Covered Entity Details

DSH340113BY CAROLINAS MEDICAL CENTER (Active) - information as of 4/25/2025 5:38:56 PM

Main Details

Name

CAROLINAS MEDICAL CENTER

Subdivision Name

Levine Cancer Institute Medical Oncology Clinic Concord

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340113BY

Medicare Provider Number

340113

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2015

Participating Start Date

10/1/2015

Participating Approval Date

8/7/2015

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Atrium Health
Don McCoy Mabe, VP, Pharmacy
(704) 512-7623

Primary Contact

North Carolina Baptist Hospital
Bibi W Wishart, Program Director, 340B
(336) 713-3426

Addresses

Street Address

100 Medical Park Drive
Suite 110
Concord, NC 28025

Billing Address

Atrium Health Accounts Payable
PO Box 516
Elmsford, NY 10523

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
SC	336688	1295789907
NC		1295789907

Shipping Addresses

Shipping Address 1

Levine Cancer Institute Medical Oncology
100 Medical Park Drive
Suite 110
Concord, NC 28025

Shipping Address 2

Levine Cancer Institute Pharmacy
100 Medical Park Drive
Suite 010C
Concord, NC 28025

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
DSH340113A	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Biddle Point	1801 ROZZELLES FERRY ROAD	CHARLOTTE	NC	Active
DSH340113AA	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Kidney	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AB	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Heart	1025 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113AC	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Liver	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AD	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center - Pancreas	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AF	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant & Liver Care	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113AG	Child	DSH	CAROLINAS MEDICAL CENTER	Radiation Oncology	1310 E. Morehead St	Charlotte	NC	Active
DSH340113AH	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Heart Success and Transition Clinic	1237 Harding Place	Charlotte	NC	Active
DSH340113AJ	Child	DSH	CAROLINAS MEDICAL CENTER	Nuclear Medicine	1000 Blythe Blvd	Charlotte	NC	Terminated
DSH340113AK	Child	DSH	CAROLINAS MEDICAL CENTER	CMC NorthPark After-Hours Pediatric Clinic	251 Eastway Drive	Charlotte	NC	Terminated
DSH340113AL	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Sleep Disorder Lab	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AM	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Orthopedics	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AN	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - General Surgery	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AP	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Obstetrics & Gynecology	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AQ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Pediatrics	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	100 Medical Park Drive	Concord	NC	Active
DSH340113AS	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Internal Medicine	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113AT	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health NorthPark - Obstetrics & Gynecology	251 Eastway Drive	Charlotte	NC	Active
DSH340113AU	Child	DSH	CAROLINAS MEDICAL CENTER	Southeast Pain Care Center	3030 Randolph Road	Charlotte	NC	Terminated
DSH340113AV	Child	DSH	CAROLINAS MEDICAL CENTER	Carolinas Wound Care Center	1601 Abbey Place	Charlotte	NC	Terminated
DSH340113AW	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	945 North Fifth Street	Albemarle	NC	Active
DSH340113AX	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Emergency Department	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AY	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Kidney Dialysis Unit	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113AZ	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Same Day Procedures	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113B	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health NorthPark - Family Medicine	251 EASTWAY DRIVE	CHARLOTTE	NC	Active
DSH340113BA	Child	DSH	CAROLINAS MEDICAL CENTER	CMC-Mercy Endoscopy	2001 Vail Avenue	Charlotte	NC	Terminated
DSH340113BB	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Internal Medicine Specialty	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113BC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic	1021 Morehead Medical Dr	Charlotte	NC	Active
DSH340113BD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Rare/Complex Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Breast Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute GYN Clinic	1021 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113BG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer GU Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BH	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Gynecological Oncology Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BJ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Surgical Oncology	1021 Morehead Medical Drive	Charlotte	NC	ToBeTerminated
DSH340113BK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	4525 Cameron Valley Parkway	Charlotte	NC	Active
DSH340113BL	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	4525 Cameron Valley Parkway	Charlotte	NC	Active
DSH340113BM	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	10660 Park Road	Charlotte	NC	Active
DSH340113BN	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113BP	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113BQ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113BR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center (0001 344200)	1100 South Tryon St	Charlotte	NC	Terminated
DSH340113BS	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology (0001 344400)	1100 South Tryon St	Charlotte	NC	Terminated
DSH340113BT	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Infusion Center (0001 342800)	10826 Mallard Creek Road	Charlotte	NC	Terminated
DSH340113BU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Medical Oncology (0001 343700)	10826 Mallard Creek Road	Charlotte	NC	Terminated
DSH340113BV	Child	DSH	CAROLINAS MEDICAL CENTER	HPB (Hepato-Pancreatico-Biliary) Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113BW	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Primary Care	501 Billingsley Rd.	Charlotte	NC	Terminated
DSH340113BX	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health SouthPark Emergency Department	6965 Fairview Rd.	Charlotte	NC	Active
