Covered Entity Details

DSH330197Z CANTON-POTSDAM HOSPITAL (Active) - information as of 5/10/2025 11:17:13 PM

Main Details

Name

CANTON-POTSDAM HOSPITAL

Subdivision Name

CPH PHYSIATRY

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330197Z

Medicare Provider Number

330197

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2021

Participating Start Date

10/6/2021

Participating Approval Date

10/6/2021

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Rochester Regional Health
Shawn Bishop, Vice President, RRH Revenue & Reimbursement
(585) 922-0056

Primary Contact

RRH
Robert Michael Scardino, 340B Pharmacy System Manager
(585) 319-6750

Addresses

Street Address

6119 US HIGHWAY 11
CANTON, NY 13617

Billing Address

CANTON-POTSDAM HOSPITAL
50 LEROY STREET
POTSDAM, NY 13676

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (10/1/2015) until terminated effective date: (10/01/21), reinstatement effective date: (10/06/21)	10/06/2021

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
NY	00354196	1568548782

Shipping Addresses

Shipping Address 1

CANTON-POTSDAM HOSPITAL
50 LEROY STREET
POTSDAM, NY 13676

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
DSH330197A	Child	DSH	CANTON-POTSDAM HOSPITAL	AFTERHOURS HEALTHCARE	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197AA	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PHYSIATRY	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Terminated
DSH330197AB	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY PRACTICE	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197AC	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY PRACTICE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AD	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH RHEUMATOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AE	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR GENERAL SURGERY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AF	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR INTERNAL MEDICINE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AG	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR OB/GYN	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AH	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ENDOCRINOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AJ	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR PAIN PRACTICE	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AK	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CANTON PAIN PRACTICE	80 EAST MAIN STREET	CANTON	NY	Terminated
DSH330197AL	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR MEDICAL ONCOLOGY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AM	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GOUVERNEUR ORTHOPEDICS	77 WEST BARNEY STREET	GOUVERNEUR	NY	Active
DSH330197AN	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OTOLARYNGOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AP	Child	DSH	CANTON-POTSDAM HOSPITAL	GASTROENTEROLOGY-SHAH	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AQ	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH INFECTIOUS DISEASE	80 East Main Street	CANTON	NY	Active
DSH330197AR	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH INTERNAL MEDICINE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Terminated
DSH330197AS	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PSYCHIATRY AND ADDICTION MEDICINE - PSYCHIATRY AND ADDICTION MEDICINE	12 ELM STREET	POTSDAM	NY	Active
DSH330197AT	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH DERMATOLOGY - DERMATOLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197AU	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GENERAL SURGERY - GENERAL SURGERY	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AV	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OTOLARYNGOLOGY - POTSDAM - OTOLARYNGOLOGY	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197AW	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH URGENT CARE - URGENT CARE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197AX	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PULMONOLOGY - PULMONOLOGY	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AY	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH BEHAVIORAL HEALTH - BEHAVIORAL HEALTH	77 WEST BARNEY STREET	GOUVERNEUR	NY	Terminated
