Covered Entity Details

PED033302-66 PHOENIX CHILDREN'S HOSPITAL (Terminated) - information as of 4/23/2025 10:54:25 PM

Main Details

Name

PHOENIX CHILDREN'S HOSPITAL

Subdivision Name

Phoenix Children's Hospital Hemodialysis

Type

Children's Hospital

Rural

340B ID

PED033302-66

Medicare Provider Number

033302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/10/2015

Participating Start Date

10/1/2015

Participating Approval Date

8/25/2015

Last Recertification Date

11/7/2017

Termination Date
Termination Reason

10/1/2018
Other

Contacts

Authorizing Official

Phoenix Children's Hospital
Kari Cornicelli, Executive Vice President and Chief Financial Officer
(602) 933-5468

Primary Contact

Phoenix Children's Hospital
Yolanda Douthard, Chief of Pharmacy Services
(602) 933-1891

Addresses

Street Address

1920 East Cambridge Avenue
Suite 102
Phoenix, AZ 85006

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?
No

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
PED033302-01	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Surgery Center	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-03	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PHOENIX CHILDREN'S SPECIALTY CARE CENTER SCOTTSDALE - URGENT CARE	6990 E. Shea. Blvd.	SCOTTSDALE	AZ	Terminated
PED033302-06	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Dermatology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-07	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Endocrinology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-08	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Gastroenterology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-09	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Hematology and Oncology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-10	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Nephrology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-100	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pulmonology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-101	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Tucson - Dermatology	5983 E. Grant Road	Tucson	AZ	Terminated
PED033302-102	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-103	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Plastic Surgery	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-104	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-105	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurology	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-106	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Developmental Pediatrics - Developmental Pediatrics	18555 N. 79th Avenue	Glendale	AZ	Terminated
PED033302-107	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Dermatology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-108	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Genetics	3420 Mercy Road	Gilbert	AZ	Active
PED033302-109	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pain Clinic	3420 Mercy Road	Gilbert	AZ	Active
PED033302-11	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Neurology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-110	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Cottonwood	800 Cove Parkway	Cottonwood	AZ	Terminated
PED033302-111	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - San Tan Village	1790 E Boston Street	Gilbert	AZ	Terminated
PED033302-112	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Urology	6524 W SACK DR	Glendale	AZ	Active
PED033302-113	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Nephrology	6524 W SACK DR	Glendale	AZ	Active
PED033302-114	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-115	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Allergy & Immunology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-116	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Cardiology	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-117	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neuropsychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-118	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Rheumatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-119	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Endocrinology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-12	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Orthopedics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-120	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Genetics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-121	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Pain Medicine	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-122	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Northwest Valley Specialty Care Center - Neurosurgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-123	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Plastic Surgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-124	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Casa Grande	1828 E Florence Boulevard, Building C	Casa Grande	AZ	Terminated
PED033302-125	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Radiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-126	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Genetics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-127	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Developmental Pediatrics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-128	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pediatric Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-129	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pain Management	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-13	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychiatry	3370 Mercy Road	Gilbert	AZ	Active
PED033302-130	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Neurosurgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-131	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Plastic Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-132	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pediatric Surgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-133	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Douglas	815 15th Street	Douglas	AZ	Terminated
PED033302-134	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Plastic Surgery	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-135	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Developmental Pediatrics	6524 W SACK DR	Glendale	AZ	Active
PED033302-136	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Genetics	6524 W SACK DR	Glendale	AZ	Active
PED033302-137	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurosurgery	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-138	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Plastic Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-139	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Neurosurgery	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-14	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - NeuroPsychology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-140	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Developmental Pediatrics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-141	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Pediatric Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-142	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Safford	2115 W 16th Street	Safford	AZ	Terminated
PED033302-143	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Plastic Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-144	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Sierra Vista	155 Calle Portal	Sierra Vista	AZ	Terminated
PED033302-145	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-146	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Orthopedics	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-147	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Ambulatory - Nephrology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-148	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurosurgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-149	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Cardiology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-15	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Pulmonology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-150	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-151	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Otolaryngology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-152	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Gastroenterology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-153	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ortho Radiology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-154	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric & Adolescent Gynecology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-155	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Developmental Pediatrics	3370 Mercy Road	Gilbert	AZ	Active
