Covered Entity Details

DSH490032CM VCU HEALTH SYSTEM MCV HOSPITAL (Terminated) - information as of 4/23/2025 10:53:57 PM

Main Details

Name

VCU HEALTH SYSTEM MCV HOSPITAL

Subdivision Name

Inflammatory Bowel Disease Clinic - N5DH

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH490032CM

Medicare Provider Number

490032

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/7/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/16/2015

Last Recertification Date

8/30/2016

Termination Date
Termination Reason

4/1/2017
Site closure

Contacts

Authorizing Official

VCU Health System
Paul Wesolowski, Chief Operating Officer
(804) 828-4607

Primary Contact

VCU Health System
Rodney Stiltner, Director of Pharmacy
(804) 828-5468

Addresses

Street Address

1300 E Marshall St
5th Floor
Richmond, VA 23298

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
VA	8506744
		1437175734

Shipping Addresses

Shipping Address 1

VCU Health System
403 N 13th St
Room B-328
Richmond, VA 23298

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
DSH490032AA	Child	DSH	Virginia Commonwealth University Health System	VCUHS Ambulaory Care Center Neurology	417 North 11th Street	Richmond	VA	Active
DSH490032AC	Child	DSH	Virginia Commonwealth University Health System	VCUHS Infectious Disease	1001 E Leigh Street	Richmond	VA	Active
DSH490032AD	Child	DSH	Virginia Commonwealth University Health System	VCUHS Stony Point Hematology & Medical Oncology	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032AE	Child	DSH	Virginia Commonwealth University Health System	Complex Care Clinic	417 North 11th Street 2nd Floor	Richmond	VA	Active
DSH490032AF	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Hematology/Oncolgy	1213 East Clay Street	Richmond	VA	Terminated
DSH490032AG	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Women's Health / General Medicine	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032AH	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Womens Health / OB/GYN Endocrine Infertility	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AJ	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Womens Health / OB/GYN Primary Care	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AK	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Cardiology at Stony Point Multispecialty Clinic	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AL	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Endocrinology at Stony Point Multispecialty Clinic	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AM	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Rheumatolgy, Allergy, Immunology at Stony Point Multispecialty Clic	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AN	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Dermatology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AP	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Pediatrics / Oncology Pediatric Clinic at Stony Point Pediatrics	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AQ	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Pediatrics / Pediatric Gestroenterology at Stony Point Pediatrics	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032AR	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Pediatric Hematology Oncology Clinic	1000 East Broad Street	Richmond	VA	Active
DSH490032AS	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Pediatric Neurology	1000 East Broad Street	Richmond	VA	Active
DSH490032AT	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion Pediatrics General Primary Care / General Pediatrics at Ped Specialties Downtown	1000 East Broad Street	Richmond	VA	Terminated
DSH490032AU	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Orthopedics	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032AV	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Dermatology	1001 E Leigh St	Richmond	VA	Active
DSH490032AW	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Ambulatory Oncology Clinc / Hematology and Medical Oncology	1001 E Leigh St	Richmond	VA	Active
DSH490032AX	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Ambulatory Oncology Clinic / Leukemia and Lymphoma Clinic	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032AY	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Ambulatory Oncology Clinic / Oncology Pain Clinic	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032AZ	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Psychiatry Clinic	401 North 11th Street	Richmond	VA	Active
DSH490032BA	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Ophthalmology Clinic	401 North 11th Street	Richmond	VA	Active
DSH490032BB	Child	DSH	Virginia Commonwealth University Health System	VCU Health System RMC Ophthalmology	8700 Stony Point Parkway	Richmond	VA	Terminated