DSH330197AZ	Child	DSH	CANTON-POTSDAM HOSPITAL	NEUROLOGY - NEUROLOGY	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197B	Child	DSH	CANTON-POTSDAM HOSPITAL	BRASHER FALLS HEALTH CLINIC	899 STATE HIGHWAY 11C	BRASHER FALLS	NY	Active
DSH330197BA	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH POTSDAM DERM - dermatology	49 Lawrence Ave	POTSDAM	NY	Active
DSH330197BB	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CANTON GEN SURG - General Surgery	80 E Main St	Canton	NY	Active
DSH330197BC	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH UROLOGY CANTON - Urology	80 E Main St	Canton	NY	Active
DSH330197BD	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ORTHO AT LAW AVE - Orthopedic Surgery	49 Lawrence Ave	Potsdam	NY	Active
DSH330197BE	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH O/P SUBSTANCE USE - Behavioral Health	12 Elm St	POTSDAM	NY	Active
DSH330197BF	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PODIATRY AT MH - podiatry	181 MAPLE ST	Massena	NY	Active
DSH330197BG	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH CARDIO POTSDAM - cardiology	201 MARKET ST	potsdam	NY	Active
DSH330197BH	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH GENERAL SURG MH - General Surgery	181 Maple St	MASSENA	NY	Active
DSH330197C	Child	DSH	CANTON-POTSDAM HOSPITAL	Canton OB/GYN	80 E MAIN ST	CANTON	NY	Active
DSH330197D	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH FAMILY & PEDIATRICS SERVICES - CANTON	EJ NOBLE BUILDING	CANTON	NY	Active
DSH330197E	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PSYCHIATRY SERVICES	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197F	Child	DSH	CANTON-POTSDAM HOSPITAL	NORFOLK COMMUNITY HEALTH CENTER	35 W. MAIN STREET	NORFOLK	NY	Active
DSH330197G	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PRIMARY CARE AND INTERNAL MEDICINE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197I	Child	DSH	CANTON-POTSDAM HOSPITAL	CHEMICAL DEPENDENCY	12 ELM STREET	POTSDAM	NY	Terminated
DSH330197K	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology and Surgical Services-Wilson	15 Raymond Street	Potsdam	NY	Terminated
DSH330197L	Child	DSH	CANTON-POTSDAM HOSPITAL	ORTHOPEDICS AND SPORTS MEDICINE	6119 US HIGHWAY 11	CANTON	NY	Active
DSH330197M	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PEDIATRICS PRACTICE	15 Raymond Street	Potsdam	NY	Active
DSH330197N	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH POTSDAM OB/GYN PRACTICE	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197P	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Eye Care	Lawrence Avenue Medical Campus	Potsdam	NY	Active
DSH330197Q	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology and Surgical Services-Stoin	15 Raymond Street	Potsdam	NY	Terminated
DSH330197R	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Pain Management	LAWRENCE AVENUE MEDICAL CAMPUS	Potsdam	NY	Active
DSH330197S	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Gastroenterology Services	50 LEROY STREET	POTSDAM	NY	Terminated
DSH330197T	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH OB/GYN Lawrence Avenue	Lawrence Avenue Medical Campus	Potsdam	NY	Terminated
DSH330197U	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH Cardiology Lawrence Avenue	50 LEROY STREET	Potsdam	NY	Terminated
DSH330197V	Child	DSH	CANTON-POTSDAM HOSPITAL	ALLERGY AND IMMUNOLOGY	6119 US HIGHWAY 11	Canton	NY	Active
DSH330197X	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH ORTHOPEDICS PRACTICE	EJ NOBLE BUILDING	CANTON	NY	Terminated
DSH330197Y	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PULMONOLOGY	LAWRENCE AVENUE MEDICAL CAMPUS	POTSDAM	NY	Active
