Covered Entity Details

DSH030002R Banner – University Medical Center Phoenix (Active) - information as of 4/27/2025 1:51:09 AM

Main Details

Name

Banner – University Medical Center Phoenix

Subdivision Name

Endocrinology Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030002R

Medicare Provider Number

030002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/22/2015

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Banner University Medical Center Phoenix
Cody W Ziemer, Chief Financial Officer
(602) 839-8507

Primary Contact

Banner University Medical Center Phoenix
Jeff Anderson, Director, Pharmacy Academic
(602) 839-2657

Addresses

Street Address

1441 N 12th St
2nd Floor
Phoenix, AZ 85006

Billing Address

Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062

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
AZ	086497,529985	1841224870,1437529245

Shipping Addresses

Shipping Address 1

Banner University Medical Center Phoenix
1111 E McDowell Rd
Phoenix, AZ 85006

Shipping Address 2

Banner University Medical Center Endocrinology Clinic
1441 N 12th St
2nd Floor
Phoenix, AZ 85006

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
DSH030002AA	Child	DSH	Banner – University Medical Center Phoenix	Musculoskeletal - Musculoskeletal - OSI	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002AB	Child	DSH	Banner – University Medical Center Phoenix	C/P-Sexual Health-Clinic - C/P-Sexual Health-Clinic - Women's Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002AC	Child	DSH	Banner – University Medical Center Phoenix	C/P ORTHO SPORTS MEDICINE - CLINI - C/P ORTHO SPORTS MEDICINE - CLINI - OSI	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002AD	Child	DSH	Banner – University Medical Center Phoenix	C/P-Endocrine Surgery-Clinic - C/P-Endocrine Surgery-Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002AE	Child	DSH	Banner – University Medical Center Phoenix	C/P-Adult Recon/Musculosk Onco - C/P-Adult Recon/Musculosk Onco - OSI	755 E McDowell Rd, Second Floor	PHOENIX	AZ	Terminated
DSH030002AF	Child	DSH	Banner – University Medical Center Phoenix	Multiple Sclerosis (MS)-Clinic - Multiple Sclerosis (MS)-Clinic - Neurology	755 E McDowell Rd , Third Floor , Phoenix AZ 85006	PHOENIX	AZ	Terminated
DSH030002AG	Child	DSH	Banner – University Medical Center Phoenix	C/P-Min Invasive Gynecol Surg - C/P-Min Invasive Gynecol Surg - Women's Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002AH	Child	DSH	Banner – University Medical Center Phoenix	C/P-BUMCP Medical Oncology-Hosp	925 E McDowell Rd	Phoenix	AZ	Active
DSH030002AJ	Child	DSH	Banner – University Medical Center Phoenix	C/P Spine Health-Clinic - C/P Spine Health Clinic - OSI	755 E McDowell Rd	Phoenix	AZ	Terminated
DSH030002AK	Child	DSH	Banner – University Medical Center Phoenix	C/P-Musculoskeletal Trauma - C/P-Musculoskeletal Trauma - OSI	755 E McDowell Rd, Second Floor	PHOENIX	AZ	Terminated
DSH030002AL	Child	DSH	Banner – University Medical Center Phoenix	Rheumatology - Rheumatology	1441 N 12th St	Phoenix	AZ	Active
DSH030002AM	Child	DSH	Banner – University Medical Center Phoenix	Digestive Health - Digestive Health	1441 N 12th St	Phoenix	AZ	Active
DSH030002AN	Child	DSH	Banner – University Medical Center Phoenix	C/P-Hand and Upper-Clinic - C/P-Hand and Upper-Clinic-OSI	755 E McDowell Rd, Second Floor	Phoenix	AZ	Terminated
DSH030002AP	Child	DSH	Banner – University Medical Center Phoenix	BUMCP SAFA Wound Plastics - Wound Plastics	1111 E McDowell Rd	Phoenix	AZ	Active
DSH030002AQ	Child	DSH	Banner – University Medical Center Phoenix	Clinic - C/P-Pre-Liver Transplant-Clnc	1441 N 12th St	Phoenix	AZ	Active
DSH030002AR	Child	DSH	Banner – University Medical Center Phoenix	CLINIC - C/P-Post-Liver Transplant-Cln	1441 N 12th St	Phoenix	AZ	Active
DSH030002AS	Child	DSH	Banner – University Medical Center Phoenix	CLINIC - C/P-Neurosurgery-Clinic	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002AT	Child	DSH	Banner – University Medical Center Phoenix	CLINIC - C/P-Pre-Kidney Transplant-Cln	1441 N 12th St	Phoenix	AZ	Active
DSH030002AU	Child	DSH	Banner – University Medical Center Phoenix	CLINIC - C/P-Post-Kidney Transplant-Cln	1441 N 12th St	Phoenix	AZ	Active
DSH030002AV	Child	DSH	Banner – University Medical Center Phoenix	CLINIC - Colorectal Surgery-Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002AW	Child	DSH	Banner – University Medical Center Phoenix	AMB CARE - OP - Amb Care-Clinic	925 E McDowell Rd	Phoenix	AZ	Active
DSH030002AX	Child	DSH	Banner – University Medical Center Phoenix	Banner MD Anderson Cancer Center - Radiation Oncology - Radiation Oncology	925 E McDowell Rd	Phoenix	AZ	Active
DSH030002AY	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Breast Ctr-Hospital	925 E McDowell Rd	Phoenix	AZ	Active
DSH030002AZ	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - MD Anderson Cancer Center - PET Scanning	925 E MCDOWELL RD	PHOENIX	AZ	Active
DSH030002B	Child	DSH	Banner – University Medical Center Phoenix	OMFS Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002BA	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Internal Medicine - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BB	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Gastroenterology - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BC	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Bariatric Medicine - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BD	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Rheumatology - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Terminated
DSH030002BE	Child	DSH	Banner – University Medical Center Phoenix	Banner MD Anderson Cancer Center - Support Services - Banner MD Anderson Cancer Center - Support Services	925 E McDowell Rd	Phoenix	AZ	Active