DSH340113BY	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic Concord	100 Medical Park Drive	Concord	NC	Active
DSH340113BZ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic Albemarle	945 North Fifth Street	Albemarle	NC	Active
DSH340113C	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Emergency Department	501 BILLINGSLEY ROAD	CHARLOTTE	NC	Active
DSH340113CA	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Hematology and Lymphoma Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute / Sickle Cell Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CC	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Heart Failure (CHF) Clinic	1025 Medical Center Drive	Charlotte	NC	Terminated
DSH340113CD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center (0001 331300)	1401 Matthews Township Pkwy	Matthews	NC	Terminated
DSH340113CE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic (0001 331400)	1401 Matthews Township Pkwy	Matthews	NC	Terminated
DSH340113CF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Infusion Center	15830 Ballantyne Medical Place	Charlotte	NC	Active
DSH340113CG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Medical Oncology Clinic	15830 BALLANTYNE MEDICAL PLACE	CHARLOTTE	NC	Active
DSH340113CH	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Gastroenterology & Hepatology	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CJ	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Survivorship / Survivorship (338600)	711 E. Morehead St	Charlotte	NC	Terminated
DSH340113CK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Palliative Care	1021 Morehead Medical Dr	Charlotte	NC	Active
DSH340113CL	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute / ALS Center, and Neuromuscular, Movement, and Headache Programs	1010 Edgehill Rd	Charlotte	NC	Active
DSH340113CM	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute / Infusion Service	1225 Harding Place	Charlotte	NC	Active
DSH340113CN	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park - Medication Management Clinic	1350 S. Kings Drive	Charlotte	NC	Active
DSH340113CP	Child	DSH	CAROLINAS MEDICAL CENTER	ADULT INTEGRATED CONTINUUM - Eagle Program	501 Billingsley Road	Charlotte	NC	Active
DSH340113CQ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute - Epilepsy Clinic	1225 Harding Place	Charlotte	NC	Active
DSH340113CR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	101 WT Harris Blvd	Charlotte	NC	Active
DSH340113CS	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CT	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113CU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Surgical Oncology	10660 Park Road	Charlotte	NC	Active
DSH340113CV	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center	16455 Statesville Rd	Huntersville	NC	Active
DSH340113CW	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology	16455 Statesville Rd	Huntersville	NC	Active
DSH340113CX	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Endocrine Oncology	10660 Park Road	Charlotte	NC	ToBeTerminated
DSH340113CY	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Cutaneous/Plastics	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113CZ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health General & Complex Abdominal Surgery - CMC Trauma Clinic	1025 Morehead Medical Drive	Charlotte	NC	ToBeTerminated
DSH340113D	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Myers Park Infectious Diseases Clinic	1350 SOUTH KINGS DRIVE	CHARLOTTE	NC	Terminated
DSH340113DA	Child	DSH	CAROLINAS MEDICAL CENTER	Pediatric Outpatient Infusion Center CLIV	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113DB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Union	1550 Faulk Street	Monroe	NC	Active
DSH340113DC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Union	1550 Faulk Street	Monroe	NC	Active
DSH340113DD	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Lincoln	447 McAlister Road	Lincolnton	NC	Active
DSH340113DE	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Lincoln	447 McAlister Road	Lincolnton	NC	Active
DSH340113DF	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center - Cleveland	201 East Grover St	Shelby	NC	Active
DSH340113DG	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology Clinic - Cleveland	201 East Grover St	Shelby	NC	Active
DSH340113DH	Child	DSH	CAROLINAS MEDICAL CENTER	Radiation Oncology - Radiation Therapy and Brachytherapy	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DJ	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Community Care Primary Care - Archdale Family Medicine	5929 South Blvd	Charlotte	NC	Active
DSH340113DK	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Surgical Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DL	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Supportive Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DM	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Infusion Center	1100 Healing Way	Indian Trail	NC	Active
DSH340113DN	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute - Medical Oncology	1100 Healing Way	Indian Trail	NC	Active
DSH340113DP	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC AYA Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DQ	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - US	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DR	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - Thoracic Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DS	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - NM	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DT	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - PET	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DU	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC Cancer Rehab Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DV	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - Thoracic Cardiology Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DW	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - CT	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DX	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - CMC Sexual Health	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113DY	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Kenilworth - Kenilworth Infusion Center	1225 Harding Place	Charlotte	NC	Active
DSH340113DZ	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - MR	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113E	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Infusion Center	1601 Abbey Place	Charlotte	NC	Active
DSH340113EA	Child	DSH	CAROLINAS MEDICAL CENTER	Morehead Imaging Center - XR	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113EB	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer - GI Clinic	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113EC	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Infusion Center - Non-Oncology Infusion service line	100 Medical Park Drive	Concord	NC	Active
