Covered Entity Details

DSH330241AX UNIVERSITY HOSPITAL (Active) - information as of 5/5/2025 11:58:57 PM

Main Details

Name

UNIVERSITY HOSPITAL

Subdivision Name

Outpatient Infusion Services - CC

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330241AX

Medicare Provider Number

330241

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/6/2015

Participating Start Date

1/1/2016

Participating Approval Date

10/30/2015

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

SUNY Upstate Medical University Hospital
Stuart M. Wright, Chief Financial Officer
(315) 464-5179

Primary Contact

SUNY Upstate Medical University Hospital
Amanda Marzella, 340B Contract Pharmacy Manager
(315) 464-6039

Addresses

Street Address

4900 Broad Road
Outpatient Surgery Center
1st Floor
SYRACUSE, NY 13215

Billing Address

Upstate University Hospital
750 East Adams Street
Syracuse, NY 13210

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
NY	03001723,06561191,07399897,05062253	1578554630,1740796697,1396330932,1306567474

Shipping Addresses

Shipping Address 1

Upstate University Hospital at Community
4900 Broad Road
Syracuse, NY 13215

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
DSH330241A	Child	DSH	UNIVERSITY HOSPITAL	Upstate Urology	550 Harrison Street	Syracuse	NY	Active
DSH330241AA	Child	DSH	UNIVERSITY HOSPITAL	University Geriatricians	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241AB	Child	DSH	UNIVERSITY HOSPITAL	Upstate University Hospital Dental Services	Upstate Health Care Center	Syracuse	NY	Active
DSH330241AC	Child	DSH	UNIVERSITY HOSPITAL	Women's Health Services	Upstate Health Care Center	Syracuse	NY	Active
DSH330241AD	Child	DSH	UNIVERSITY HOSPITAL	Adult Medicine	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241AE	Child	DSH	UNIVERSITY HOSPITAL	Regional Oncology Center	750 East Adams Street	Syracuse	NY	Terminated
DSH330241AF	Child	DSH	UNIVERSITY HOSPITAL	Health Services - Employee and Student Health	175 Elizabeth Blackwell Street	Syracuse	NY	Terminated
DSH330241AG	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Surgery	Physicians Office Building	Syracuse	NY	Active
DSH330241AH	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Urology	Physicians Office Building	Syracuse	NY	Active
DSH330241AJ	Child	DSH	UNIVERSITY HOSPITAL	ENT Clinic	550 Harrison Street	Syracuse	NY	Active
DSH330241AK	Child	DSH	UNIVERSITY HOSPITAL	Women's Imaging 550 Harrison	550 Harrison Street	Syracuse	NY	Active
DSH330241AL	Child	DSH	UNIVERSITY HOSPITAL	Upstate Comprehensive Pain Management - CC	4900 Broad Road	Syracuse	NY	Terminated
DSH330241AM	Child	DSH	UNIVERSITY HOSPITAL	Emergency Department - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AN	Child	DSH	UNIVERSITY HOSPITAL	Epilepsy Monitoring Unit - CC	4900 Broad Road	Syracuse	NY	Terminated
DSH330241AP	Child	DSH	UNIVERSITY HOSPITAL	Radiology - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AQ	Child	DSH	UNIVERSITY HOSPITAL	Upstate Golisano After Hours Care - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AR	Child	DSH	UNIVERSITY HOSPITAL	Respiratory Care - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AS	Child	DSH	UNIVERSITY HOSPITAL	Upstate Vascular Surgery - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AT	Child	DSH	UNIVERSITY HOSPITAL	Upstate Bariatric, General & Thoracic Surgery - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AU	Child	DSH	UNIVERSITY HOSPITAL	Upstate Urology - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AV	Child	DSH	UNIVERSITY HOSPITAL	Upstate Midwifery and Gynecology - CC	4900 Broad Road	Syracuse	NY	Terminated
