Covered Entity Details

DSH330307A CAYUGA MEDICAL CENTER AT ITHACA (Terminated) - information as of 5/17/2025 10:56:17 PM

Main Details

Name

CAYUGA MEDICAL CENTER AT ITHACA

Subdivision Name

Urgent Care East Campus

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330307A

Medicare Provider Number

330307

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

5/21/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/22/2019

Last Recertification Date

8/19/2021

Termination Date
Termination Reason

1/1/2022
Site closure

Contacts

Authorizing Official

Cayuga Medical Center at Ithaca
John Collett, CHIEF FINANCIAL OFFICER
(607) 274-4441

Primary Contact

Cayuga Medical Center at Ithaca
Annette Griswold, Pharmacy Business Analyst/340B Coordinator
(607) 274-4218

Addresses

Street Address

10 Arrowwood Drive
Ithaca, NY 14850

Billing Address

Cayuga Medical Center at Ithaca
101 Dates Drive
Ithaca, NY 14850

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 1/1/2016, terminated 7/1/2018. Reinstated 7/1/2019.	05/22/2019

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	03001085	1962422733

Shipping Addresses

Shipping Address 1

Cayuga Medical Center at Ithaca
101 Dates Drive
3rd Floor
Ithaca, NY 14850

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
DSH330307A	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Urgent Care East Campus	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307B	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Urgent Care - Cortland	1129 Commons Ave	Cortland	NY	Active
DSH330307C	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA Main Oncology	401 Cayuga Park Lane	Ithaca	NY	Active
DSH330307D	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA East Campus Oncology	10 Arrowwood Drive	Ithaca	NY	Active
DSH330307E	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Surgicare	10 Arrowwood Drive	Ithaca	NY	Active
DSH330307F	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Sports Medicine	310 Taughannock Blvd	Ithaca	NY	Active
DSH330307G	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging - Cortland - MRI	1129 Commons Ave.	Cortland	NY	Terminated
DSH330307H	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging- Cortland - CT	1129 Commons Ave.	Cortland	NY	Terminated
DSH330307J	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging - East - MRI	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307K	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Imaging-East-Cat Scan	10 Arrowwood Drive	Ithaca	NY	Terminated
DSH330307L	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Infusion - Cortland Infusion - Infusion	1129 Commons Ave.	Cortland	NY	Active
DSH330307M	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Endoscopy - East - Gastro Intestinal Services	2435 North Triphammer Road	Ithaca	NY	Active
DSH330307N	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CHOA Cortland Campus Oncology - Oncology	1081 Commons Ave	Cortland	NY	Active
DSH330307P	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Pain Clinic - East - Pain Clinic	10 Arrowwood Dr.	Ithaca	NY	Active
DSH330307Q	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	CAYUGA CENTER FOR HEALTHLY LIVING - CCHL	310 TAUGHANNOCK BLVD	ITHACA	NY	Active
DSH330307R	Child	DSH	CAYUGA MEDICAL CENTER AT ITHACA	Cayuga Urology - Urology	201 Dates Dr	ITHACA	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2021 12:00:00 AM	12/27/2021 10:26 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/27/2021 10:26 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	12/27/2021 10:26 AM
Terminations	Termination Effective Date	Update	Termination Request		12/31/2021 12:00:00 AM	12/27/2021 10:26 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	12/27/2021 10:26 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 10:07:40 AM	8/19/2021 2:24:47 PM	8/19/2021 2:24 PM
Contacts	Authorizing Official	Update	Profile Change Request	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441-6073879264	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441	6/14/2021 11:04 AM
Contacts	Signed By	Update	Profile Change Request	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441-6073879264	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441	6/14/2021 11:04 AM
Contacts	Authorizing Official	Update	Profile Change Request	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithacq 6072744441	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441-6073879264	12/27/2020 11:46 AM
Contacts	Signed By	Update	Profile Change Request	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithacq 6072744441	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithaca 6072744441-6073879264	12/27/2020 11:46 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1962422733	9/1/2020 10:07 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/1/2020 10:07 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1962422733 ( )		9/1/2020 10:07 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 1:17:28 PM	9/1/2020 10:07:40 AM	9/1/2020 10:07 AM
Details	Last Recertification Date	Update	Recertification		8/26/2019 1:17:28 PM	8/26/2019 1:17 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Addresses	Billing Address	Insert	Reinstatement		Cayuga Medical Center at Ithaca 101 Dates Drive Ithaca, NY 14850	5/22/2019 12:49 PM
Addresses	Shipping Address	Insert	Reinstatement		Cayuga Medical Center at Ithaca 101 Dates Drive 3rd Floor Ithaca, NY 14850	5/22/2019 12:49 PM