DSH340113F	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Children's Specialty Center	1001 Blythe Blvd	CHARLOTTE	NC	Active
DSH340113G	Child	DSH	CAROLINAS MEDICAL CENTER	Carolinas Diabetes Center	1025 Morehead Medical Drive	Charlotte	NC	Terminated
DSH340113H	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health General & Complex Abdominal Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113J	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Orthopedic Surgery	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113K	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Dental Clinic	1000 Blythe Blvd	Charlotte	NC	Active
DSH340113L	Child	DSH	CAROLINAS MEDICAL CENTER	CMC Elizabeth Family Medicine	2001 Vail Avenue	Charlotte	NC	Active
DSH340113M	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Neurosciences Institute/MS Center, Sleep Center, and Sub-specialty Services	1225 Harding Place	Charlotte	NC	Active
DSH340113N	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health One Day Surgery	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113Q	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Pain Management	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113R	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Children's Cancer & Blood Disorders	1001 Blythe Blvd	Charlotte	NC	Active
DSH340113S	Child	DSH	CAROLINAS MEDICAL CENTER	Adult Integrated Continuum	501 Billingsley Road	Charlotte	NC	Active
DSH340113T	Child	DSH	CAROLINAS MEDICAL CENTER	CHS CMC Behavioral Health Child and Adolescent OP	300 Billingsley Road	Charlotte	NC	Terminated
DSH340113U	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Outpatient Medication Services Clinic	501 Billingsley Road	Charlotte	NC	Active
DSH340113V	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Behavioral Health Observation Unit	501 Billingsley Road	Charlotte	NC	Active
DSH340113W	Child	DSH	CAROLINAS MEDICAL CENTER	Teen Health Connection	3541 Randolph Road	Charlotte	NC	Active
DSH340113X	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Fertility Center Morehead Medical Plaza	1025 Morehead Medical Drive	Charlotte	NC	Active
DSH340113Y	Child	DSH	CAROLINAS MEDICAL CENTER	Levine Cancer Institute Blumenthal Infusion Center	1021 Morehead Medical Drive	Charlotte	NC	Active
DSH340113Z	Child	DSH	CAROLINAS MEDICAL CENTER	Atrium Health Transplant Center	1025 Morehead Medical Drive	Charlotte	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	Wishart, Bibi W Program Director, 340B North Carolina Baptist Hospital 3367133426	4/15/2025 11:06 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 10:30:52 AM	9/4/2024 9:40:41 AM	9/4/2024 9:40 AM
Contacts	Authorizing Official	Update	Profile Change Request	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	8/13/2024 2:16 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1295789907	7/15/2024 5:07 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	7/15/2024 5:07 PM
Details	Entity Subname	Update	Change Request	Levine Cancer Institute Medical Oncology Clinic Concord (0001 348600)	Levine Cancer Institute Medical Oncology Clinic Concord	4/1/2024 2:36 PM
Addresses	Shipping Address	Insert	Recertification		Levine Cancer Institute Medical Oncology 100 Medical Park Drive Suite 110 Concord, NC 28025	9/6/2023 10:30 AM
Addresses	Shipping Address	Insert	Recertification		Levine Cancer Institute Pharmacy 100 Medical Park Drive Suite 010C Concord, NC 28025	9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	93756534 (NM)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	CAR0113N (AL)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	003223331A (GA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	01520493 (KY)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1295789907-001 (ME)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00097237 (MS)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3096344 (NH)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007534530004 (PA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	2036578 (WA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3043387 (CT)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	32050200 (DC)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0548222 (IA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	016956401 (MO)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	072536801 (TX)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	217955500 (MD)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000185407 (CO)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	022529400 (FL)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	30003945240002 (KS)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300042056 (IN)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q050668 (TN)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000104101A (GA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	125311105 (AR)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	320546 (AZ)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	003043387 (CT)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	032050200 (DC)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	548222 (IA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	561398929001 (IL)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1748412 (LA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110027109B (MA)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	16956401 (MO)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	97237 (MS)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00350665 (NY)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	2625476 (OH)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	10069210A (OK)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	203849 (OR)		9/6/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	72536801 (TX)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (IA)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (ID)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (MN)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (VA)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (WI)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (CA)		9/6/2023 10:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 (MI)		9/6/2023 10:30 AM
Details	Last Recertification Date	Update	Recertification	9/14/2022 1:49:06 PM	9/6/2023 10:30:52 AM	9/6/2023 10:30 AM
