| Addresses | Billing Address | Update | Group Change Request | Dignity Health AP
3400 Data Drive
Rancho Cordova, CA 95670 | UCSF HEALTH - ST. MARY'S HOSPITAL
1500 Owens Street, Ste. 460
San Francisco, CA 94158 | 4/7/2025 4:34 PM |
| Details | Entity Name | Update | Change Request | ST. MARY'S MEDICAL CENTER | UCSF HEALTH - ST. MARY'S HOSPITAL | 1/22/2025 11:41 AM |
| Contacts | Primary Contact | Update | Group Change Request | Pearcy, Ryan
340B Region Manager
CommonSpirit Health
8592295654 | Hahn, Raechel
340B Analyst
UCSF Medical Center
5107367335 | 1/16/2025 6:52 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Bennan, James
COO Community Hospital Division
UCSF Medical Center
4155038667 | Bennan, James
COO Community Hospital Division
UCSF Health
4155038667 | 1/14/2025 8:42 AM |
| Contacts | Authorizing Official | Update | Change Request | Brown Sims, Kim
VP, CNE
UCSF Health
4153536600 | Bennan, James
COO Community Hospital Division
UCSF Medical Center
4155038667 | 1/14/2025 8:14 AM |
| Contacts | Authorizing Official | Update | Change Request | Brown Sims, Kim
VP, Chief Nurse Executive Officer
Saint Francis Memorial Hospital
4153536600 | Brown Sims, Kim
VP, CNE
UCSF Health
4153536600 | 1/8/2025 6:58 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2023 7:10:56 PM | 8/19/2024 12:07:51 PM | 8/19/2024 12:07 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Pearcy, Ryan
340B Division Manager
CommonSpirit Health
8592295654 | Pearcy, Ryan
340B Region Manager
CommonSpirit Health
8592295654 | 8/6/2024 9:42 AM |
| Addresses | Shipping Address | Insert | Change Request | | ST. MARY'S MEDICAL CENTER
450 Stanyan Street
San Francisco, CA 94117 | 1/8/2024 7:05 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Brown Sims, Kim
VP, Chief Nurse Executive Officer
Saint Francis Memorial Hospital
5305740430 | Brown Sims, Kim
VP, Chief Nurse Executive Officer
Saint Francis Memorial Hospital
4153536600 | 1/4/2024 4:12 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/17/2023 7:10 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | PHA457910 | 8/17/2023 7:10 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CA | 8/17/2023 7:10 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2022 1:00:46 PM | 8/17/2023 7:10:56 PM | 8/17/2023 7:10 PM |
| Contacts | Primary Contact | Update | Change Request | Nguyen, Minh Thu
Director of Pharmacy
St. Mary's Medical Center
4157504988 | Pearcy, Ryan
340B Division Manager
CommonSpirit Health
8592295654 | 9/21/2022 12:57 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2021 11:36:32 AM | 8/26/2022 1:00:46 PM | 8/26/2022 1:00 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2020 7:11:18 PM | 9/10/2021 11:36:32 AM | 9/10/2021 11:36 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Kelly, Kecia
COO/CNO
Dignity Health Saint Francis Memorial Hospital
4153536173 | Brown Sims, Kim
VP, Chief Nurse Executive Officer
Saint Francis Memorial Hospital
5305740430 | 9/8/2021 8:07 AM |
| Contacts | Authorizing Official | Update | Change Request | Ambrose, Sherie
Vice President/ Chief Nurse Executive/ COO
St. Mary's Dignity Health
4157505716 | Kelly, Kecia
COO/CNO
Dignity Health Saint Francis Memorial Hospital
4153536173 | 10/30/2020 12:24 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1104198670 ( ) | | 9/8/2020 7:11 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1174667158 | 9/8/2020 7:11 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/8/2020 7:11 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2019 4:22:56 PM | 9/8/2020 7:11:18 PM | 9/8/2020 7:11 PM |
| Addresses | Billing Address | Update | Change Request | St. Mary's Medical Center
450 Stanyan Street
San Francisco, CA 94117 | Dignity Health AP
3400 Data Drive