PED033302-156	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Gilbert	2550 E Guadalupe Road	Gilbert	AZ	Terminated
PED033302-157	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Chandler	60 S Kyrene Road	Chandler	AZ	Terminated
PED033302-158	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Tempe	6301 S McClintock Drive	Tempe	AZ	Terminated
PED033302-159	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - San Tan	3592 S Atherton Blvd	Gilbert	AZ	Terminated
PED033302-16	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Radiology and Imaging	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-160	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Behavioral Health	3370 Mercy Road	Gilbert	AZ	Active
PED033302-161	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Psychology	6990 E Shea Blvd	Scottssdale	AZ	Active
PED033302-162	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Allergy & Immunology	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-163	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital - Ambulatory Physical Medicine Clinic	1919 E. Thomas Rd	Phoenix	AZ	Active
PED033302-164	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pulmonology - Pulmonology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-165	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Hand Surgery - Hand Surgery	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-166	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Developmental Pediatrics - Developmental Pediatrics	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-167	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Physical Medicine & Rehabilitation - Physical Medicine & Rehabilitation	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-168	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - GI Surgery - GI Surgery	5131 E Southern Ave	Mesa	AZ	Active
PED033302-169	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - GI Surgery - GI Surgery	6990 E Shea Blvd	Scottsdale	AZ	Active
PED033302-17	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Rheumatology	5131 E Southern Ave	Mesa	AZ	Active
PED033302-170	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Emergency Department - Avondale Campus - Emergency Department	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-18	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Urgent Care	5131 E Southern Ave	Mesa	AZ	Terminated
PED033302-19	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Endocrinology	6524 W SACK DR	Glendale	AZ	Active
PED033302-20	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Gastroenterology	6524 W SACK DR	Glendale	AZ	Active
PED033302-21	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Neurology	6524 W SACK DR	Glendale	AZ	Active
PED033302-22	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Orthopedics	6524 W SACK DR	Glendale	AZ	Active
PED033302-23	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pulmonology	6524 W SACK DR	Glendale	AZ	Active
PED033302-24	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Urgent Care	20325 N 51st Avenue	Glendale	AZ	Terminated
PED033302-25	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Center - Scottsdale Cardiology	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-26	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Endocrinology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-27	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Gastroenterology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-28	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Nephrology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-29	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-30	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Orthopedics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-31	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Pulmonology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-32	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Urgent Care	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-33	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Urology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-34	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - General Pediatrics	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-35	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Gynecology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-36	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Hematology/Oncology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-37	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Nephrology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-38	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg - Radiology & Imaging	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-39	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Rheumatology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-40	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Urology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-41	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Hemodialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-42	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Dermatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-43	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Endocrinology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-44	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Gastroenterology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-45	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – General Pediatrics	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-46	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center – Hematology & Oncology Clinic	6524 W SACK DR	Glendale	AZ	Active
PED033302-47	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neuropsychology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-48	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neurology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-49	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Orthopedics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-50	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Urgent Care	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-51	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Psychiatry	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-52	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Pulmonology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-53	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Neurology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-54	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Audiology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-55	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurosurgery	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-56	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychiatry	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-57	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-58	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-59	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Ambulatory Surgery Center	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-60	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PCMG Radiology	1920 E. Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-61	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Urology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-62	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Rehabilitation	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-63	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Nephrology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-64	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg - Infusion Center	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-65	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Peritoneal Dialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-66	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Hemodialysis	1920 East Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-67	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Genetics and Metabolism	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-68	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Diagnostic Radiology	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-69	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Respiratory Therapy	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-70	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Neurosurgery	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-71	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurosurgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-72	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – UMOM New Day Center	3333 E Van Buren Street	Phoenix	AZ	Terminated