DSH330241AW	Child	DSH	UNIVERSITY HOSPITAL	Wellspring Breast Cancer Center - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AX	Child	DSH	UNIVERSITY HOSPITAL	Outpatient Infusion Services - CC	4900 Broad Road	SYRACUSE	NY	Active
DSH330241AY	Child	DSH	UNIVERSITY HOSPITAL	Labor and Delivery - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241AZ	Child	DSH	UNIVERSITY HOSPITAL	ENT Clinic - CC	4900 Broad Road	SYRACUSE	NY	Active
DSH330241B	Child	DSH	UNIVERSITY HOSPITAL	Joslin Diabetes Center	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241BA	Child	DSH	UNIVERSITY HOSPITAL	Upstate Internists	Nappi Wellness Institute	SYRACUSE	NY	Active
DSH330241BB	Child	DSH	UNIVERSITY HOSPITAL	CT SCAN - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BC	Child	DSH	UNIVERSITY HOSPITAL	Ultrasound - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BD	Child	DSH	UNIVERSITY HOSPITAL	Nuclear Medicine - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BE	Child	DSH	UNIVERSITY HOSPITAL	MRI - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BF	Child	DSH	UNIVERSITY HOSPITAL	Stress Echo / Echocardiology - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BG	Child	DSH	UNIVERSITY HOSPITAL	Upstate Health Care Center / Radiology	Upstate Health Care Center	Syracuse	NY	Active
DSH330241BH	Child	DSH	UNIVERSITY HOSPITAL	Radiology - 550 Harrison	550 Harrison Street	Syracuse	NY	Active
DSH330241BJ	Child	DSH	UNIVERSITY HOSPITAL	Ambulatory Surgical Center - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BK	Child	DSH	UNIVERSITY HOSPITAL	Post-Op - CC	4900 Broad Road	Syracuse	NY	Active
DSH330241BL	Child	DSH	UNIVERSITY HOSPITAL	Main Operating Room - CC	4900 Broad Road	Syracuse	NY	Terminated
DSH330241BM	Child	DSH	UNIVERSITY HOSPITAL	Psychiatric Hospital - Outpatient Psychiatric Clinic - Adult	713 Harrison Street	Syracuse	NY	Active
DSH330241BP	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 4 East PMR CC - Observation	4900 Broad Road	Syracuse	NY	Terminated
DSH330241BQ	Child	DSH	UNIVERSITY HOSPITAL	Family Medicine - Family Medicine-NAPPI	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241BR	Child	DSH	UNIVERSITY HOSPITAL	Psychiatric Hospital - Outpatient Psychiatric Clinic - Pediatric	713 Harrison Street	Syracuse	NY	Active
DSH330241BS	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 5 West Psychiatry CC -Observation	4900 Broad Road	Syracuse	NY	Terminated
DSH330241BT	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - ICU CC -Observation	4900 Broad Road	Syracuse	NY	Active
DSH330241BU	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 4 North Med/Surg CC - Observation	4900 Broad Road	Syracuse	NY	Active
DSH330241BV	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 6 Med/Surg/Ortho CC - Observation	4900 Broad Road	Syracuse	NY	Active
DSH330241BW	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 2 POSTPARTUM GYN CC - Observation	4900 Broad Road	Syracuse	NY	Active
DSH330241BX	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 3 WEST MEDICAL CC - Observation	4900 Broad Road	Syracuse	NY	Active
DSH330241BY	Child	DSH	UNIVERSITY HOSPITAL	Community General Hospital - 5 East Transitional Care Unit CC - Observation	4900 Broad Road	Syracuse	NY	Terminated
DSH330241BZ	Child	DSH	UNIVERSITY HOSPITAL	Radiation Oncology- Seneca Hill - Radiation Oncology	105 County Route 45A	Oswego	NY	Active
DSH330241C	Child	DSH	UNIVERSITY HOSPITAL	Wound Care - CC	4900 Broad Road	Syracuse	NY	Terminated
DSH330241CA	Child	DSH	UNIVERSITY HOSPITAL	Joslin Adult Center-Community Campus - Diabetes	4900 Broad Road POB North	Syracuse	NY	Terminated