DSH490032BC	Child	DSH	Virginia Commonwealth University Health System	VCU Health System RMC Otolaryngology Clinic	8700 Stony Point Parkway	Richmond	VA	Terminated
DSH490032BD	Child	DSH	Virginia Commonwealth University Health System	VCU Health System PM&R Neuropsychology	8730 Stony Point Parkway	Richmond	VA	Active
DSH490032BE	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Orthopedic Surgery Practice / Orthopedic Surgery Clinic	417 North 11th Street	Richmond	VA	Terminated
DSH490032BF	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Primary Care Associates / Primay Care - Resident	417 North 11th Street	Richmond	VA	Terminated
DSH490032BG	Child	DSH	Virginia Commonwealth University Health System	Nelson Otolaryngology / OTO Audiology	401 North 11th Street	Richmond	VA	Terminated
DSH490032BH	Child	DSH	Virginia Commonwealth University Health System	Nelson Otolaryngology / ENT	401 North 11th Street	Richmond	VA	Terminated
DSH490032BJ	Child	DSH	Virginia Commonwealth University Health System	Otolaryngology Adult Outpatient Pavilion	1001 E Leigh St	Richmond	VA	Active
DSH490032BK	Child	DSH	Virginia Commonwealth University Health System	General Dental Medicine (OMFS Clinic)	1001 E Leigh St	Richmond	VA	Active
DSH490032BL	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties - Faculty Clinic / Pulmonary	417 North 11th Street	Richmond	VA	Terminated
DSH490032BM	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties - Faculty Clinic / Endocrinology	417 North 11th Street	Richmond	VA	Terminated
DSH490032BN	Child	DSH	Virginia Commonwealth University Health System	Urology Clinic - Adult Outpatient Pavilion	1001 E Leigh St	Richmond	VA	Active
DSH490032BP	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties - Faculty / General Medicine - Infusion Therapy	417 North 11th Street	Richmond	VA	Terminated
DSH490032BQ	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties - Faculty / Nephrology	417 North 11th Street	Richmond	VA	Terminated
DSH490032BR	Child	DSH	Virginia Commonwealth University Health System	Med Specialties - Faculty Clinic / Cardiology	417 North 11th Street	Richmond	VA	Terminated
DSH490032BS	Child	DSH	Virginia Commonwealth University Health System	Cardiology Clinic - Adult Outpatient Pavilion	1001 E Leigh St	Richmond	VA	Active
DSH490032BT	Child	DSH	Virginia Commonwealth University Health System	Neurosurgery Practice	417 North 11th Street	Richmond	VA	Active
DSH490032BU	Child	DSH	Virginia Commonwealth University Health System	Physical Medicine & Rehab	1001 E Leigh St	Richmond	VA	Active
DSH490032BV	Child	DSH	Virginia Commonwealth University Health System	Med Specialties Resident Clin / Connective Tissue Clininc	417 North 11th Street	Richmond	VA	Terminated
DSH490032BW	Child	DSH	Virginia Commonwealth University Health System	Surgery Multispecialties / Vascular Surgery	417 North 11th Street	Richmond	VA	Terminated
DSH490032BX	Child	DSH	Virginia Commonwealth University Health System	Internal Med Specialties Resident Clinic / GI Clinic	417 North 11th Street	Richmond	VA	Terminated
DSH490032BY	Child	DSH	Virginia Commonwealth University Health System	Surgery Multispecialties / General Surgery	1001 E Leigh St	Richmond	VA	Active
DSH490032BZ	Child	DSH	Virginia Commonwealth University Health System	Pediatric Primary Care	1000 E Broad Street	Richmond	VA	Active
DSH490032CA	Child	DSH	Virginia Commonwealth University Health System	Pediatric Primary Care - Group Practice	1000 East Broad Street	Richmond	VA	Active
DSH490032CB	Child	DSH	Virginia Commonwealth University Health System	Adolescent Medicine Clinic	1000 East Broad Street	Richmond	VA	Active
DSH490032CC	Child	DSH	Virginia Commonwealth University Health System	Pediatrics Fredericksburg CHoR	10528 Spotsylvania Avenue	Fredericksburg	VA	Active
DSH490032CD	Child	DSH	Virginia Commonwealth University Health System	Stony Point Hand/Upper Extremity and Peripheral Nerve Center	8700 Stony Point Parkway	Richmond	VA	Terminated
DSH490032CE	Child	DSH	Virginia Commonwealth University Health System	Stony Point Multispecialties / Neurosurgery	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032CF	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialties / Nephrology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032CG	Child	DSH	Virginia Commonwealth University Health System	Stony Point Multispecialties / Pulmonary	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032CH	Child	DSH	Virginia Commonwealth University Health System	Surgery Multispecialties / Vascular Access Clinic	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032CJ	Child	DSH	Virginia Commonwealth University Health System	Plastic Surgery Burn Unit - CCH	1213 East Clay Street	Richmond	VA	Active
DSH490032CK	Child	DSH	Virginia Commonwealth University Health System	Rheumatology/Allergy/Immunology Clinic	417 North 11th Street	Richmond	VA	Terminated
DSH490032CL	Child	DSH	Virginia Commonwealth University Health System	Family Medicine Clinic Downtown	1001 East Leigh Street	Richmond	VA	Active
