Covered Entity Details

DSH180040AE UofL Health -- Louisville (Active) - information as of 4/28/2025 12:42:25 AM

Main Details

Name

UofL Health -- Louisville

Subdivision Name

Jewish Hospital Outpatient Care Center / Surgery

Type

Disproportionate Share Hospital

Rural

340B ID

DSH180040AE

Medicare Provider Number

180040

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/13/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/17/2015

Last Recertification Date

8/31/2024

Contacts

Authorizing Official

University of Louisville Hospital
Steve Amsler, Senior Vice President of Operations
(502) 562-4122

Primary Contact

UofL Health
Robert Michael Fink, System Vice President, Pharmacy Services
(502) 562-3211

Addresses

Street Address

225 Abraham Flexner Way
Louisville, KY 40202

Billing Address

University of Louisville Hospital
530 South Jackson Street
Louisville, KY 40202

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
KY	01022367	1639711294
IN	300038900	1639711294

Shipping Addresses

Shipping Address 1

Jewish Hospital
200 Abraham Flexner Way
Louisville, KY 40202

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
DSH180040A	Child	DSH	JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)	DBA Amerimed1	5111 COMMERCE CROSSING DRIVE	LOUISVILLE	KY	Terminated
DSH180040AA	Child	DSH	UofL Health -- Louisville	Jewish Hospital Outpatient Care Center / Endoscopy 2	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040AB	Child	DSH	UofL Health -- Lousiville	Jewish Hospital Outpatient Care Center / Endoscopy	225 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040AC	Child	DSH	UofL Health -- Louisville	Jewish Hospital Outpatient Care Center / PACU	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040AD	Child	DSH	UofL Health -- Louisville	Jewish Hospital Outpatient Care Center / Pre-Op	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040AE	Child	DSH	UofL Health -- Louisville	Jewish Hospital Outpatient Care Center / Surgery	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040AF	Child	DSH	UofL Health -- Louisville	Medical Center Southwest / Emergency Department	9700 Stonestreet Road	Louisville	KY	Active
DSH180040AG	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Pulmonary Rehab	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AH	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Cardiac Cath Lab	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AJ	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / CT Scan	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AK	Child	DSH	UofL Health -- Lousiville	Mary & Elizabeth Hospital / Radiation Therapy	1850 Bluegrass Ave	Louisville	KY	Terminated
DSH180040AL	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Nuclear Imaging	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AM	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / MRI	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AN	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Interventional Radiology	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AP	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Radiology	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AQ	Child	DSH	UofL Health -- Louisville	Mary & ELizabeth Hospital / Recovery Room	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AR	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Surgery Second floor	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AS	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Surgery first floor	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040AT	Child	DSH	UofL Health -- Louisville	Medical Center Southwest / CT Scan	9700 Stonestreet Road	Louisville	KY	Active
DSH180040AU	Child	DSH	UofL Health -- Lousiville	Medical Center Southwest / Neurodiagnostics	9700 Stonestreet Road	Louisville	KY	Terminated
DSH180040AV	Child	DSH	UofL Health -- Louisville	Medical Center East / Operating Pre-op Room Pod D	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040AW	Child	DSH	UofL Health -- Louisville	Medical Center East / Operating Pre-op Room Pod C	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040AX	Child	DSH	UofL Health -- Louisville	Medical Center East / Operating Pre-Op Room East Pod B	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040AY	Child	DSH	UofL Health -- Louisville	Medical Center East / Surgery	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040AZ	Child	DSH	UofL Health -- Louisville	Medical Center Southwest / Ultrasound	9700 Stonestreet Road	Louisville	KY	Active
DSH180040B	Child	DSH	UofL Health -- Louisville	MARY & ELIZABETH HOSPITAL	1850 BLUEGRASS AVE	LOUISVILLE	KY	Terminated
DSH180040BA	Child	DSH	UofL Health -- Louisville	Medical Center Southwest / MRI	9700 Stonestreet Road	Louisville	KY	Active
DSH180040BB	Child	DSH	UofL Health -- Louisville	Medical Center South / PACU	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040BC	Child	DSH	UofL Health -- Louisville	Medical Center South / Surgery & Endoscopy	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040BD	Child	DSH	UofL Health -- Louisville	Medical Center Southwest / Diagnostic Imaging	9700 Stonestreet Road	Louisville	KY	Active
DSH180040BE	Child	DSH	UofL Health -- Lousiville	Medical Center South / Endoscopy	1903 West Hebron Lane	Shepherdsville	KY	Terminated
DSH180040BF	Child	DSH	UofL Health -- Louisville	MEDICAL CENTER EAST / ENDO	3920 DUTCHMAN'S LANE	LOUISVILLE	KY	Active
