N	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / BReast Clinic	77-11 Broadway	Elmhurst	NY	Active
DSH330128P	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Pacemaker	77-11 Broadway	Elmhurst	NY	Active
DSH330128Q	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Cardiology	77-11 Broadway	Elmhurst	NY	Active
DSH330128R	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Diabetes	77-11 Broadway	Elmhurst	NY	Active
DSH330128S	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Hematology	77-11 Broadway	Elmhurst	NY	Active
DSH330128T	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Chest Clinic	77-11 Broadway	Elmhurst	NY	Active
DSH330128U	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Arthritis	77-11 Broadway	Elmhurst	NY	Active
DSH330128V	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Elmhurst Hospital: Hope Pavilion / Thyroid Clinic	77-11 Broadway	Elmhurst	NY	Active
DSH330128W	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Women's Health Pavillion: OB/GYN Clinic	78-20 41st Ave	Elmhurst	NY	Active
DSH330128X	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	ACT Program (Assertive Community Treatment)	78-07 41st Avenue	Elmhurst	NY	Active
DSH330128Y	Child	DSH	ELMHURST HOSPITAL CENTER (NYCHHC)	Meyers Clinic - Mental Health	600 E.125 St.	Wards Island	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Brown, Deborah Alyse Senior Vice President, External and Regulatory Affairs NYC Health + Hospitals 3479470446	Brown, Deborah Alyse Senior Vice President, Chief External Affairs Officer NYC Health + Hospitals 3479470446	11/15/2024 1:26 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 2:25:27 PM	9/3/2024 2:47:26 PM	9/3/2024 2:47 PM
Details	Last Recertification Date	Update	Recertification	9/2/2022 11:22:19 AM	8/29/2023 2:25:27 PM	8/29/2023 2:25 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 7:20:46 PM	9/2/2022 11:22:19 AM	9/2/2022 11:22 AM
Contacts	Primary Contact	Update	Group Change Request	Than, Min Assistant Vice President New York City Health and Hospitals 2124423854	Capuano, Mark Senior Director, Corporate Pharmacy 340B Program NYC Health + Hospitals 3478359198	8/23/2022 7:11 AM
Contacts	Authorizing Official	Update	AO Change Request	Albertson, Paul Vice President New York City Health and Hospitals 2127482256	Brown, Deborah Alyse Senior Vice President, External and Regulatory Affairs NYC Health + Hospitals 3479470446	8/22/2022 6:47 AM
Contacts	Primary Contact	Update	Profile Change Request	Than, Min Sr. Director New York City Health and Hospitals 2124423854	Than, Min Assistant Vice President New York City Health and Hospitals 2124423854	8/24/2021 6:37 PM
Details	Last Recertification Date	Update	Recertification	9/4/2020 11:41:53 AM	8/19/2021 7:20:46 PM	8/19/2021 7:20 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 11:41 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 7:22:46 AM	9/4/2020 11:41:53 AM	9/4/2020 11:41 AM
Contacts	Primary Contact	Update	Change Request	Sestito, Danielle Senior Director, 340B Operations New York City Health + Hospitals 2124423892	Than, Min Sr. Director New York City Health and Hospitals 2124423854	7/29/2020 7:22 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 1:27:08 AM	8/28/2019 7:22:46 AM	8/28/2019 7:22 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 9:21:31 AM	9/10/2018 1:27:08 AM	9/10/2018 1:27 AM
Addresses	Shipping Address	Insert	Recertification		Elmhurst Hospital 79-01 Broadway Elmhurst, NY 11373	11/7/2017 9:21 AM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/7/2017 9:21:31 AM	11/7/2017 9:21 AM
Contacts	Primary Contact	Insert	Change Request		Sestito, Danielle Senior Director, 340B Operations New York City Health + Hospitals 2124423892	10/4/2017 12:02 PM
Contacts	Authorizing Official	Update	Profile Change Request	Albertson, Paul Vice President Elmhurst Hospital 2127482256	Albertson, Paul Vice President New York City Health and Hospitals 2127482256	9/21/2017 5:59 PM
Details	Entity Name	Update	Change Request	ELMHURST HOSPITAL CENTER	ELMHURST HOSPITAL CENTER (NYCHHC)	9/21/2017 5:30 PM
Contacts	Authorizing Official	Update	Change Request	Albertson, Paul Vice President 2127482256	Albertson, Paul Vice President Elmhurst Hospital 2127482256	9/20/2017 11:54 AM
Contacts	Authorizing Official	Insert			Albertson, Paul Vice President 2127482256	8/14/2017 11:29 AM
Contacts	Signed By	Insert			Martin, Antonio Ececutive Vice President & Chief Operating Officier 2127883479	8/14/2017 11:24 AM
Addresses	Main Address	Insert			77-11 Broadway Elmhurst, NY 11373	4/18/2017 7:35 AM
Addresses	Billing Address	Insert			Elmhurst Hospital 79-01 Broadway Elmhurst, NY 11373	4/18/2017 7:35 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 11:58 AM
Details	Last Recertification Date	Update			8/5/2015 12:00:00 AM	8/5/2015 3:31 PM
Details	Entity Subname	Update		Elmhurst Hospital: Hope Pavilion Breast Clinic / BReast Clinic	Elmhurst Hospital: Hope Pavilion / BReast Clinic	2/9/2015 4:55 PM
Dates	Participating Approval Date	Update			2/9/2015 12:00:00 AM	2/9/2015 4:55 PM
Details	State	Update		Pending	Active	2/9/2015 4:55 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	2/9/2015 4:55 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49705	DSH330128N	1/22/2015 1:47 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49705	1/15/2015 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 11:16 AM
Medicaid Billing	Medicaid: Number	Insert			00246075	1/15/2015 11:16 AM
Medicaid Billing	Medicaid: State	Insert			NY	1/15/2015 11:16 AM
Medicaid Billing	NPI: Number	Insert			1063426377	1/15/2015 11:16 AM
Details	Last Recertification Date	Insert				1/15/2015 11:16 AM
Details	Grant Number	Insert				1/15/2015 11:16 AM
Details	340B ID	Insert				1/15/2015 11:16 AM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 11:16 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 11:16 AM
Details	Medicare Provider Number	Insert			330128	1/15/2015 11:16 AM
Details	Entity Name	Insert			ELMHURST HOSPITAL CENTER	1/15/2015 11:16 AM
Details	Program Code	Insert			DSH	1/15/2015 11:16 AM
Details	Entity Subname	Insert			Elmhurst Hospital: Hope Pavilion Breast Clinic / BReast Clinic	1/15/2015 11:16 AM
Dates	Participating Approval Date	Insert				1/15/2015 11:16 AM
Details	State	Insert			Pending	1/15/2015 11:16 AM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 11:16 AM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 11:16 AM
Dates	Start Date	Insert				1/15/2015 11:16 AM
Terminations	Termination Comments	Insert				1/15/2015 11:16 AM
Terminations	Termination Date	Insert				1/15/2015 11:16 AM
Terminations	Termination Effective Date	Insert				1/15/2015 11:16 AM
Terminations	Termination Reason	Insert				1/15/2015 11:16 AM