Covered Entity Details

DSH450024H UNIVERSITY MEDICAL CENTER OF EL PASO (Active) - information as of 5/5/2025 10:11:51 PM

Main Details

Name

UNIVERSITY MEDICAL CENTER OF EL PASO

Subdivision Name

Mattox Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450024H

Medicare Provider Number

450024

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/8/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/14/2015

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

University Medical Center of El Paso
MICHAEL NUNEZ, CFO
(915) 521-7626

Primary Contact

UNIVERSITY MEDICAL CENTER OF EL PASO
DAVID CHAN, Asst Administrator Pharmacy Services
(915) 521-7662

Addresses

Street Address

3700 Mattox Street
El Paso, TX 79925

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
TX	251003,138951211	1063756609,1316936990

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
DSH450024A	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UNIVERSITY MEDICAL CENTER - NORTHEAST	9839 KENWORTHY ST	EL PASO	TX	Active
DSH450024B	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UNIVERSITY MEDICAL CENTER YSLETA	300 S ZARAGOZA RD.	EL PASO	TX	Active
DSH450024C	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	University Medical Center Dieter	1485 George Dieter Dr, STE 107	El Paso	TX	Active
DSH450024D	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	University Medical Center Fabens	101 Potasio ST	Fabens	TX	Active
DSH450024E	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UMC Neighborhood Health Center Crossroads	5021 Crossroads Drive	El Paso	TX	Terminated
DSH450024F	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	University Medical Center East	1521 Joe Battle Blvd	EL PASO	TX	Active
DSH450024G	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	NEUROSURGICAL CARE CLINIC	4824 ALBERTA AVE	EL PASO	TX	Active
DSH450024H	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	Mattox Clinic	3700 Mattox Street	El Paso	TX	Active
DSH450024J	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	Delta Clinic	6314 Delta Drive	El Paso	TX	Terminated
DSH450024K	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UNIVERSITY MEDICAL CENTER West	6600 N Desert Blvd	EL PASO	TX	Active
DSH450024L	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UMC of El Paso - Northeast Emergency Department - Emergency	4669 Cohen Avenue	El Paso	TX	Active
DSH450024M	Child	DSH	UNIVERSITY MEDICAL CENTER OF EL PASO	UMC of El Paso - East Emergency Department - Emergency	1521 Joe Battle Blvd	El Paso	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Lewis, Myron Ray Director of Pharmacy University Medical Center of El Paso 9155217662	CHAN, DAVID Asst Administrator Pharmacy Services UNIVERSITY MEDICAL CENTER OF EL PASO 9155217662	10/31/2024 7:06 AM
Details	Last Recertification Date	Update	Recertification	8/16/2023 9:46:36 AM	8/13/2024 8:29:45 AM	8/13/2024 8:29 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 8:57:00 AM	8/16/2023 9:46:36 AM	8/16/2023 9:46 AM
Details	Last Recertification Date	Update	Recertification	8/18/2021 4:17:24 PM	8/31/2022 8:57:00 AM	8/31/2022 8:57 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 2:30:37 PM	8/18/2021 4:17:24 PM	8/18/2021 4:17 PM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/27/2020 2:30 PM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/27/2020 2:30 PM
Details	Last Recertification Date	Update	Recertification	8/23/2019 1:02:20 PM	8/27/2020 2:30:37 PM	8/27/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		251003	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		138951211	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	10/7/2019 10:48 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	H04500247 (TX)		10/7/2019 10:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1063756609	10/7/2019 10:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1316936990	10/7/2019 10:48 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1942337381 ( )		10/7/2019 10:48 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 9:50:44 AM	8/23/2019 1:02:20 PM	8/23/2019 1:02 PM
Details	Last Recertification Date	Update	Recertification	11/13/2017 4:11:17 PM	8/22/2018 9:50:44 AM	8/22/2018 9:50 AM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/13/2017 4:11:17 PM	11/13/2017 4:11 PM
Contacts	Authorizing Official	Update		NUNEZ, MICHAEL CFO 9155217626	NUNEZ, MICHAEL CFO University Medical Center of El Paso 9155217626	9/29/2017 3:38 PM
Contacts	Signed By	Update		NUNEZ, MICHAEL CFO 9155217626	NUNEZ, MICHAEL CFO University Medical Center of El Paso 9155217626	9/29/2017 3:38 PM
Contacts	Primary Contact	Update		Lewis, Myron Director of Pharmacy 9155217662	Lewis, Myron Ray Director of Pharmacy University Medical Center of El Paso 9155217662	9/29/2017 7:59 AM
Contacts	Primary Contact	Insert			Lewis, Myron Director of Pharmacy 9155217662	5/2/2017 2:51 PM
Contacts	Authorizing Official	Insert			NUNEZ, MICHAEL CFO 9155217626	5/2/2017 2:51 PM
Contacts	Signed By	Insert			NUNEZ, MICHAEL CFO 9155217626	5/2/2017 2:51 PM
Addresses	Main Address	Insert			3700 Mattox Street El Paso, TX 79925	9/2/2016 11:03 AM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 11:03 AM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 5:36 PM
Dates	Participating Approval Date	Update			5/14/2015 12:00:00 AM	5/14/2015 10:57 AM
Details	State	Update		Pending	Active	5/14/2015 10:57 AM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/14/2015 10:57 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_50894	DSH450024H	4/10/2015 8:55 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_50894	4/8/2015 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/8/2015 4:52 PM
Medicaid Billing	Medicaid: Number	Insert			H04500247	4/8/2015 4:52 PM
Medicaid Billing	Medicaid: State	Insert			TX	4/8/2015 4:52 PM
Medicaid Billing	NPI: Number	Insert			1942337381	4/8/2015 4:52 PM
Details	Last Recertification Date	Insert				4/8/2015 4:52 PM
Details	Grant Number	Insert				4/8/2015 4:52 PM
Details	340B ID	Insert				4/8/2015 4:52 PM
Details	Is Authorizing Official EHB Data	Insert				4/8/2015 4:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/8/2015 4:52 PM
Details	Medicare Provider Number	Insert			450024	4/8/2015 4:52 PM
Details	Entity Name	Insert			UNIVERSITY MEDICAL CENTER OF EL PASO	4/8/2015 4:52 PM
Details	Program Code	Insert			DSH	4/8/2015 4:52 PM
Details	Entity Subname	Insert			Mattox Clinic	4/8/2015 4:52 PM
Dates	Participating Approval Date	Insert				4/8/2015 4:52 PM
Details	State	Insert			Pending	4/8/2015 4:52 PM
Dates	Registration Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 4:52 PM
Dates	Signed By Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 4:52 PM
Dates	Start Date	Insert				4/8/2015 4:52 PM
Terminations	Termination Comments	Insert				4/8/2015 4:52 PM
Terminations	Termination Date	Insert				4/8/2015 4:52 PM
Terminations	Termination Effective Date	Insert				4/8/2015 4:52 PM
Terminations	Termination Reason	Insert				4/8/2015 4:52 PM