DSH490032CM	Child	DSH	VCU HEALTH SYSTEM MCV HOSPITAL	Inflammatory Bowel Disease Clinic - N5DH	1300 E Marshall St	Richmond	VA	Terminated
DSH490032CN	Child	DSH	Virginia Commonwealth University Health System	VCU BAIRD VASCULAR INSTITUTE	205 North Hamilton Street	RICHMOND	VA	Active
DSH490032CP	Child	DSH	Virginia Commonwealth University Health System	Liver Transplant Clinic / Hepatology	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032CQ	Child	DSH	Virginia Commonwealth University Health System	PACE Clinic (Pre-Operative Assessment Communication Education Clinic)	1200 East Marshall Street	Richmond	VA	Active
DSH490032CR	Child	DSH	Virginia Commonwealth University Health System	Pediatric Pulmonary Center	1000 East Broad Street	Richmond	VA	Active
DSH490032CS	Child	DSH	Virginia Commonwealth University Health System	Radiation Oncology - Stony Point	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032CT	Child	DSH	Virginia Commonwealth University Health System	Radiation Oncology	1001 E Leigh St	Richmond	VA	Active
DSH490032CU	Child	DSH	Virginia Commonwealth University Health System	Radiation Oncology - Hanover	8222 Meadowbridge Road	Mechanicsville	VA	Active
DSH490032CW	Child	DSH	Virginia Commonwealth University Health System	Hemodialysis / Pediatrics	1000 East Broad Street	Richmond	VA	Active
DSH490032CX	Child	DSH	Virginia Commonwealth University Health System	Hemodialysis / Adult	1200 East Marshall Street	Richmond	VA	Active
DSH490032CY	Child	DSH	Virginia Commonwealth University Health System	Endoscopy	1200 East Marshall Street	Richmond	VA	Active
DSH490032CZ	Child	DSH	Virginia Commonwealth University Health System	Endoscopy / Bronchoscopy	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032DB	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Surgery Post Anethesia Care Unit	417 North 11th Street	Richmond	VA	Active
DSH490032DC	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Surgery Center	417 North 11th Street	Richmond	VA	Active
DSH490032DD	Child	DSH	Virginia Commonwealth University Health System	Transplant Clinic - Renal / Dermatology	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032DE	Child	DSH	Virginia Commonwealth University Health System	Transplant Clinic - Renal / Infectious Disease	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032DF	Child	DSH	Virginia Commonwealth University Health System	Transplant Clinic - Renal / Endocrine Transplant	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032DG	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties / Hematology - Sickle Cell Practice	1001 E Leigh St	Richmond	VA	Active
DSH490032DH	Child	DSH	Virginia Commonwealth University Health System	Internal Med Specialties / Asthma Clinic (Pulmonary)	417 North 11th Street	Richmond	VA	Terminated
DSH490032DJ	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties / Anti-Coagulation Clinic	417 North 11th Street	Richmond	VA	Active
DSH490032DK	Child	DSH	VCU HEALTH SYSTEM MCV HOSPITAL	Hemodialysis	1213 E Clay St	Richmond	VA	Terminated
DSH490032DL	Child	DSH	VCU HEALTH SYSTEM MCV HOSPITAL	Inflammatory Bowel Disease / Pancreatitis Clinic	1300 E Marshall Street	Richmond	VA	Terminated
DSH490032DM	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Oncology / Dalton Oncology Clinic - Endocrinology	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032DN	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Oncology / Gynecology Oncology	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032DP	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Oncology / Neuro-Oncology Clinic	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032DQ	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Oncology / Oncology - Head Neck	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032DR	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Oncology / Surgical Oncology	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032DS	Child	DSH	Virginia Commonwealth University Health System	General Medicine Primary Care / Geriatrics	417 North 11th Street	Richmond	VA	Terminated
DSH490032DT	Child	DSH	Virginia Commonwealth University Health System	Surgery Practice / Structural Heart Disease Practice (Cardiac Surgery)	417 North 11th Street	Richmond	VA	Terminated
DSH490032DU	Child	DSH	Virginia Commonwealth University Health System	Surgery Practice / Thoracic Surgery Practice	417 North 11th Street	Richmond	VA	Terminated
DSH490032DV	Child	DSH	Virginia Commonwealth University Health System	Surgery Practice / Trauma Critical Care Surgery Practice	417 North 11th Street	Richmond	VA	Terminated
DSH490032DW	Child	DSH	Virginia Commonwealth University Health System	Orthopedic Surgery Practice / Orthopedic Hand Clinic	417 North 11th Street	Richmond	VA	Terminated