DSH030002BF	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Bariatric Surgery - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BG	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Orthopedic Surgery - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BH	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Neurology - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BJ	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Neurosurgery - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BK	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Orthopedic Primary Care - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BL	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Pulmonology - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BM	Child	DSH	Banner – University Medical Center Phoenix	Banner - University Medical Center - Cardiology - Arcadia	4200 E Camelback Rd	Phoenix	AZ	Active
DSH030002BN	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - General Surgery - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BP	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Family Medicine - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BQ	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Womens Services - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BR	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Orthopedic and Sports Medicine - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BS	Child	DSH	Banner – University Medical Center Phoenix	Sports Medicine - Sports Medicine	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002BT	Child	DSH	Banner – University Medical Center Phoenix	Sleep Disorders Ctr - Sleep Disorders Ctr	755 Annex E. McDowell Rd.	Phoenix	AZ	Active
DSH030002BU	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Endocrinology - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002BV	Child	DSH	Banner – University Medical Center Phoenix	BANNER - UNIVERSITY MEDICAL CENTER - Colorectal Surgery - Arcadia	4200 E CAMELBACK RD	PHOENIX	AZ	Active
DSH030002C	Child	DSH	Banner – University Medical Center Phoenix	C/P-Urology-Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002D	Child	DSH	Banner – University Medical Center Phoenix	Rehab Physician Clinical Services/PMR	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002E	Child	DSH	Banner – University Medical Center Phoenix	Sam Beh Hlth Ctr-Clinic	1300 N 12th St	Phoenix	AZ	Active
DSH030002F	Child	DSH	Banner – University Medical Center Phoenix	Women's Health Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002G	Child	DSH	Banner – University Medical Center Phoenix	Banner Health Clinic - ENT	1441 N 12th St. 2nd Floor	Phoenix	AZ	Terminated
DSH030002H	Child	DSH	Banner – University Medical Center Phoenix	Family Practice Center	1300 N 12th St	Phoenix	AZ	Active
DSH030002J	Child	DSH	Banner – University Medical Center Phoenix	Internal Medicine	1300 N 12th St	Phoenix	AZ	Active
DSH030002K	Child	DSH	Banner – University Medical Center Phoenix	Liver Disease Center-Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002L	Child	DSH	Banner – University Medical Center Phoenix	Phoenix Integrated Surgical Residency Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002M	Child	DSH	Banner – University Medical Center Phoenix	Trauma Physician Clinical Services	1111 E McDowell Rd	Phoenix	AZ	Active
DSH030002N	Child	DSH	Banner – University Medical Center Phoenix	Toxicology Clinic	1441 12th St 2nd Floor	PHOENIX	AZ	Terminated
DSH030002P	Child	DSH	Banner – University Medical Center Phoenix	C/P-Neurology-Clinic	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002Q	Child	DSH	Banner – University Medical Center Phoenix	Neuro-Psych Clinic	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002R	Child	DSH	Banner – University Medical Center Phoenix	Endocrinology Clinic	1441 N 12th St	Phoenix	AZ	Active
DSH030002S	Child	DSH	Banner – University Medical Center Phoenix	BUMCP Infectious Disease	1441 N 12th St	Phoenix	AZ	Active
DSH030002T	Child	DSH	Banner – University Medical Center Phoenix	General Neurology	755 E McDowell Rd	Phoenix	AZ	Terminated
DSH030002U	Child	DSH	Banner – University Medical Center Phoenix	Neuro / Epilepsy Clinic	755 E McDowell Rd	Phoenix	AZ	Terminated
DSH030002V	Child	DSH	Banner – University Medical Center Phoenix	BUMCP Cavanagh Cardiovascular	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002W	Child	DSH	Banner – University Medical Center Phoenix	BUMCP Advanced Lung Disease	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002X	Child	DSH	Banner – University Medical Center Phoenix	Headache Clinic - Headache Clinic	755 East McDowell Road	Phoenix	AZ	Terminated
DSH030002Y	Child	DSH	Banner – University Medical Center Phoenix	Sleep Clinic - Sleep Clinic	755 E McDowell Rd	Phoenix	AZ	Active
DSH030002Z	Child	DSH	Banner – University Medical Center Phoenix	C/P-Bariatric Surgery-Clinic - C/P-Bariatric Surgery-Clinic	1441 N 12th St	Phoenix	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	Gernhart, Diana L Chief Financial Officer Banner University Medical Center Phoenix 6028398507	Ziemer, Cody W Chief Financial Officer Banner University Medical Center Phoenix 6028398507	4/3/2025 9:02 AM
Details	Last Recertification Date	Update	Recertification	8/22/2023 1:25:36 PM	8/12/2024 11:45:15 AM	8/12/2024 11:45 AM
Addresses	Shipping Address	Delete	Recertification	Banner University Medical Center Endocrinology Clinic 1441 12th St Suite 2 Second Floor Phoenix, AZ 85006		8/22/2023 1:25 PM
Addresses	Shipping Address	Insert	Recertification		Banner University Medical Center Endocrinology Clinic 1441 N 12th St 2nd Floor Phoenix, AZ 85006	8/22/2023 1:25 PM
Addresses	Main Address	Update	Recertification	1441 12th St Suite 2 2nd Floor PHOENIX, AZ 85006-2850	1441 N 12th St 2nd Floor Phoenix, AZ 85006	8/22/2023 1:25 PM