DSH330241CB	Child	DSH	UNIVERSITY HOSPITAL	Radiation Oncology-Hill Med Ct - Radiation Oncology	1000 East Genesee Street	Syracuse	NY	Active
DSH330241CC	Child	DSH	UNIVERSITY HOSPITAL	Family Medicine- Community Campus - Primary Care/ Family and Preventive Medicine	4900 Broad Road	Syracuse	NY	Active
DSH330241CD	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Infectious Disease Provider-Based Clinic - Pediatric Hematology and Infectious Disease	Physicians Office Building	Syracuse	NY	Active
DSH330241CE	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Specialty Clinic - Pediatric Pulmonary, CF and adult CF	475 Irving Avenue	Syracuse	NY	Active
DSH330241CF	Child	DSH	UNIVERSITY HOSPITAL	OSWEGO HEMATOLOGY/ONCOLOGY HOSPITAL BASED CLINIC - HEMATOLOGY/ONCOLOGY	140 W. 6th Street	Oswego	NY	Active
DSH330241CG	Child	DSH	UNIVERSITY HOSPITAL	INTERVENTIONAL RADIOLOGY-COMMUNITY CAMPUS - Interventional Radiology	4900 Broad Road	Syracuse	NY	Active
DSH330241CH	Child	DSH	UNIVERSITY HOSPITAL	MEDICAL TOXICOLOGY- PROVIDER BASED NAPPI - Medical Toxicology/Bridge Clinic	Nappi Wellness Institute	SYRACUSE	NY	Active
DSH330241CJ	Child	DSH	UNIVERSITY HOSPITAL	CENTER FOR SPECIAL NEEDS-HOSPITAL BASED - DEVELOPMENTAL EVALUATION CENTER	Upstate Health Care Center	SYRACUSE	NY	Terminated
DSH330241CK	Child	DSH	UNIVERSITY HOSPITAL	Golisano Center for Special Needs - Development, Behavior, & Genetics- Provider Based	475 Irving Avenue	Syracuse	NY	Active
DSH330241CL	Child	DSH	UNIVERSITY HOSPITAL	McMahon Ryan Child Advocacy Center - C.A.R.E Clinic	601 East Genesee Street	Syracuse	NY	Active
DSH330241CM	Child	DSH	UNIVERSITY HOSPITAL	Influenza-Like Illness Clinic - Adult and Pediatric Seasonal Clinic	4900 Broad Road	Syracuse	NY	Terminated
DSH330241CN	Child	DSH	UNIVERSITY HOSPITAL	Sleep Disorder Lab at Community - Electroencephalography (EEG)	4900 Broad Road	Syracuse	NY	Active
DSH330241CP	Child	DSH	UNIVERSITY HOSPITAL	Upstate Brain & Spine Center - Neurosurgery- Provider Based CC POB	4900 Broad Road	Syracuse	NY	Active
DSH330241CQ	Child	DSH	UNIVERSITY HOSPITAL	4 West at Community-Outpatient Observation Beds - Med/Surg-Observation	Upstate University Hospital at Community Campus	Syracuse	NY	Active
DSH330241CR	Child	DSH	UNIVERSITY HOSPITAL	Gynecology Oncology Hospital Based Madison Irving Med Ctr - Gynecology Oncology	Upstate University Hospital	Syracuse	NY	Active
DSH330241CS	Child	DSH	UNIVERSITY HOSPITAL	Upstate Cancer Center at Community (Hospital-Based) - Hematology/Oncology	Upstate University Hospital at Community Campus	Syracuse	NY	Active
DSH330241CT	Child	DSH	UNIVERSITY HOSPITAL	Connect Care Program Clinic - Continuous Care	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241CU	Child	DSH	UNIVERSITY HOSPITAL	Center for International Health - Primary Care	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241CV	Child	DSH	UNIVERSITY HOSPITAL	Breast Care and Plastic Surgery Center (Provider-Based CC POB) - Breast Care	4900 Broad Road	Syracuse	NY	Active
DSH330241CW	Child	DSH	UNIVERSITY HOSPITAL	CARDIOLOGY PROVIDER-BASED MANLIUS - CARDIOLOGY	102 West Seneca Street	Manlius	NY	Active
DSH330241CX	Child	DSH	UNIVERSITY HOSPITAL	TRANSPLANT CLINIC- PROVIDER BASED 550HAR - Transplant	550 Harrison Street	Syracuse	NY	Active
DSH330241CY	Child	DSH	UNIVERSITY HOSPITAL	UPSTATE BRAIN AND SPINE CENTER at UHCC - NEUROSURGERY-PROVIDER BASED	Upstate Health Care Center	Syracuse	NY	Active
DSH330241CZ	Child	DSH	UNIVERSITY HOSPITAL	RADIOLOGY NAPPI - Radiology Services	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241D	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Rheumatology and Integrative Medicine	Physicians Office Building	Syracuse	NY	Active