DSH490032DX	Child	DSH	Virginia Commonwealth University Health System	Internal Medicine Specialties / Infectious Disease Practice	417 North 11th Street	Richmond	VA	Terminated
DSH490032DY	Child	DSH	Virginia Commonwealth University Health System	Family Practice Downtown / Family Medicine Psychiatry	401 North 11th Street	Richmond	VA	Terminated
DSH490032DZ	Child	DSH	Virginia Commonwealth University Health System	Bone Marrow Transplant Clinic / Bone Marrow Transplant - Endocrinology	1300 East Marshall Street	Richmond	VA	Active
DSH490032EA	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Urology	1213 East Clay Street	Richmond	VA	Terminated
DSH490032EB	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Renal	1213 East Clay Street	Richmond	VA	Terminated
DSH490032EC	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Neurology	1213 East Clay Street	Richmond	VA	Terminated
DSH490032ED	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Gastroenterology	1213 East Clay Street	Richmond	VA	Terminated
DSH490032EE	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / Rheumatology/Immunology	1213 East Clay Street	Richmond	VA	Terminated
DSH490032EF	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Security Care Clinic / General Surgery	1213 East Clay Street	Richmond	VA	Terminated
DSH490032EG	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Pavilion Infusion Center	11958 West Broad Street	Henrico	VA	Active
DSH490032EH	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Rheumatology	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EJ	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Physical Medicine & Rehabilitation	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EK	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Neurosurgery	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EL	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Neurology	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EM	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Anesthesiology (Pain Management)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EN	Child	DSH	Virginia Commonwealth University Health System	VCU Health Neuroscience, Orthopaedic and Wellness / Orthopaedics	11958 West Broad Street	Henrico	VA	Terminated
DSH490032EP	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Orthopedics / Podiatry	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EQ	Child	DSH	Virginia Commonwealth University Health System	Medicine Specialties / Ambulatory Care Center 4 Infusion Therapy (Med Specialties)	417 North 11th St	Richmond	VA	Terminated
DSH490032ER	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Urology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032ES	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Surgical Oncology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032ET	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / General Surgery	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EU	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Gastroenterology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EV	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Multispecialty / Cardiothoracic Surgery	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EW	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Womens Health / Urology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EX	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point Womens Health / Surgical Oncology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032EY	Child	DSH	Virginia Commonwealth University Health System	Pediatric Oncology Clinic / Hemophilia	1000 E Broad Street	Richmond	VA	Terminated
DSH490032EZ	Child	DSH	Virginia Commonwealth University Health System	Pediatric Oncology Clinic / Psychiatry	1000 East Broad Street	Richmond	VA	Terminated
DSH490032FA	Child	DSH	Virginia Commonwealth University Health System	VCU Health System - Stony Point Pediatrics / Pediatric Plastics	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032FB	Child	DSH	Virginia Commonwealth University Health System	VCU Health System - Stony Point Pediatrics / Urology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032FC	Child	DSH	Virginia Commonwealth University Health System	VCU Health System - Stony Point Pediatrics / Nephrology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032FD	Child	DSH	Virginia Commonwealth University Health System	VCU Health System - Stony Point Pediatrics / Pulmonary	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032FE	Child	DSH	Virginia Commonwealth University Health System	VCU Health System - Stony Point Pediatrics / Asthma, Allergy and Immunology	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032FF	Child	DSH	Virginia Commonwealth University Health System	Telemedicine Clinic	401 North 11th Street	Richmond	VA	Active
DSH490032FG	Child	DSH	Virginia Commonwealth University Health System	Pauley Heart Center	417 North 11th Street	Richmond	VA	Active