Details	Last Recertification Date	Update	Recertification	9/1/2022 10:06:06 AM	8/22/2023 1:25:36 PM	8/22/2023 1:25 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841224870 (CO)		3/21/2023 9:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841224870 (NE)		3/21/2023 9:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841224870 (CA)		3/21/2023 9:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1437529245 (CO)		3/21/2023 9:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1437529245 (NE)		3/21/2023 9:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1437529245 (CA)		3/21/2023 9:47 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	166977 (CA)		3/15/2023 11:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/15/2023 11:35 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		086497	3/15/2023 11:35 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AZ	3/15/2023 11:35 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1841224870 (CA)		3/15/2023 11:35 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04577256 (CO)		3/15/2023 11:35 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10025141001 (NE)		3/15/2023 11:35 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Endocrinology Clinic 1441 12th St Suite 2 Second Floor Phoenix, AZ 85006	12/14/2022 8:40 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 11:10:45 AM	9/1/2022 10:06:06 AM	9/1/2022 10:06 AM
Contacts	Authorizing Official	Update	Change Request	Scherpf, John W. Chief Operating Officer Banner University Medical Center Phoenix 6028398504	Gernhart, Diana L Chief Financial Officer Banner University Medical Center Phoenix 6028398507	12/27/2021 8:40 AM
Addresses	Shipping Address	Delete	Group Change Request	Banner Health 7300 W. Detroit St. Chandler, AZ 85226		9/3/2021 1:45 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 10:37:12 AM	8/16/2021 11:10:45 AM	8/16/2021 11:10 AM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Phoenix 1111 E McDowell Rd Phoenix, AZ 85006	Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	5/7/2021 6:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (ID)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	270036499001 (IL)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (SC)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (WI)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00323681 (NC)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (MI)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (MN)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (VA)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	901449700 (FL)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	618348897A (GA)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1702668 (LA)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (MT)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	A0907 (NM)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2284077 (OH)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100690420A (OK)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	244196 (OR)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	071472701 (TX)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	270036499001 (UT)		1/8/2021 5:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3024858 (WA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (NC)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (TX)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (OK)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (LA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (MT)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (ID)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (SC)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (WI)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (OH)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (OR)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (UT)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (IL)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (WA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (GA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (FL)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (NM)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (MI)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (MN)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (VA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (MI)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (MN)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (VA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (NC)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (TX)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (OK)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (LA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (MT)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (ID)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (SC)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (WI)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (OH)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (OR)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (UT)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (IL)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (WA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (GA)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (FL)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437529245 (NM)		1/8/2021 5:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841224870	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841224870	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841224870	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	12/10/2020 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	12/10/2020 5:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/10/2020 5:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	577338 (IA)		11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/12/2020 2:59 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1005535 (AK)		11/12/2020 2:59 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (AK)		11/12/2020 2:59 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841224870 (IA)		11/12/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	11/12/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	11/12/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	11/12/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	11/12/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437529245	11/12/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	11/12/2020 2:59 PM