DSH330197Z	Child	DSH	CANTON-POTSDAM HOSPITAL	CPH PHYSIATRY	6119 US HIGHWAY 11	CANTON	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 4:37:26 PM	8/28/2024 12:48:09 PM	8/28/2024 12:48 PM
Details	Last Recertification Date	Update	Recertification	9/18/2022 12:29:00 PM	8/29/2023 4:37:26 PM	8/29/2023 4:37 PM
Contacts	Primary Contact	Update	PC Change Request	Kinter, Karen M Vice President of Specialty Revenue Programs Rochester Regional 5853683537	Scardino, Robert Michael 340B Pharmacy System Manager RRH 5853196750	7/20/2023 4:18 PM
Contacts	Authorizing Official	Update	Change Request	Thomas, Hugh Executive Vice President, Chief Administrative Officer Rochester Regional Health 5859224941	Bishop, Shawn Vice President, RRH Revenue & Reimbursement Rochester Regional Health 5859220056	6/9/2023 6:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/18/2022 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00354196	9/18/2022 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/18/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1568548782	9/18/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/18/2022 12:29 PM
Details	Last Recertification Date	Update	Recertification		9/18/2022 12:29:00 PM	9/18/2022 12:29 PM
Contacts	Primary Contact	Update	PC Change Request	SOGOIAN, DAVID DIRECTOR OF PHARMACY Canton-Potsdam Hospital 3152615510	Kinter, Karen M Vice President of Specialty Revenue Programs Rochester Regional 5853683537	8/31/2022 6:29 AM
Contacts	Authorizing Official	Update	Profile Change Request	Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	Thomas, Hugh Executive Vice President, Chief Administrative Officer Rochester Regional Health 5859224941	7/8/2022 12:36 PM
Contacts	Authorizing Official	Update	AO Change Request	McGregor, Donna M System CFO Canton-Potsdam Hospital 3152615451	Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	7/5/2022 1:22 PM
Details	State	Update	OPA Edit	Approved	Active	10/6/2021 9:48 AM
Dates	Start Date	Update	OPA Edit	1/1/2022 12:00:00 AM	10/6/2021 12:00:00 AM	10/6/2021 9:48 AM
Addresses	Billing Address	Insert	Reinstatement		CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM, NY 13676	10/6/2021 9:47 AM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	330197 (NY)		10/6/2021 9:47 AM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	00354196 (NY)		10/6/2021 9:47 AM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1568548782 (NY)		10/6/2021 9:47 AM
Contacts	Signed By	Update	Reinstatement	JACOBS, RICHARD D. VP FOR FINANCE AND CFO Canton-Potsdam Hospital 3152615100	McGregor, Donna M System CFO Canton-Potsdam Hospital 3152615451	10/6/2021 9:47 AM
Details	Last Recertification Date	Update	Reinstatement	9/8/2020 3:33:38 PM		10/6/2021 9:47 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/30/2021 12:00:00 AM		10/6/2021 9:47 AM
Dates	Participating Approval Date	Update	Reinstatement	7/23/2015 12:00:00 AM	10/6/2021 9:47:06 AM	10/6/2021 9:47 AM
Details	State	Update	Reinstatement	Terminated	Approved	10/6/2021 9:47 AM
Dates	Registration Date	Update	Reinstatement	7/15/2015 12:00:00 AM	10/4/2021 4:49:34 PM	10/6/2021 9:47 AM
Dates	Signed By Date	Update	Reinstatement	7/15/2015 12:00:00 AM	10/5/2021 2:49:35 PM	10/6/2021 9:47 AM
Dates	Start Date	Update	Reinstatement	10/1/2015 12:00:00 AM	1/1/2022 12:00:00 AM	10/6/2021 9:47 AM
Terminations	Termination Date	Update	Reinstatement	10/1/2021 12:00:00 AM		10/6/2021 9:47 AM
Terminations	Termination Effective Date	Update	Reinstatement	10/1/2021 12:00:00 AM		10/6/2021 9:47 AM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		10/6/2021 9:47 AM
Details	Comments Public	Insert	Reinstatement		Participating from effective date: (10/1/2015) until terminated effective date: (10/01/21), reinstatement effective date: (10/06/21)	10/6/2021 7:11 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		9/30/2021 12:00:00 AM	9/17/2021 7:41 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/17/2021 7:41 AM
Terminations	Termination Date	Update	Recertification		10/1/2021 12:00:00 AM	9/17/2021 7:41 AM