DSH490032FH	Child	DSH	Virginia Commonwealth University Health System	Pediatric Infusion Clinic - Children's Pavilion	1000 East Broad Street	Richmond	VA	Active
DSH490032FJ	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion Infusion Center	1001 E Leigh St	Richmond	VA	Active
DSH490032FK	Child	DSH	Virginia Commonwealth University Health System	Gateway 5 - Same Day Surgery (2602)	1200 East Marshall Street	Richmond	VA	Active
DSH490032FL	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Orthopedics	1000 East Broad Street	Richmond	VA	Active
DSH490032FM	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Endocrinology - A (1261)	1000 East Broad Street	Richmond	VA	Active
DSH490032FN	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Physical Medicine and Rehabilitation	1000 East Broad Street	Richmond	VA	Active
DSH490032FP	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Human Genetics	1000 East Broad Street	Richmond	VA	Active
DSH490032FQ	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Allergy/Immunology	1000 East Broad Street	Richmond	VA	Active
DSH490032FR	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Gastroenterology	1000 East Broad Street	Richmond	VA	Active
DSH490032FS	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Nephrology	1000 East Broad Street	Richmond	VA	Active
DSH490032FT	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Muscular Dystrophy Clinic (1261)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032FU	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Spasticity Clinic (1261)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032FV	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Infectious Disease	1000 East Broad Street	Richmond	VA	Active
DSH490032FW	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Ear Nose and Throat	1000 East Broad Street	Richmond	VA	Active
DSH490032FX	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Rheumatology Allergy Immunology	1000 East Broad Street	Richmond	VA	Active
DSH490032FY	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Traumatic Brain Injury clinic (1261)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032FZ	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Surgery	1000 East Broad Street	Richmond	VA	Active
DSH490032GA	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Oncology Infusion Center	1000 East Broad Street	Richmond	VA	Active
DSH490032GB	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Operating Room	1000 East Broad Street	Richmond	VA	Active
DSH490032GC	Child	DSH	Virginia Commonwealth University Health System	Childrens Pavillion - Pediatric Radiology	1000 East Broad Street	Richmond	VA	Active
DSH490032GD	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Spina Bifida Clinic (1261)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032GE	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Pediatric Plastic Surgery	1000 East Broad Street	Richmond	VA	Active
DSH490032GF	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Endocrinology - G (1260)	1000 East Broad Street	Richmond	VA	Active
DSH490032GG	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Urology	1000 East Broad Street	Richmond	VA	Active
DSH490032GH	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Cardiology	1000 East Broad Street	Richmond	VA	Active
DSH490032GJ	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Endocrinology - E (1262)	1000 East Broad Street	Richmond	VA	Active
DSH490032GK	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Cardio/Thoracic Surgery	1000 East Broad Street	Richmond	VA	Active
DSH490032GL	Child	DSH	Virginia Commonwealth University Health System	Jackson Center - Psychiatric Clinic	501 North 2nd Street	Richmond	VA	Active
DSH490032GM	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Neurosurgery Clinic	1000 East Broad Street	Richmond	VA	Active
DSH490032GN	Child	DSH	Virginia Commonwealth University Health System	Children's Pavilion - Pediatric Cerebral Palsy Clinic	1000 East Broad Street	Richmond	VA	Active
DSH490032GP	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Childrens Pavillion - Pediatric Gyn Care (1262)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032GQ	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Children's Pavilion - Pediatric Ophthalmology	1000 East Broad Street	Richmond	VA	Active
DSH490032GR	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Childrens Pavillion - Pediatric Transplant Surgery (1261)	1000 East Broad Street	Richmond	VA	Terminated
DSH490032GS	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - VCU Health Neuroscience, Orthopaedic and Wellness - Plastic Surgery (4606)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032GT	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pelvic Health at Stony Point - Urology (2226)	8700 Stony Point Parkway	Richmond VA	VA	Terminated
