Covered Entity Details

DSH330046K ST. LUKES ROOSEVELT HOSPITAL CENTER (Terminated) - information as of 5/3/2025 11:31:46 PM

Main Details

Name

ST. LUKES ROOSEVELT HOSPITAL CENTER

Subdivision Name

MARTIN LUTHER KING JR. HIGH SCHOOL

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330046K

Medicare Provider Number

330046

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/10/2015

Last Recertification Date

8/18/2016

Termination Date
Termination Reason

1/1/2017
Site closure

Contacts

Authorizing Official

Mount Sinai
Michael Pastier, Senior VP/CFO - The Mount Sinai Hospital
(212) 731-3149

Primary Contact

mount sinai health system
Philip Manning, Senior Director of Pharmacy
(718) 267-4295

Addresses

Street Address

122 AMSTERDAM AVENUE
NEW YORK, NY 10023-6407

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
NY	00354967,03001801,01650173,02239247
		1104982917,1508001405,1417192311

Shipping Addresses

Shipping Address 1

MOUNT SINAI ROOSEVELT HOSPITAL
1000 TENTH AVE
NEW YORK, NY 10019

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
DSH330046A	Child	DSH	MOUNT SINAI WEST	ROOSEVELT HOSPITAL	1000 10TH AVENUE	NEW YORK	NY	Active
DSH330046B	Child	DSH	MOUNT SINAI WEST	ST LUKE'S HOSPITAL	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046C	Child	DSH	ST LUKE'S ROOSEVELT HOSPITAL CENTER	TRANSPLANT PROGRAM	2074 Frederick Douglas Boulevard	NEW YORK	NY	Terminated
DSH330046D	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychiatric Center - PTSD	411 West 114th Street	New York City	NY	Active
DSH330046E	Child	DSH	MOUNT SINAI WEST	Center for Comprehensive Care West 17th Street Division	230 west 17th street	New York City	NY	Terminated
DSH330046F	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychatric Center/Mental health Day Treatment	411 west 114th street	New York City	NY	Active
DSH330046G	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychatric Center/Mental health Clinic	411 west 114th street	New York City	NY	Active
DSH330046H	Child	DSH	MOUNT SINAI WEST	Opioid Treatment Program (MMTP)	1000 TENTH AVENUE	NEW YORK	NY	Active
DSH330046J	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	A. PHILIP RANDOLPH CAMPUS HIGH SCHO	443 WEST 135TH STREET	NEW YORK	NY	Terminated
DSH330046K	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	MARTIN LUTHER KING JR. HIGH SCHOOL	122 AMSTERDAM AVENUE	NEW YORK	NY	Terminated
DSH330046L	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	LOUIS BRANDEIS HIGH SCHOOL	145 WEST 84TH STREET	NEW YORK	NY	Terminated
DSH330046M	Child	DSH	MOUNT SINAI WEST	CARDIOLOGY CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046N	Child	DSH	MOUNT SINAI WEST	ST. LUKE'S INFECTIOUS DISEASE CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046P	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI ST. LUKE'S SURGERY CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046Q	Child	DSH	MOUNT SINAI WEST	ST. LUKE'S GENERAL CLINIC	158 W 124th St	New York	NY	Active
DSH330046R	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI WEST INFUSION	425 W 59th Street	New York	NY	Active
DSH330046S	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI Saint Luke's Outpatient Clinic	1111 Amsterdam Ave.	New York	NY	Active
DSH330046T	Child	DSH	MOUNT SINAI WEST	Mount Sinai St. Luke's - Emergency Department	1111 Amsterdam Ave	New York	NY	Active
DSH330046U	Child	DSH	MOUNT SINAI WEST	Mount Sinai Morningside - Institute for Advanced Medicine	158 W 124th St	New York	NY	Active
DSH330046V	Child	DSH	MOUNT SINAI WEST	Mount Sinai Morningside - Oncology	440 W 114th St	New York	NY	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Bruno, Michael Sr. Vice President Beth Israel Medicial Center 2125237140	Pastier, Michael Senior VP/CFO - The Mount Sinai Hospital Mount Sinai 2127313149	10/26/2018 1:38 PM