Rancho Cordova, CA 95670 | 3/3/2020 12:20 PM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2018 5:36:33 PM | 9/11/2019 4:22:56 PM | 9/11/2019 4:22 PM |
| Contacts | Authorizing Official | Update | Change Request | Allen, John
President & CEO
St. Mary's Medical Center
4157504855 | Ambrose, Sherie
Vice President/ Chief Nurse Executive/ COO
St. Mary's Dignity Health
4157505716 | 7/5/2019 7:29 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Allen, John
CFO
St. Mary's Medical Center
4157504855 | Allen, John
President & CEO
St. Mary's Medical Center
4157504855 | 9/6/2018 5:38 PM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 5:39:20 PM | 9/6/2018 5:36:33 PM | 9/6/2018 5:36 PM |
| Details | Last Recertification Date | Update | Recertification | 9/4/2016 12:00:00 AM | 11/3/2017 5:39:20 PM | 11/3/2017 5:39 PM |
| Contacts | Authorizing Official | Update | Change Request | Allen, John
CFO
4157504855 | Allen, John
CFO
St. Mary's Medical Center
4157504855 | 9/29/2017 6:50 PM |
| Contacts | Primary Contact | Update | | Nguyen, Minh Thu
Director of Pharmacy
4157504988 | Nguyen, Minh Thu
Director of Pharmacy
St. Mary's Medical Center
4157504988 | 9/27/2017 1:33 PM |
| Contacts | Authorizing Official | Insert | | | Allen, John
CFO
4157504855 | 6/15/2017 11:14 AM |
| Addresses | Main Address | Insert | | |
2250 Hayes Street
San Francisco, CA 94117 | 2/15/2017 2:15 PM |
| Addresses | Billing Address | Insert | | | St. Mary's Medical Center
450 Stanyan Street
San Francisco, CA 94117 | 2/15/2017 2:15 PM |
| Contacts | Signed By | Insert | | | BRETTNER, ERIC
CFO
4157505726 | 2/15/2017 2:15 PM |
| Contacts | Primary Contact | Insert | | | Nguyen, Minh Thu
Director of Pharmacy
4157504988 | 2/15/2017 2:15 PM |
| Details | Last Recertification Date | Update | | | 9/4/2016 12:00:00 AM | 9/4/2016 1:18 PM |
| Dates | Participating Approval Date | Update | | | 8/11/2015 12:00:00 AM | 8/11/2015 12:12 PM |
| Details | State | Update | | Pending | Active | 8/11/2015 12:12 PM |
| Dates | Start Date | Update | | | 10/1/2015 12:00:00 AM | 8/11/2015 12:12 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_53171 | DSH050457E | 8/11/2015 10:45 AM |
| Details | Entity Subname | Update | | Cancer/Oncology Clinic / Cancer/Oncology Clinic | Cancer / Oncology Clinic | 8/11/2015 10:45 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_53171 | 7/12/2015 11:38 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1104198670 | 7/12/2015 11:38 PM |
| Details | Last Recertification Date | Insert | | | | 7/12/2015 11:38 PM |
| Details | Grant Number | Insert | | | | 7/12/2015 11:38 PM |
| Details | 340B ID | Insert | | | | 7/12/2015 11:38 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/12/2015 11:38 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/12/2015 11:38 PM |
| Details | Medicare Provider Number | Insert | | | 050457 | 7/12/2015 11:38 PM |
| Details | Entity Name | Insert | | | ST. MARY'S MEDICAL CENTER | 7/12/2015 11:38 PM |
| Details | Program Code | Insert | | | DSH | 7/12/2015 11:38 PM |
| Details | Entity Subname | Insert | | | Cancer/Oncology Clinic / Cancer/Oncology Clinic | 7/12/2015 11:38 PM |
| Dates | Participating Approval Date | Insert | | | | 7/12/2015 11:38 PM |
| Details | State | Insert | | | Pending | 7/12/2015 11:38 PM |
| Dates | Registration Date | Insert | | | 7/12/2015 12:00:00 AM | 7/12/2015 11:38 PM |
| Dates | Signed By Date | Insert | | | 7/12/2015 12:00:00 AM | 7/12/2015 11:38 PM |
| Dates | Start Date | Insert | | | | 7/12/2015 11:38 PM |
| Terminations | Termination Comments | Insert | | | | 7/12/2015 11:38 PM |
| Terminations | Termination Date | Insert | | | | 7/12/2015 11:38 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/12/2015 11:38 PM |
| Terminations | Termination Reason | Insert | | | | 7/12/2015 11:38 PM |