DSH490032GU	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pelvic Health at Stony Point - Gastroenterology (2226)	8700 Stony Point Parkway	Richmond VA	VA	Terminated
DSH490032GV	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - VCU Health Neuroscience, Orthopaedic and Wellness - Endocrinology (4606)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032GW	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - VCU Health Neuroscience, Orthopaedic and Wellness - General Surgery (4606)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032GX	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pelvic Health at Stony Point - UroGynecology (2226)	8700 Stony Point Parkway	Richmond VA	VA	Terminated
DSH490032GY	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pauley Heart Center at Stony Point (2225)	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032GZ	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - VCU Health Neuroscience, Orthopaedic and Wellness - Pediatric Neurology (4606)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032H	Child	DSH	Virginia Commonwealth University Health System	NELSON FAMILY PRACTICE - NELSON CLINIC	401 North 11th Street	RICHMOND	VA	Terminated
DSH490032HA	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Jackson Center Motivate Clinic	501 North 2nd Street	Richmond	VA	Active
DSH490032HB	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pelvic Health at Stony Point - Colon & Rectal Surgery (2226)	8700 Stony Point Parkway	Richmond VA	VA	Terminated
DSH490032HC	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Stony Point Non-Invasive Cardiology (1606)	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032HD	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - PACE Center (Pre-Operative Assessment Communication Education Clinic) at Stony Point (2801)	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032HE	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Ambulatory Oncology - Hemophilia (2205)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HF	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pelvic Health at Stony Point (2226)	9105 Stony Point Parkway	Richmond	VA	Active
DSH490032HG	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Internal Medicine - Cardiology (2204)	417 North 11th Street	Richmond	VA	Terminated
DSH490032HH	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - VCU Health Neuroscience, Orthopaedic and Wellness - Physical Medicine & Rehabilitation 3 (4606)	11958 West Broad Street	Henrico	VA	Terminated
DSH490032HJ	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Pain Medicine Clinic - (2228)	1001 E Leigh St	Richmond	VA	Active
DSH490032HK	Child	DSH	Virginia Commonwealth University Health System	Gateway 3 - Cardiovascular Procedure Care Unit	1200 East Marshall Street	Richmond	VA	Active
DSH490032HL	Child	DSH	Virginia Commonwealth University Health System	Emergency Department - Pediatrics (2004)	1001 East Marshall Street	Richmond	VA	Active
DSH490032HM	Child	DSH	Virginia Commonwealth University Health System	Emergency Department - Trauma Acute	1213 East Clay Street	RICHMOND	VA	Active
DSH490032HN	Child	DSH	Virginia Commonwealth University Health System	Emergency Department - Clinical Decision Unit	1213 East Clay Street	RICHMOND	VA	Active
DSH490032HP	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Transplant (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HQ	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - General Surgery (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HR	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Rheumatology/Allergy/Immunology (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HS	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Cardiology	1300 East Marshall Street	RICHMOND	VA	Terminated
DSH490032HT	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Pulmonary (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HU	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Neurology (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HV	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Pediatric Endocrinology (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HW	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Endocrinology (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HX	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - Hematology/Oncology (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HY	Child	DSH	Virginia Commonwealth University Health System	Clinical Reseach Center - General Medicine (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032HZ	Child	DSH	Virginia Commonwealth University Health System	Clinical Research Center - GI (2301)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032J	Child	DSH	Virginia Commonwealth University Health System	VCU Sports Medicine	1300 West Broad Street	Richmond	VA	Active