PED033302-73	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Cardiology - Scottsdale	10250 N 92nd Street	Scottsdale	AZ	Active
PED033302-74	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Crews'n Healthmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-75	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – Children’s First Leadership Academy	1648 S 16th Street	Phoenix	AZ	Terminated
PED033302-76	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Breathmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-77	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Cardiology	18555 N 79th Avenue	Glendale	AZ	Active
PED033302-78	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Heart Center - East Valley	3420 South Mercy Road	Gilbert	AZ	Terminated
PED033302-79	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Endocrinology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-80	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Scottsdale	5425 E Bell Road	Scottsdale	AZ	Terminated
PED033302-81	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Infusion Center	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-82	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center - CCBD and Infusion Center	6524 W SACK DR	Glendale	AZ	Active
PED033302-83	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Allergy & Immunology	1920 E Cambridge Ave	Phoenix	AZ	Terminated
PED033302-84	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Phoenix Dream Center	3210 NW Grand Avenue	Phoenix	AZ	Terminated
PED033302-85	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Gilbert - Cardiology	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-86	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Cardiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-87	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ophthalmology	3370 S Mercy Road	Glbert	AZ	Terminated
PED033302-88	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-89	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Glendale	6320 W Union Hills Drive	Glendale	AZ	Terminated
PED033302-90	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Scottsdale	20201 N Scottsdale Healthcare Drive	Scottsdale	AZ	Terminated
PED033302-91	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Arizona Pediatric Eye Specialists - Shea	4530 East Shea Blvd.	Phoenix	AZ	Terminated
PED033302-92	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Ophthalmology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-93	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Phoenix	9250 W Thomas Rd	Phoenix	AZ	Terminated
PED033302-94	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics – North Phoenix	3805 E Bell Road	Phoenix	AZ	Terminated
PED033302-95	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics - Dobson Village	205 S Dobson Road	Chandler	AZ	Terminated
PED033302-96	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Speciality Care ENT/Otolaryngology - Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-97	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - ENT/Otolaryngology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-98	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care ENT/Otolarngology - West Phoenix	9250 W Thomas Road	Phoenix	AZ	Terminated
PED033302-99	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Urology	3370 S Mercy Road	Gilbert	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	Higginson, David A COO Phoenix Childrens Hospital 4803995046	Cornicelli, Kari Executive Vice President and Chief Financial Officer Phoenix Children's Hospital 6029335468	9/5/2019 1:23 PM
Contacts	Primary Contact	Update	Change Request	Douthard, Yolanda CHIEF OF PHARMACY Phoenix Children's Hospital 6029331891	Douthard, Yolanda Chief of Pharmacy Services Phoenix Children's Hospital 6029331891	4/23/2019 11:42 PM
Contacts	Authorizing Official	Update	AO Change Request	Myers, Douglas T CFO Phoenix Childrens 6029331393	Higginson, David A COO Phoenix Childrens Hospital 4803995046	1/29/2019 10:46 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/3/2018 12:00:00 AM	7/3/2018 12:56 PM
Details	State	Update	Termination Request	Active	To Be Terminated	7/3/2018 12:56 PM
Terminations	Termination Date	Update	Termination Request		10/1/2018 12:00:00 AM	7/3/2018 12:56 PM
Terminations	Termination Effective Date	Update	Termination Request		7/3/2018 12:00:00 AM	7/3/2018 12:56 PM
Terminations	Termination Reason	Update	Termination Request		Other	7/3/2018 12:56 PM
Contacts	Authorizing Official	Update	AO Change Request	MCKNIGHT, CRAIG CFO Phoenix Childrens Hospital 6025465468	Myers, Douglas T CFO Phoenix Childrens 6029331393	12/13/2017 1:19 PM
Details	Entity Name	Update	Recertification	PHOENIX CHILDRENS HOSPITAL	PHOENIX CHILDREN'S HOSPITAL	11/8/2017 2:14 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/7/2017 5:27:12 PM	11/7/2017 5:27 PM
Contacts	Authorizing Official	Update		MCKNIGHT, CRAIG CFO 6025465468	MCKNIGHT, CRAIG CFO Phoenix Childrens Hospital 6025465468	11/7/2017 5:11 PM
Contacts	Signed By	Update		MCKNIGHT, CRAIG CFO 6025465468	MCKNIGHT, CRAIG CFO Phoenix Childrens Hospital 6025465468	11/7/2017 5:11 PM
Contacts	Primary Contact	Update		Douthard, Yolanda CHIEF OF PHARMACY 6029331891	Douthard, Yolanda CHIEF OF PHARMACY Phoenix Children's Hospital 6029331891	10/15/2017 7:00 PM
Contacts	Authorizing Official	Insert			MCKNIGHT, CRAIG CFO 6025465468	8/14/2017 1:35 PM
Contacts	Signed By	Insert			MCKNIGHT, CRAIG CFO 6025465468	8/14/2017 1:35 PM
Contacts	Primary Contact	Insert			Douthard, Yolanda CHIEF OF PHARMACY 6029331891	8/14/2017 1:35 PM
Addresses	Main Address	Insert			1920 East Cambridge Avenue Suite 102 Phoenix, AZ 85006	7/26/2017 11:48 AM
Details	Last Recertification Date	Update			8/17/2016 12:00:00 AM	8/17/2016 6:26 PM
Dates	Participating Approval Date	Update			8/25/2015 12:00:00 AM	8/25/2015 3:51 PM
Details	State	Update		Pending	Active	8/25/2015 3:51 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	8/25/2015 3:51 PM
Details	Entity Subname	Update		Phoenix Children's Hospital Hemodialysis / Hemodialysis	Phoenix Children's Hospital Hemodialysis	7/22/2015 9:40 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53021	PED033302-66	7/22/2015 8:45 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53021	7/10/2015 1:13 PM
Details	Last Recertification Date	Insert				7/10/2015 1:13 PM
Details	Grant Number	Insert				7/10/2015 1:13 PM
Details	340B ID	Insert				7/10/2015 1:13 PM
Details	Is Authorizing Official EHB Data	Insert				7/10/2015 1:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/10/2015 1:13 PM
Details	Medicare Provider Number	Insert			033302	7/10/2015 1:13 PM
Details	Entity Name	Insert			PHOENIX CHILDRENS HOSPITAL	7/10/2015 1:13 PM
Details	Program Code	Insert			PED	7/10/2015 1:13 PM
Details	Entity Subname	Insert			Phoenix Children's Hospital Hemodialysis / Hemodialysis	7/10/2015 1:13 PM
Dates	Participating Approval Date	Insert				7/10/2015 1:13 PM
Details	State	Insert			Pending	7/10/2015 1:13 PM
Dates	Registration Date	Insert			7/10/2015 12:00:00 AM	7/10/2015 1:13 PM
Dates	Signed By Date	Insert			7/10/2015 12:00:00 AM	7/10/2015 1:13 PM
Dates	Start Date	Insert				7/10/2015 1:13 PM
Terminations	Termination Comments	Insert				7/10/2015 1:13 PM
Terminations	Termination Date	Insert				7/10/2015 1:13 PM
Terminations	Termination Effective Date	Insert				7/10/2015 1:13 PM
Terminations	Termination Reason	Insert				7/10/2015 1:13 PM