Addresses	Billing Address	Update	Group Change Request	Atrium Health Accounts Payable PO Box 5379 Portland, OR 97228-5379	Atrium Health Accounts Payable PO Box 516 Elmsford, NY 10523	1/31/2023 11:56 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 4:09:03 PM	9/14/2022 1:49:06 PM	9/14/2022 1:49 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	092547100 (FL)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9501101 (CO)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000185407	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		022529400	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003945240002	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		300042056	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IN	8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	92547100 (FL)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	95011011 (CO)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100106450A (KS)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4105335 (MT)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	56139892900 (NE)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	20001280 (NH)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1007534530001 (PA)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3003316 (WA)		8/24/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0340113 (VT)		9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9501101	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3043387	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		32050200	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0548222	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		016956401	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		072536801	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		217955500	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	807415100 (ID)		9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	179230001 (ME)		9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	340113 (VT)		9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	80627000 (WI)		9/9/2021 4:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2021 4:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/9/2021 4:09 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2021 4:09 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/9/2021 4:09 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 12:55:08 PM	9/9/2021 4:09:03 PM	9/9/2021 4:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		CAR0113N	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		092547100	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003223331A	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01520493	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1295789907-001	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00097237	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3096344	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007534530004	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0340113	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2036578	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/9/2020 12:55 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3400113 (NC)		9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1295789907 ( )		9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/9/2020 12:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295789907	9/9/2020 12:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/9/2020 12:55 PM
Contacts	Primary Contact	Update	Recertification	Paul-Aviles, Fern Assistant Vice President, Pharmacy Atrium Health 7046499691	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	9/9/2020 12:55 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 4:16:49 PM	9/9/2020 12:55:08 PM	9/9/2020 12:55 PM
Contacts	Authorizing Official	Update	AO Change Request	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	8/14/2020 11:17 AM
Contacts	Authorizing Official	Update	AO Change Request	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	6/3/2020 8:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	Paul-Aviles, Fern Assistant Vice President, Pharmacy Atrium Health 7046499691	9/12/2019 2:13 PM
Addresses	Billing Address	Update	Recertification	Carolinas HealthCare System Accounts Payable PO Box 5379 Portland, OR 97228-5379	Atrium Health Accounts Payable PO Box 5379 Portland, OR 97228-5379	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		93756534	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	0340113	Q050668	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	009814159 (VA)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0175950000 (WV)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	092547100	92547100	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	XHSP41718 (CA)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	0548222	548222	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100036400A (IN)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	217955500 (MD)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	406753300 (MN)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	016956401	16956401	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	00097237	97237	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4173902 (NJ)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	072536801	72536801	9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	561398929004 (UT)		9/10/2019 4:16 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	0340113	340113	9/10/2019 4:16 PM
Details	Last Recertification Date	Update	Recertification	9/4/2018 1:39:35 PM	9/10/2019 4:16:49 PM	9/10/2019 4:16 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 8:11:58 PM	9/4/2018 1:39:35 PM	9/4/2018 1:39 PM
Details	Entity Subname	Update	Recertification	Levine Cancer Institute Medical Oncology Clinic Concord	Levine Cancer Institute Medical Oncology Clinic Concord (0001 348600)	9/4/2018 1:39 PM
Addresses	Main Address	Update	Recertification	100 Medical Park Drive, Suite 110 Concord, NC 28025	100 Medical Park Drive Suite 110 Concord, NC 28025	11/29/2017 8:11 PM
Addresses	Billing Address	Update	Recertification	Accounts Payable PO Box 37972 Charlotte, NC 28237	Carolinas HealthCare System Accounts Payable PO Box 5379 Portland, OR 97228-5379	11/29/2017 8:11 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/29/2017 8:11:58 PM	11/29/2017 8:11 PM
Contacts	Authorizing Official	Update		Leighty, Scott Senior Vice President 7045122414	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	10/12/2017 9:08 AM
Contacts	Primary Contact	Update		Paul-Aviles, Fern Pharmacy Director 7046499691	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	9/22/2017 2:54 PM
Contacts	Primary Contact	Insert			Paul-Aviles, Fern Pharmacy Director 7046499691	7/25/2017 1:24 PM
Contacts	Authorizing Official	Insert			Leighty, Scott Senior Vice President 7045122414	7/25/2017 1:24 PM