DSH490032JA	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System Medicine Infusion Therapy (N8) - General Medicine (2221)	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032JB	Child	DSH	Virginia Commonwealth University Health System	NEUROSCIENCE ORTHOPEDIC WELLNESS CE - Neuro Ophthalmology	11958 W BROAD ST	HENRICO	VA	Terminated
DSH490032JC	Child	DSH	Virginia Commonwealth University Health System	Clinical Research - Sicke Cell Infusion	1300 East Marshall Street	Richmond	VA	Terminated
DSH490032JD	Child	DSH	Virginia Commonwealth University Health System	VCU Health Emergency Center at New Kent - Emergency Department	2495 Pocahontas Trail	Quinton	VA	Active
DSH490032JE	Child	DSH	Virginia Commonwealth University Health System	North Ground Imaging - MRI	1300 East Marshall Street	Richmond	VA	Active
DSH490032JF	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Nuclear Medicine	1200 East Marshall Street	Richmond	VA	Active
DSH490032JG	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - for Sleep Medicine	2529 Professional Road	Richmond	VA	Terminated
DSH490032JH	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Stony Point Multispecialty Clinic	9000 Stony Point Parkway	Richmond	VA	Active
DSH490032JJ	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Stony Point Pediatric Clinic	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032JK	Child	DSH	Virginia Commonwealth University Health System	CENTER FOR ENDOCRINOLOGY DIABETES - Pediatric Diabetes	2305 N PARHAM RD	RICHMOND	VA	Active
DSH490032JL	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Security Care Clinic	1213 East Clay Street	Richmond	VA	Active
DSH490032JM	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Internal Medicine Specialties	1001 E Leigh St	Richmond	VA	Active
DSH490032JN	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Clinical Research Center	1300 East Marshall Street	Richmond	VA	Active
DSH490032JP	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Short Pump Pavilion	11958 West Broad Street	Henrico	VA	Active
DSH490032JQ	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Allogenic Stem Cell Acquisition - Cellular Therapeutics Lab	737 North 5th Street	Richmond	VA	Active
DSH490032JR	Child	DSH	Virginia Commonwealth University Health System	CHILDRENS PAVILION - Pediatrics Clinic	1000 E BROAD ST	RICHMOND	VA	Active
DSH490032JS	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Medical Center - Adult Outpatient Pavilion Orthopedics	1001 E Leigh Street	Richmond	VA	Active
DSH490032JT	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion - OB-GYN 10th Floor	1001 E Leigh Street	Richmond	VA	Active
DSH490032JU	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion - Neuroscience	1001 E Leigh Street	Richmond	VA	Active
DSH490032JV	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Care Center 2nd Floor - Primary Care Associates	417 North 11th Street	Richmond	VA	Active
DSH490032JW	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Care Center 5/6 - Pain Management	417 North 11th Street	Richmond	VA	Terminated
DSH490032JX	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion - Multispecialty Clinic 11th Floor	1001 E Leigh Street	Richmond	VA	Active
DSH490032JY	Child	DSH	Virginia Commonwealth University Health System	Ambulatory Care Center - Medical Specialties	417 North 11th Street	Richmond	VA	Active
DSH490032JZ	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion - Medication Management Clinic	1001 East Leigh Street	Richmond	VA	Active
DSH490032K	Child	DSH	Virginia Commonwealth University Health System	VCU Health System Stony Point	9000 Stony Point Parkway	Richmond	VA	Terminated
DSH490032KA	Child	DSH	Virginia Commonwealth University Health System	Adult Outpatient Pavilion - Team Care	1001 E Leigh St	Richmond	VA	Active
DSH490032KB	Child	DSH	Virginia Commonwealth University Health System	Virginia Commonwealth University Health System - Cellular Immunotherapy and Transplant Treatment	1300 E Marshall Street	Richmond	VA	Active
DSH490032KC	Child	DSH	Virginia Commonwealth University Health System	VCU Health Medical Center - Cellular Immunotherapy and Transplant	1300 East Marshall Street	Richmond	VA	Active
DSH490032L	Child	DSH	Virginia Commonwealth University Health System	Hayes E Willis Family Medicine	4730 North Southside Plaza	Richmond	VA	Active
DSH490032M	Child	DSH	Virginia Commonwealth University Health System	Womens Health Adult Outpatient Pavilion	1001 E Leigh St	Richmond	VA	Active
DSH490032N	Child	DSH	Virginia Commonwealth University Health System	VCUHS Ophthalmology	401 North 11th Street	Richmond	VA	Terminated
DSH490032P	Child	DSH	Virginia Commonwealth University Health System	VCUHS Oral Surgery Clinic	401 North 11th Street	Richmond	VA	Terminated
DSH490032Q	Child	DSH	Virginia Commonwealth University Health System	VCUHS Spine Center	8700 Stony Point Parkway	Richmond	VA	Terminated