Contacts	Authorizing Official	Update	Change Request	Rhoden, Patricia Chief Financial Officer BUMCP 6028398507	Scherpf, John W. Chief Operating Officer Banner University Medical Center Phoenix 6028398504	11/3/2020 10:45 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841224870 ( )		9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841224870	9/9/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/9/2020 10:37 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 11:50:33 AM	9/9/2020 10:37:12 AM	9/9/2020 10:37 AM
Contacts	Primary Contact	Update	Profile Change Request	Anderson, Jeff pharmacy director Banner University Medical Center Phoenix 6028392657	Anderson, Jeff Director, Pharmacy Academic Banner University Medical Center Phoenix 6028392657	9/8/2020 5:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/22/2020 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00323681	5/22/2020 2:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	5/22/2020 2:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200458490A (IN)		5/22/2020 2:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110074222B (MA)		5/22/2020 2:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (NV)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	152540105 (AR)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	008051472 (CT)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (CT)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	38311600 (DC)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (DE)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (IA)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	806962100 (ID)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (IL)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200005120A (KS)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01200401 (KY)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7207751 (MA)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	416239100 (MD)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (ME)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (MI)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	498748900 (MN)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00323681 (NC)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0307955 (NJ)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1020313860001 (PA)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1182A (SC)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	13109B (SD)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q024011 (TN)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1841224870 (VA)		2/24/2020 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100047022 (WI)		2/24/2020 3:24 PM
Addresses	Billing Address	Insert	Change Request		Banner University Medical Center Phoenix 1111 E McDowell Rd Phoenix, AZ 85006	2/18/2020 6:20 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Phoenix 1111 E McDowell Rd Phoenix, AZ 85006	2/18/2020 6:20 AM
Addresses	Shipping Address	Insert	Change Request		Banner Health 7300 W. Detroit St. Chandler, AZ 85226	2/18/2020 6:20 AM
Contacts	Primary Contact	Update	Change Request	Cortese, Al Sr. Director of Pharmacy Banner Pharmacy Services 5208344210	Anderson, Jeff pharmacy director Banner University Medical Center Phoenix 6028392657	2/18/2020 6:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		577338	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		270036499001	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	12/2/2019 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	12/2/2019 9:51 AM
Contacts	Primary Contact	Update	Change Request	Welch, Carol Director of Pharmacy Banner University Medical Center - Phoenix 6028394556	Cortese, Al Sr. Director of Pharmacy Banner Pharmacy Services 5208344210	9/24/2019 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/2/2018 10:58:47 PM	9/5/2019 11:50:33 AM	9/5/2019 11:50 AM
Contacts	Primary Contact	Update	Change Request	Reilly, Joan C. Senior Pharmacy Manager Banner University Medical Center - Phoenix 6028395819	Welch, Carol Director of Pharmacy Banner University Medical Center - Phoenix 6028394556	7/12/2019 7:22 AM
Contacts	Authorizing Official	Update	AO Change Request	Tinkle, Josh L Associate Administrator Banner University Medical Center - Phoenix 6028398508	Rhoden, Patricia Chief Financial Officer BUMCP 6028398507	6/18/2019 2:46 PM
Contacts	Authorizing Official	Update	Change Request	Blain, Trent S. Sr Dir Finance Banner Health 6028395114	Tinkle, Josh L Associate Administrator Banner University Medical Center - Phoenix 6028398508	1/3/2019 12:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2018 10:16 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		166977	11/28/2018 10:16 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	11/28/2018 10:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/28/2018 10:16 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	11/28/2018 10:16 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	11/28/2018 10:16 PM