Terminations	Termination Effective Date	Update	Recertification		10/1/2021 12:00:00 AM	9/17/2021 7:41 AM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	9/17/2021 7:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		330197	9/8/2020 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/8/2020 3:33 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/8/2020 3:33 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 5:07:12 PM	9/8/2020 3:33:38 PM	9/8/2020 3:33 PM
Contacts	Authorizing Official	Update	AO Change Request	JACOBS, RICHARD D. VP FOR FINANCE AND CFO Canton-Potsdam Hospital 3152615100	McGregor, Donna M System CFO Canton-Potsdam Hospital 3152615451	7/13/2020 7:34 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 10:22:14 AM	9/3/2019 5:07:12 PM	9/3/2019 5:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1568548782	5/9/2019 12:52 PM
Details	Last Recertification Date	Update	Recertification	12/1/2017 10:08:01 AM	8/23/2018 10:22:14 AM	8/23/2018 10:22 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	12/1/2017 10:08:01 AM	12/1/2017 10:08 AM
Contacts	Primary Contact	Update	Recertification	SOGOIAN, DAVID DIRECTOR OF PHARMACY 3152615510	SOGOIAN, DAVID DIRECTOR OF PHARMACY Canton-Potsdam Hospital 3152615510	12/1/2017 9:44 AM
Contacts	Authorizing Official	Update		JACOBS, RICHARD D. VP FOR FINANCE AND CFO 3152615100	JACOBS, RICHARD D. VP FOR FINANCE AND CFO Canton-Potsdam Hospital 3152615100	10/16/2017 11:32 AM
Contacts	Signed By	Update		JACOBS, RICHARD D. VP FOR FINANCE AND CFO 3152615100	JACOBS, RICHARD D. VP FOR FINANCE AND CFO Canton-Potsdam Hospital 3152615100	10/16/2017 11:32 AM
Contacts	Authorizing Official	Insert			JACOBS, RICHARD D. VP FOR FINANCE AND CFO 3152615100	7/25/2017 7:36 AM
Contacts	Signed By	Insert			JACOBS, RICHARD D. VP FOR FINANCE AND CFO 3152615100	7/25/2017 7:36 AM
Contacts	Primary Contact	Update		BOIALLIS, CHRISTOPHER DIRECTOR OF PHARMACY 3152615510	SOGOIAN, DAVID DIRECTOR OF PHARMACY 3152615510	7/25/2017 7:36 AM
Addresses	Main Address	Insert			6119 US HIGHWAY 11 CANTON, NY 13617	7/24/2017 7:02 PM
Addresses	Billing Address	Insert			CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM, NY 13676	7/24/2017 7:02 PM
Addresses	Shipping Address	Insert			CANTON-POTSDAM HOSPITAL 50 LEROY STREET POTSDAM, NY 13676	7/24/2017 7:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/5/2017 11:58 AM
Medicaid Billing	Medicaid: Number	Insert			00354196	5/5/2017 11:58 AM
Medicaid Billing	Medicaid: State	Insert			NY	5/5/2017 11:58 AM
Contacts	Primary Contact	Insert			BOIALLIS, CHRISTOPHER DIRECTOR OF PHARMACY 3152615510	8/18/2016 3:09 PM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 3:09 PM
Dates	Participating Approval Date	Update			7/23/2015 12:00:00 AM	7/23/2015 10:49 AM
Details	State	Update		Pending	Active	7/23/2015 10:49 AM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/23/2015 10:49 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53941	DSH330197Z	7/23/2015 9:09 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53941	7/15/2015 2:50 PM
Details	Last Recertification Date	Insert				7/15/2015 2:50 PM
Details	Grant Number	Insert				7/15/2015 2:50 PM
Details	340B ID	Insert				7/15/2015 2:50 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 2:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 2:50 PM
Details	Medicare Provider Number	Insert			330197	7/15/2015 2:50 PM
Details	Entity Name	Insert			CANTON-POTSDAM HOSPITAL	7/15/2015 2:50 PM
Details	Program Code	Insert			DSH	7/15/2015 2:50 PM
Details	Entity Subname	Insert			CPH PHYSIATRY	7/15/2015 2:50 PM
Dates	Participating Approval Date	Insert				7/15/2015 2:50 PM
Details	State	Insert			Pending	7/15/2015 2:50 PM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 2:50 PM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 2:50 PM
Dates	Start Date	Insert				7/15/2015 2:50 PM
Terminations	Termination Comments	Insert				7/15/2015 2:50 PM
Terminations	Termination Date	Insert				7/15/2015 2:50 PM
Terminations	Termination Effective Date	Insert				7/15/2015 2:50 PM
Terminations	Termination Reason	Insert				7/15/2015 2:50 PM