DSH490032R	Child	DSH	Virginia Commonwealth University Health System	VCUHS Liver Transplant Clinic	1200 East Marshall Street	Richmond	VA	Terminated
DSH490032S	Child	DSH	Virginia Commonwealth University Health System	VCUHS BMT Clinic	1300 East Marshall Street	Richmond	VA	Active
DSH490032T	Child	DSH	Virginia Commonwealth University Health System	VCUHS Ambulatory Care Center Orthopedic Clinic	1001 E Leigh St	Richmond	VA	Terminated
DSH490032U	Child	DSH	Virginia Commonwealth University Health System	VCUHS Transplant Clinic	1200 East Marshall Street	Richmond	VA	Active
DSH490032V	Child	DSH	Virginia Commonwealth University Health System	Hayes E Willis Psychiatry	4730 North Southside Plaza	Richmond	VA	Terminated
DSH490032W	Child	DSH	Virginia Commonwealth University Health System	VCUHS Hayes E Willis Medicine Specialties	4730 North Southside Plaza	Richmond	VA	Terminated
DSH490032X	Child	DSH	Virginia Commonwealth University Health System	VCUHS Childrens Pavilion Pediatric Allergy	1000 East Broad Street	Richmond	VA	Active
DSH490032Y	Child	DSH	Virginia Commonwealth University Health System	VCUHS Ambulatory Care Center Med Specialties	1001 E Leigh St	Richmond	VA	Active
DSH490032Z	Child	DSH	Virginia Commonwealth University Health System	VCUHS Ambulatory Care Center Primary Care	417 North 11th Street	Richmond	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Stiltner, Rodney Director of Pharmacy VCU Health Sytem 8048285468	Stiltner, Rodney Director of Pharmacy VCU Health System 8048285468	10/16/2017 11:01 AM
Contacts	Authorizing Official	Update		Wesolowski, Paul Chief Operating Officer 8048284607	Wesolowski, Paul Chief Operating Officer VCU Health System 8048284607	10/11/2017 3:17 PM
Contacts	Primary Contact	Update		Stiltner, Rodney Director of Pharmacy 8048285468	Stiltner, Rodney Director of Pharmacy VCU Health Sytem 8048285468	10/9/2017 4:20 PM
Contacts	Authorizing Official	Insert			Wesolowski, Paul Chief Operating Officer 8048284607	8/3/2017 12:53 PM
Contacts	Primary Contact	Insert			Stiltner, Rodney Director of Pharmacy 8048285468	8/3/2017 12:53 PM
Contacts	Signed By	Insert			Wesolowski, Paul Vice President, Professional Services 8048284684	8/3/2017 7:11 AM
Addresses	Main Address	Insert			1300 E Marshall St 5th Floor Richmond, VA 23298	8/3/2017 7:11 AM
Addresses	Shipping Address	Insert			VCU Health System 403 N 13th St Room B-328 Richmond, VA 23298	8/3/2017 7:11 AM
Dates	Last Date That 340B Drugs Purchased	Update			12/1/2016 12:00:00 AM	3/3/2017 7:07 AM
Details	State	Update		Active	Terminated	3/3/2017 7:07 AM
Terminations	Termination Comments	Update			Clinic closed for renovations.	3/3/2017 7:07 AM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	3/3/2017 7:07 AM
Terminations	Termination Effective Date	Update			12/1/2016 12:00:00 AM	3/3/2017 7:07 AM
Terminations	Termination Reason	Update			Site closure	3/3/2017 7:07 AM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 10:05 AM
Dates	Participating Approval Date	Update			7/16/2015 12:00:00 AM	7/16/2015 10:05 AM
Details	State	Update		Pending	Active	7/16/2015 10:05 AM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/16/2015 10:05 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_52450	DSH490032CM	7/14/2015 11:59 AM
Details	Entity Subname	Update		VCU Health System Inflammatory Bowel Disease Clinic - N5DH	Inflammatory Bowel Disease Clinic - N5DH	7/14/2015 11:59 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_52450	7/7/2015 5:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/7/2015 5:01 PM
Medicaid Billing	Medicaid: Number	Insert			8506744	7/7/2015 5:01 PM
Medicaid Billing	Medicaid: State	Insert			VA	7/7/2015 5:01 PM
Medicaid Billing	NPI: Number	Insert			1437175734	7/7/2015 5:01 PM
Details	Last Recertification Date	Insert				7/7/2015 5:01 PM
Details	Grant Number	Insert				7/7/2015 5:01 PM
Details	340B ID	Insert				7/7/2015 5:01 PM
Details	Is Authorizing Official EHB Data	Insert				7/7/2015 5:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/7/2015 5:01 PM
Details	Medicare Provider Number	Insert			490032	7/7/2015 5:01 PM
Details	Entity Name	Insert			VCU HEALTH SYSTEM MCV HOSPITAL	7/7/2015 5:01 PM
Details	Program Code	Insert			DSH	7/7/2015 5:01 PM
Details	Entity Subname	Insert			VCU Health System Inflammatory Bowel Disease Clinic - N5DH	7/7/2015 5:01 PM
Dates	Participating Approval Date	Insert				7/7/2015 5:01 PM
Details	State	Insert			Pending	7/7/2015 5:01 PM
Dates	Registration Date	Insert			7/7/2015 12:00:00 AM	7/7/2015 5:01 PM
Dates	Signed By Date	Insert			7/7/2015 12:00:00 AM	7/7/2015 5:01 PM
Dates	Start Date	Insert				7/7/2015 5:01 PM
Terminations	Termination Comments	Insert				7/7/2015 5:01 PM
Terminations	Termination Date	Insert				7/7/2015 5:01 PM
Terminations	Termination Effective Date	Insert				7/7/2015 5:01 PM
Terminations	Termination Reason	Insert				7/7/2015 5:01 PM