Addresses	Shipping Address	Delete	Reinstatement	Cayuga Medical Center at Ithaca 101 Dates Drive Ithaca, NY 14850		5/22/2019 12:49 PM
Dates	Participating Approval Date	Update	Reinstatement		5/22/2019 12:49:00 PM	5/22/2019 12:49 PM
Details	State	Update	Reinstatement	Pending	Approved	5/22/2019 12:49 PM
Dates	Signed By Date	Update	Reinstatement	10/6/2015 12:00:00 AM	5/21/2019 3:35:15 PM	5/22/2019 12:49 PM
Dates	Start Date	Update	Reinstatement		7/1/2019 12:00:00 AM	5/22/2019 12:49 PM
Details	Comments Public	Insert	Reinstatement		Participated starting 1/1/2016, terminated 7/1/2018. Reinstated 7/1/2019.	5/22/2019 12:29 PM
Details	Last Recertification Date	Update	Reinstatement	11/6/2017 11:08:16 AM		5/21/2019 3:35 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	5/31/2018 12:00:00 AM		5/21/2019 3:35 PM
Dates	Participating Approval Date	Update	Reinstatement	10/26/2015 12:00:00 AM		5/21/2019 3:35 PM
Details	State	Update	Reinstatement	Terminated	Pending	5/21/2019 3:35 PM
Dates	Registration Date	Update	Reinstatement	10/6/2015 12:00:00 AM	5/21/2019 3:35:12 PM	5/21/2019 3:35 PM
Dates	Start Date	Update	Reinstatement	1/1/2016 12:00:00 AM		5/21/2019 3:35 PM
Terminations	Termination Comments	Update	Reinstatement	New DSH % effective 5/31/18 8.11%.		5/21/2019 3:35 PM
Terminations	Termination Date	Update	Reinstatement	7/1/2018 12:00:00 AM		5/21/2019 3:35 PM
Terminations	Termination Effective Date	Update	Reinstatement	5/31/2018 12:00:00 AM		5/21/2019 3:35 PM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		5/21/2019 3:35 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/31/2018 12:00:00 AM	6/4/2018 6:28 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/4/2018 6:28 AM
Terminations	Termination Comments	Update	Termination Request		New DSH % effective 5/31/18 8.11%.	6/4/2018 6:28 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	6/4/2018 6:28 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2018 12:00:00 AM	6/4/2018 6:28 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/4/2018 6:28 AM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	11/6/2017 11:08:16 AM	11/6/2017 11:08 AM
Contacts	Authorizing Official	Update		Collett, John CHIEF FINANCIAL OFFICER 6072744441	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithacq 6072744441	10/11/2017 10:49 AM
Contacts	Signed By	Update		Collett, John CHIEF FINANCIAL OFFICER 6072744441	Collett, John CHIEF FINANCIAL OFFICER Cayuga Medical Center at Ithacq 6072744441	10/11/2017 10:49 AM
Contacts	Primary Contact	Update		Griswold, Annette Pharmacy Business Analyst/340B Coordinator 6072744218	Griswold, Annette Pharmacy Business Analyst/340B Coordinator Cayuga Medical Center at Ithaca 6072744218	9/19/2017 3:24 PM
Contacts	Authorizing Official	Insert			Collett, John CHIEF FINANCIAL OFFICER 6072744441	8/2/2017 1:51 PM
Contacts	Signed By	Insert			Collett, John CHIEF FINANCIAL OFFICER 6072744441	8/2/2017 1:51 PM
Addresses	Main Address	Insert			10 Arrowwood Drive Ithaca, NY 14850	8/11/2016 2:41 PM
Contacts	Primary Contact	Update		Wilkins, Karen Cayuga Medical Center at Ithaca 6072744406	Griswold, Annette Pharmacy Business Analyst/340B Coordinator 6072744218	8/11/2016 2:41 PM
Details	Last Recertification Date	Update			8/11/2016 12:00:00 AM	8/11/2016 2:41 PM
Addresses	Billing Address	Insert			Cayuga Medical Center at Ithaca 101 Dates Drive Ithaca, NY 14850	8/1/2016 11:23 AM
Addresses	Shipping Address	Insert			Cayuga Medical Center at Ithaca 101 Dates Drive Ithaca, NY 14850	8/1/2016 11:23 AM
Contacts	Primary Contact	Insert			Wilkins, Karen Cayuga Medical Center at Ithaca 6072744406	1/5/2016 11:28 AM
Dates	Participating Approval Date	Update			10/26/2015 12:00:00 AM	10/26/2015 3:26 PM
Details	State	Update		Pending	Active	10/26/2015 3:26 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	10/26/2015 3:26 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_54552	DSH330307A	10/7/2015 1:51 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_54552	10/6/2015 12:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2015 12:36 PM
Medicaid Billing	Medicaid: Number	Insert			03001085	10/6/2015 12:36 PM
Medicaid Billing	Medicaid: State	Insert			NY	10/6/2015 12:36 PM
Medicaid Billing	NPI: Number	Insert			1962422733	10/6/2015 12:36 PM
Details	Last Recertification Date	Insert				10/6/2015 12:36 PM
Details	Grant Number	Insert				10/6/2015 12:36 PM
Details	340B ID	Insert				10/6/2015 12:36 PM
Details	Is Authorizing Official EHB Data	Insert				10/6/2015 12:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/6/2015 12:36 PM
Details	Medicare Provider Number	Insert			330307	10/6/2015 12:36 PM
Details	Entity Name	Insert			CAYUGA MEDICAL CENTER AT ITHACA	10/6/2015 12:36 PM
Details	Program Code	Insert			DSH	10/6/2015 12:36 PM
Details	Entity Subname	Insert			Urgent Care East Campus	10/6/2015 12:36 PM
Dates	Participating Approval Date	Insert				10/6/2015 12:36 PM
Details	State	Insert			Pending	10/6/2015 12:36 PM
Dates	Registration Date	Insert			10/6/2015 12:00:00 AM	10/6/2015 12:36 PM
Dates	Signed By Date	Insert			10/6/2015 12:00:00 AM	10/6/2015 12:36 PM
Dates	Start Date	Insert				10/6/2015 12:36 PM
Terminations	Termination Comments	Insert				10/6/2015 12:36 PM
Terminations	Termination Date	Insert				10/6/2015 12:36 PM
Terminations	Termination Effective Date	Insert				10/6/2015 12:36 PM
Terminations	Termination Reason	Insert				10/6/2015 12:36 PM