DSH330241DA	Child	DSH	UNIVERSITY HOSPITAL	HEMATOLOGY ONCOLOGY VERONA- HOSPITAL BASED - Hematology/Oncology	Upstate Cancer Center at Verona	Verona	NY	Active
DSH330241DB	Child	DSH	UNIVERSITY HOSPITAL	UROLOGY CLINIC AT VERONA- PROVIDER BASED - Urology	Upstate Cancer Center at Verona	Verona	NY	Active
DSH330241DC	Child	DSH	UNIVERSITY HOSPITAL	RADIATION ONCOLOGY VERONA- HOSPITAL BASED - Rad/Onc	Upstate Cancer Center at Verona	Verona	NY	Active
DSH330241DD	Child	DSH	UNIVERSITY HOSPITAL	CONCUSSION MANAGEMENT CLINIC CLAY- HOSPITAL BASED - Psychology	8687 Carling Road	Liverpool	NY	Active
DSH330241DE	Child	DSH	UNIVERSITY HOSPITAL	INTEGRATED CARE NAPPI- HOSPITAL BASED - Psychiatry Amb. Care	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241DF	Child	DSH	UNIVERSITY HOSPITAL	Surgical Subspecialties 550 Provider Based - Surgical Ambulatory Care	550 Harrison Street	Syracuse	NY	Active
DSH330241E	Child	DSH	UNIVERSITY HOSPITAL	Center for Development, Behavior & Genetics	Physicians Office Building	Syracuse	NY	Active
DSH330241F	Child	DSH	UNIVERSITY HOSPITAL	Upstate Dermatology	Upstate Health Care Center	Syracuse	NY	Active
DSH330241G	Child	DSH	UNIVERSITY HOSPITAL	Upstate Pediatrics at Baldwinsville	3448 Route 31	Baldwinsville	NY	Active
DSH330241H	Child	DSH	UNIVERSITY HOSPITAL	Upstate Outpatient Surgery Center	550 Harrison Street	Syracuse	NY	Active
DSH330241J	Child	DSH	UNIVERSITY HOSPITAL	Upstate Ophthalmology	550 Harrison Street	Syracuse	NY	Active
DSH330241K	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Endocrinology Joslin Clinic	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241L	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Gastroenterology, Hepatology and Nutrition	Physicians Office Building	Syracuse	NY	Active
DSH330241M	Child	DSH	UNIVERSITY HOSPITAL	Inclusive Health Services	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241N	Child	DSH	UNIVERSITY HOSPITAL	Upstate Rheumatology	Upstate Health Care Center	Syracuse	NY	Active
DSH330241P	Child	DSH	UNIVERSITY HOSPITAL	Pediatric Nephrology Center	Physicians Office Building	Syracuse	NY	Active
DSH330241Q	Child	DSH	UNIVERSITY HOSPITAL	Upstate Pediatric and Adolescent Center	Nappi Wellness Institute	Syracuse	NY	Active
DSH330241R	Child	DSH	UNIVERSITY HOSPITAL	Breast Care, Endocrine and Plastic Surgery Center	550 Harrison Street	Syracuse	NY	Active
DSH330241S	Child	DSH	UNIVERSITY HOSPITAL	Upstate Nephrology	Upstate Health Care Center	Syracuse	NY	Active
DSH330241T	Child	DSH	UNIVERSITY HOSPITAL	Glaucoma Clinic	550 Harrison Street	Syracuse	NY	Terminated
DSH330241U	Child	DSH	UNIVERSITY HOSPITAL	Renal Clinic	University Health Care Center	Syracuse	NY	Terminated
DSH330241W	Child	DSH	UNIVERSITY HOSPITAL	Perinatal Center	Upstate Health Care Center	Syracuse	NY	Active
DSH330241X	Child	DSH	UNIVERSITY HOSPITAL	Pulmonary Clinic	Upstate Health Care Center	Syracuse	NY	Active
DSH330241Y	Child	DSH	UNIVERSITY HOSPITAL	Cardiology & Heart Failure Center	Upstate Health Care Center	Syracuse	NY	Active
DSH330241Z	Child	DSH	UNIVERSITY HOSPITAL	Upstate Neurology	Upstate Health Care Center	Syracuse	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Schmidt, Katie 340B Coordinator SUNY Upstate Medical University Hospital 3154644212	Marzella, Amanda 340B Contract Pharmacy Manager SUNY Upstate Medical University Hospital 3154646039	8/30/2024 12:53 PM