Contacts	Primary Contact	Update	Change Request	Manning, Mary DIRECTOR OF PHARMACY Banner University Medical Center Phoenix 6027472335	Reilly, Joan C. Senior Pharmacy Manager Banner University Medical Center - Phoenix 6028395819	11/24/2018 12:47 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 6:02:40 PM	9/2/2018 10:58:47 PM	9/2/2018 10:58 PM
Contacts	Primary Contact	Update	Change Request	Waldrop, Scott Pharmacy Director Banner University Medical Center - Phoenix 6028392657	Manning, Mary DIRECTOR OF PHARMACY Banner University Medical Center Phoenix 6027472335	7/12/2018 2:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2018 1:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025141001	7/12/2018 1:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	7/12/2018 1:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1005535	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		152540105	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04577256	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008051472	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		38311600	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		901449700	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		618348897A	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		806962100	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200458490A	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200005120A	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01200401	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1702668	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110074222B	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7207751	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		416239100	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		498748900	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00323681	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0307955	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		A0907	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2284077	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100690420A	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		244196	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1020313860001	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1182A	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		13109B	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SD	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q024011	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		071472701	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		270036499001	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841224870	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3024858	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100047022	3/25/2018 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	3/25/2018 12:24 PM
Contacts	Primary Contact	Update	Recertification	Chase, David Interim Director of Pharmacy 6028395819	Waldrop, Scott Pharmacy Director Banner University Medical Center - Phoenix 6028392657	11/29/2017 6:02 PM
Details	Last Recertification Date	Update	Recertification	9/7/2016 12:00:00 AM	11/29/2017 6:02:40 PM	11/29/2017 6:02 PM
Details	Entity Name	Update	Change Request	BANNER GOOD SAMARITAN MEDICAL CENTER	Banner – University Medical Center Phoenix	10/4/2017 11:45 PM
Contacts	Authorizing Official	Update		Blain, Trent S. Sr Dir Finance 6028395114	Blain, Trent S. Sr Dir Finance Banner Health 6028395114	10/4/2017 11:42 PM
Contacts	Signed By	Insert			Loader, Cliff Chief Financial Officer 6028392675	8/4/2017 1:31 PM
Contacts	Authorizing Official	Insert			Blain, Trent S. Sr Dir Finance 6028395114	6/28/2017 1:01 AM
Addresses	Main Address	Insert			1441 12th St Suite 2 2nd Floor PHOENIX, AZ 85006-2850	6/15/2017 10:40 AM
Contacts	Primary Contact	Insert			Chase, David Interim Director of Pharmacy 6028395819	9/7/2016 7:16 AM
Details	Last Recertification Date	Update			9/7/2016 12:00:00 AM	9/7/2016 7:16 AM
Details	Entity Subname	Update		BANNER UNIVERSITY MEDICAL CENTER PH / Endocrinology Clinic	Endocrinology Clinic	9/7/2016 7:16 AM
Dates	Participating Approval Date	Update			7/22/2015 12:00:00 AM	7/22/2015 4:27 PM
Details	State	Update		Pending	Active	7/22/2015 4:27 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/22/2015 4:27 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53796	DSH030002R	7/22/2015 9:25 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53796	7/15/2015 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2015 11:38 AM
Medicaid Billing	Medicaid: Number	Insert			529985	7/15/2015 11:38 AM
Medicaid Billing	Medicaid: State	Insert			AZ	7/15/2015 11:38 AM
Medicaid Billing	NPI: Number	Insert			1841224870	7/15/2015 11:38 AM
Details	Last Recertification Date	Insert				7/15/2015 11:38 AM
Details	Grant Number	Insert				7/15/2015 11:38 AM
Details	340B ID	Insert				7/15/2015 11:38 AM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 11:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 11:38 AM
Details	Medicare Provider Number	Insert			030002	7/15/2015 11:38 AM
Details	Entity Name	Insert			BANNER GOOD SAMARITAN MEDICAL CENTER	7/15/2015 11:38 AM
Details	Program Code	Insert			DSH	7/15/2015 11:38 AM
Details	Entity Subname	Insert			BANNER UNIVERSITY MEDICAL CENTER PH / Endocrinology Clinic	7/15/2015 11:38 AM
Dates	Participating Approval Date	Insert				7/15/2015 11:38 AM
Details	State	Insert			Pending	7/15/2015 11:38 AM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 11:38 AM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 11:38 AM
Dates	Start Date	Insert				7/15/2015 11:38 AM
Terminations	Termination Comments	Insert				7/15/2015 11:38 AM
Terminations	Termination Date	Insert				7/15/2015 11:38 AM
Terminations	Termination Effective Date	Insert				7/15/2015 11:38 AM
Terminations	Termination Reason	Insert				7/15/2015 11:38 AM