Contacts	Authorizing Official	Update		Bruno, Michael Sr. Vice President 2125237140	Bruno, Michael Sr. Vice President Beth Israel Medicial Center 2125237140	10/13/2017 8:57 AM
Contacts	Signed By	Update		Bruno, Michael Sr. Vice President 2125237140	Bruno, Michael Sr. Vice President Beth Israel Medicial Center 2125237140	10/13/2017 8:57 AM
Contacts	Primary Contact	Update		Manning, Philip Senior Director of Pharmacy 7182674295	Manning, Philip Senior Director of Pharmacy mount sinai health system 7182674295	10/6/2017 11:08 AM
Contacts	Authorizing Official	Insert			Bruno, Michael Sr. Vice President 2125237140	8/3/2017 10:15 AM
Contacts	Signed By	Insert			Bruno, Michael Sr. Vice President 2125237140	8/3/2017 10:15 AM
Contacts	Primary Contact	Insert			Manning, Philip Senior Director of Pharmacy 7182674295	8/3/2017 10:15 AM
Addresses	Main Address	Insert			122 AMSTERDAM AVENUE NEW YORK, NY 10023-6407	10/20/2016 12:43 PM
Addresses	Shipping Address	Insert			MOUNT SINAI ROOSEVELT HOSPITAL 1000 TENTH AVE NEW YORK, NY 10019	10/20/2016 12:43 PM
Dates	Last Date That 340B Drugs Purchased	Update			6/30/2016 12:00:00 AM	10/20/2016 12:43 PM
Details	State	Update		Active	Terminated	10/20/2016 12:43 PM
Terminations	Termination Comments	Update			closed	10/20/2016 12:43 PM
Terminations	Termination Date	Update			1/1/2017 12:00:00 AM	10/20/2016 12:43 PM
Terminations	Termination Effective Date	Update			6/30/2016 12:00:00 AM	10/20/2016 12:43 PM
Terminations	Termination Reason	Update			Site closure	10/20/2016 12:43 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 12:03 PM
Details	Last Recertification Date	Update			8/31/2015 12:00:00 AM	8/31/2015 12:30 PM
Dates	Participating Approval Date	Update			3/10/2015 12:00:00 AM	3/10/2015 3:23 PM
Details	State	Update		Pending	Active	3/10/2015 3:23 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/10/2015 3:23 PM
Details	340B ID	Update		DSG330046K	DSH330046K	1/29/2015 11:39 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49965	DSG330046K	1/26/2015 10:20 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49965	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Number	Insert			00354967	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: State	Insert			NY	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Number	Insert			03001801	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: State	Insert			NY	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Number	Insert			01650173	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: State	Insert			NY	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: Number	Insert			02239247	1/15/2015 5:38 PM
Medicaid Billing	Medicaid: State	Insert			NY	1/15/2015 5:38 PM
Medicaid Billing	NPI: Number	Insert			1104982917	1/15/2015 5:38 PM
Medicaid Billing	NPI: Number	Insert			1508001405	1/15/2015 5:38 PM
Medicaid Billing	NPI: Number	Insert			1417192311	1/15/2015 5:38 PM
Details	Last Recertification Date	Insert				1/15/2015 5:38 PM
Details	Grant Number	Insert				1/15/2015 5:38 PM
Details	340B ID	Insert				1/15/2015 5:38 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 5:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 5:38 PM
Details	Medicare Provider Number	Insert			330046	1/15/2015 5:38 PM
Details	Entity Name	Insert			ST. LUKES ROOSEVELT HOSPITAL CENTER	1/15/2015 5:38 PM
Details	Program Code	Insert			DSH	1/15/2015 5:38 PM
Details	Entity Subname	Insert			MARTIN LUTHER KING JR. HIGH SCHOOL	1/15/2015 5:38 PM
Dates	Participating Approval Date	Insert				1/15/2015 5:38 PM
Details	State	Insert			Pending	1/15/2015 5:38 PM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 5:38 PM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 5:38 PM
Dates	Start Date	Insert				1/15/2015 5:38 PM
Terminations	Termination Comments	Insert				1/15/2015 5:38 PM
Terminations	Termination Date	Insert				1/15/2015 5:38 PM
Terminations	Termination Effective Date	Insert				1/15/2015 5:38 PM
Terminations	Termination Reason	Insert				1/15/2015 5:38 PM