Details	Last Recertification Date	Update	Recertification	8/14/2023 8:48:09 AM	8/12/2024 10:45:43 AM	8/12/2024 10:45 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 4:26:18 PM	8/14/2023 8:48:09 AM	8/14/2023 8:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/22/2023 2:31 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		07399897	6/22/2023 2:31 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	6/22/2023 2:31 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1306567474	6/22/2023 2:31 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	6/22/2023 2:31 PM
Addresses	Main Address	Update	Change Request	4900 Broad Road Outpatient Surgery Center SYRACUSE, NY 13215	4900 Broad Road Outpatient Surgery Center 1st Floor SYRACUSE, NY 13215	5/24/2023 11:27 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 3:41:31 PM	8/29/2022 4:26:18 PM	8/29/2022 4:26 PM
Addresses	Shipping Address	Insert	Recertification		Upstate University Hospital at Community 4900 Broad Road Syracuse, NY 13215	9/13/2021 3:41 PM
Addresses	Main Address	Update	Recertification	4900 Broad Road SYRACUSE, NY 13215	4900 Broad Road Outpatient Surgery Center SYRACUSE, NY 13215	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		03001723	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		06561191	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/13/2021 3:41 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00354590 (NY)		9/13/2021 3:41 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1396330932	9/13/2021 3:41 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/13/2021 3:41 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 4:19:28 PM	9/13/2021 3:41:31 PM	9/13/2021 3:41 PM
Details	Entity Subname	Update	Recertification	Outpatient Infusion Service - CC	Outpatient Infusion Services - CC	9/13/2021 3:41 PM
Contacts	Authorizing Official	Update	Change Request	Corona, Robert John CEO SUNY Upstate Medical University Hospital 3154644223	Wright, Stuart M. Chief Financial Officer SUNY Upstate Medical University Hospital 3154645179	2/4/2021 9:54 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	8/24/2020 4:19 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	8/24/2020 4:19 PM
Details	Last Recertification Date	Update	Recertification	8/19/2019 11:55:20 AM	8/24/2020 4:19:28 PM	8/24/2020 4:19 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 4:04:40 PM	8/19/2019 11:55:20 AM	8/19/2019 11:55 AM
Contacts	Authorizing Official	Update	Profile Change Request	Corona, Robert John interim CEO SUNY Upstate Medical University Hospital 3154644223	Corona, Robert John CEO SUNY Upstate Medical University Hospital 3154644223	1/17/2019 7:55 PM
Contacts	Primary Contact	Update	Change Request	Balotin, Eric Associate Director of Pharmacy SUNY Upstate Medical University Hospital 3154644215	Schmidt, Katie 340B Coordinator SUNY Upstate Medical University Hospital 3154644212	12/4/2018 3:12 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 1:47:12 PM	8/27/2018 4:04:40 PM	8/27/2018 4:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/21/2018 3:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05062253	5/21/2018 3:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	5/21/2018 3:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740796697	5/21/2018 3:54 PM
Contacts	Primary Contact	Update	Change Request	Richardson, Kimberly 340B Compliance Manager University Hospital 3154644212	Balotin, Eric Associate Director of Pharmacy SUNY Upstate Medical University Hospital 3154644215	5/18/2018 2:15 PM
Contacts	Authorizing Official	Update	Change Request	Scott, Steven Chief Executive Officer Upstate University Hospital 3154644223	Corona, Robert John interim CEO SUNY Upstate Medical University Hospital 3154644223	4/13/2018 12:41 PM