Contacts	Signed By	Insert			Knox, John J. Chief Administrative Officer 7043551116	7/25/2017 1:24 PM
Addresses	Main Address	Insert			100 Medical Park Drive, Suite 110 Concord, NC 28025	7/25/2017 1:24 PM
Addresses	Billing Address	Insert			Accounts Payable PO Box 37972 Charlotte, NC 28237	7/25/2017 1:24 PM
Details	Last Recertification Date	Update			8/31/2016 12:00:00 AM	8/31/2016 9:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			125311105	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			AR	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			320546	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			AZ	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			XHSP41718	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			CA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			95011011	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			CO	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			003043387	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			CT	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			032050200	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			DC	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			0548222	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			IA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			807415100	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			ID	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			561398929001	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			100036400A	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			IN	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			100106450A	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			KS	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			1748412	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			LA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			110027109B	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			217955500	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MD	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			179230001	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			ME	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			406753300	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MN	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			016956401	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MO	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			00097237	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MS	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			4105335	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			MT	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			56139892900	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			NE	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			20001280	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			NH	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			4173902	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			NJ	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			00350665	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			NY	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			2625476	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			OH	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			10069210A	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			OK	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			203849	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			OR	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			1007534530001	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			PA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			072536801	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			TX	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			561398929004	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			UT	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			0340113	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			VT	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			3003316	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			WA	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Number	Insert			80627000	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: State	Insert			WI	4/18/2016 10:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			336688	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			SC	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			0340113	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			TN	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			009814159	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			VA	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			0175950000	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			WV	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			000104101A	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			GA	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: Number	Insert			092547100	10/15/2015 1:58 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/15/2015 1:58 PM
Dates	Participating Approval Date	Update			8/7/2015 12:00:00 AM	8/7/2015 4:38 PM
Details	State	Update		Pending	Active	8/7/2015 4:38 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	8/7/2015 4:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_54050	DSH340113BY	8/7/2015 10:21 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_54050	7/15/2015 6:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2015 6:41 PM
Medicaid Billing	Medicaid: Number	Insert			3400113	7/15/2015 6:41 PM
Medicaid Billing	Medicaid: State	Insert			NC	7/15/2015 6:41 PM
Medicaid Billing	NPI: Number	Insert			1295789907	7/15/2015 6:41 PM
Details	Last Recertification Date	Insert				7/15/2015 6:41 PM
Details	Grant Number	Insert				7/15/2015 6:41 PM
Details	340B ID	Insert				7/15/2015 6:41 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 6:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 6:41 PM
Details	Medicare Provider Number	Insert			340113	7/15/2015 6:41 PM
Details	Entity Name	Insert			CAROLINAS MEDICAL CENTER	7/15/2015 6:41 PM
Details	Program Code	Insert			DSH	7/15/2015 6:41 PM
Details	Entity Subname	Insert			Levine Cancer Institute Medical Oncology Clinic Concord	7/15/2015 6:41 PM
Dates	Participating Approval Date	Insert				7/15/2015 6:41 PM
Details	State	Insert			Pending	7/15/2015 6:41 PM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 6:41 PM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 6:41 PM
Dates	Start Date	Insert				7/15/2015 6:41 PM
Terminations	Termination Comments	Insert				7/15/2015 6:41 PM
Terminations	Termination Date	Insert				7/15/2015 6:41 PM
Terminations	Termination Effective Date	Insert				7/15/2015 6:41 PM
Terminations	Termination Reason	Insert				7/15/2015 6:41 PM