Details	Last Recertification Date	Update	Recertification	10/25/2017 2:18:54 PM	11/8/2017 1:47:12 PM	11/8/2017 1:47 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	10/25/2017 2:18:54 PM	10/25/2017 2:18 PM
Contacts	Authorizing Official	Update		Scott, Steven Chief Executive Officer 3154644223	Scott, Steven Chief Executive Officer Upstate University Hospital 3154644223	10/20/2017 3:26 PM
Contacts	Primary Contact	Update		Richardson, Kimberly 340B Compliance Manager 3154644212	Richardson, Kimberly 340B Compliance Manager University Hospital 3154644212	9/20/2017 9:00 AM
Contacts	Primary Contact	Update		Boggs, Kimberly 340B Program Coordinator 3154644212	Richardson, Kimberly 340B Compliance Manager 3154644212	7/25/2017 7:34 AM
Contacts	Authorizing Official	Insert			Scott, Steven Chief Executive Officer 3154644223	7/25/2017 7:34 AM
Addresses	Main Address	Insert			4900 Broad Road SYRACUSE, NY 13215	7/13/2017 11:59 AM
Addresses	Billing Address	Insert			Upstate University Hospital 750 East Adams Street Syracuse, NY 13210	7/13/2017 11:59 AM
Contacts	Signed By	Insert			McCabe, John Chief Executive Officer 3154644223	7/13/2017 11:59 AM
Contacts	Primary Contact	Update		Ciullo, Steven Director of Pharmacy 3154644215	Boggs, Kimberly 340B Program Coordinator 3154644212	10/13/2016 9:11 AM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 4:37 PM
Contacts	Primary Contact	Insert			Ciullo, Steven Director of Pharmacy 3154644215	5/18/2016 12:12 PM
Details	Entity Name	Update		UNIVERSITY HOSPITAL AT SYRACUSE	UNIVERSITY HOSPITAL	3/31/2016 1:09 PM
Details	Entity Subname	Update		UPSTATE UNIVERSITY HOSPITAL / Outpatient Infusion Service - CC	Outpatient Infusion Service - CC	3/31/2016 1:09 PM
Dates	Participating Approval Date	Update			10/30/2015 12:00:00 AM	10/30/2015 11:04 AM
Details	State	Update		Pending	Active	10/30/2015 11:04 AM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	10/30/2015 11:04 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_54560	DSH330241AX	10/19/2015 11:31 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_54560	10/6/2015 1:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2015 1:03 PM
Medicaid Billing	Medicaid: Number	Insert			00354590	10/6/2015 1:03 PM
Medicaid Billing	Medicaid: State	Insert			NY	10/6/2015 1:03 PM
Medicaid Billing	NPI: Number	Insert			1578554630	10/6/2015 1:03 PM
Details	Last Recertification Date	Insert				10/6/2015 1:03 PM
Details	Grant Number	Insert				10/6/2015 1:03 PM
Details	340B ID	Insert				10/6/2015 1:03 PM
Details	Is Authorizing Official EHB Data	Insert				10/6/2015 1:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/6/2015 1:03 PM
Details	Medicare Provider Number	Insert			330241	10/6/2015 1:03 PM
Details	Entity Name	Insert			UNIVERSITY HOSPITAL AT SYRACUSE	10/6/2015 1:03 PM
Details	Program Code	Insert			DSH	10/6/2015 1:03 PM
Details	Entity Subname	Insert			UPSTATE UNIVERSITY HOSPITAL / Outpatient Infusion Service - CC	10/6/2015 1:03 PM
Dates	Participating Approval Date	Insert				10/6/2015 1:03 PM
Details	State	Insert			Pending	10/6/2015 1:03 PM
Dates	Registration Date	Insert			10/6/2015 12:00:00 AM	10/6/2015 1:03 PM
Dates	Signed By Date	Insert			10/6/2015 12:00:00 AM	10/6/2015 1:03 PM
Dates	Start Date	Insert				10/6/2015 1:03 PM
Terminations	Termination Comments	Insert				10/6/2015 1:03 PM
Terminations	Termination Date	Insert				10/6/2015 1:03 PM
Terminations	Termination Effective Date	Insert				10/6/2015 1:03 PM
Terminations	Termination Reason	Insert				10/6/2015 1:03 PM