DSH180040BG	Child	DSH	UofL Health -- Louisville	Peace / Psychiatric Outpatient	2020 Newburg Road	Louisville	KY	Terminated
DSH180040BH	Child	DSH	UofL Health -- Louisville	Medical Center South / Cardiopulmonary	1903 West Hebron Lane	Sheperdsville	KY	Active
DSH180040BJ	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Emergency Room	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040BK	Child	DSH	UofL Health -- Louisville	Medical Center South / Emergency Dept	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040BL	Child	DSH	UofL Health -- Louisville	Medical Center East / Emergency Room	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040BM	Child	DSH	UofL Health -- Louisville	MEDICAL CENTER NORTHEAST / MEDICAL IMAGING	2401 TERRA CROSSING BOULEVARD	LOUISVILLE	KY	Active
DSH180040BN	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital / Respiratory Care	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040BP	Child	DSH	UofL Health -- Louisville	Frazier Rehabilitation Institute / 9 Frazier North Outpatient	220 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040BQ	Child	DSH	UofL Health -- Lousiville	Frazier Rehabilitation Institute / 12 Frazier Outpatient	220 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040BR	Child	DSH	JEWISH HOSPITAL & ST MARYS HEALTH	JEWISH HOSPITAL MEDICAL CENTER NORTHEAST / INFUSION CENTER	2401 TERRA CROSSING BOULEVARD	LOUISVILLE	KY	Terminated
DSH180040BS	Child	DSH	UofL Health -- Lousiville	Mary & Elizabeth Hospital Bariatric	1850 Bluegrass Ave	Louisville	KY	Terminated
DSH180040BT	Child	DSH	JEWISH HOSPITAL & ST MARYS HEALTH	Jewish Hospital DBA STS Mary & Elizabeth Hospital / Jewish Hospital DBA STS Mary & Elizabeth Hospital Anethesiology	1850 Bluegrass Ave	Louisville	KY	Terminated
DSH180040BU	Child	DSH	UofL Health -- Louisville	MEDICAL CENTER EAST MEDICAL IMAGING/OUTPAT INJECTIONS	3920 DUTCHMAN'S LANE	LOUISVILLE	KY	Active
DSH180040BV	Child	DSH	UofL Health -- Louisville	MARY & ELIZABETH HOSPITAL / SSDAY Infusion Center	1850 BLUEGRASS AVE	LOUISVILLE	KY	Active
DSH180040BW	Child	DSH	UofL Health -- Louisville	Transplant Clinic at Frazier Rehabilitation Institute	220 Abraham Flexner Way	Louisville	KY	Active
DSH180040BX	Child	DSH	UofL Health -- Louisville	Jewish Hospital DBA Our Lady of Peace / Long Acting Injectable Clinic	2020 Newburg Road	Louisville	KY	Active
DSH180040BY	Child	DSH	UofL Health -- Louisville	Frazier Rehabilitation Institute / 6 Frazier Outpatient	220 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040BZ	Child	DSH	UofL Health -- Louisville	Outpatient Care Center	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040C	Child	DSH	UofL Health -- Louisville	Peace Hospital	2020 NEWBURG ROAD	LOUISVILLE	KY	Terminated
DSH180040CA	Child	DSH	UofL Health -- Louisville	Jewish Hospital Wound Care	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040CB	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - 5 East	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CC	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - Orthopedic	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CD	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - 3A PCU	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CE	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - 2A Med Sur	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CF	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - ICU-CCU	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CG	Child	DSH	UofL Health -- Louisville	Frazier Rehabilitation Institute / 6 Frazier OT - Occupational Therapy	220 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040CH	Child	DSH	UofL Health -- Louisville	Frazier Rehabilitation Institute / 6 Frazier ST - Speech Therapy	220 Abraham Flexner Way	Louisville	KY	Terminated
DSH180040CJ	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital - Echo Lab	1850 Bluegrass Ave	Louisville	KY	Active
DSH180040CK	Child	DSH	UofL Health -- Louisville	Medical Center South CT Scan - CT Scan	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040CL	Child	DSH	UofL Health -- Louisville	Medical Center South Ultrasound - Ultrasound	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040CM	Child	DSH	UofL Health -- Louisville	Medical Center East CT Scan - CT Scan	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040CN	Child	DSH	UofL Health -- Louisville	Medical Center South Nuclear Medicine - Nuclear Medicine	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040CP	Child	DSH	UofL Health -- Louisville	Medical Center East Ultrasound - Ultrasound	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040CQ	Child	DSH	UofL Health -- Louisville	Medical Center South Diagnostic Imaging - Diagnostic Imaging	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040CR	Child	DSH	UofL Health -- Louisville	Medical Center East Cardiopulmonary - Cardiopulmonary	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040CS	Child	DSH	UofL Health -- Louisville	Medical Center East Nuclear Medicine - Nuclear Medicine	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040CT	Child	DSH	UofL Health -- Louisville	ULH MCE MTM Clinic - Medication Therapy Management	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040CU	Child	DSH	UofL Health -- Louisville	UofL Health South Infusion - Infusion	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040CV	Child	DSH	UofL Health -- Louisville	MCNE Pain Clinic - Pain Management and Injections	2401 Terra Crossing Blvd	Louisville	KY	Active
DSH180040CW	Child	DSH	UofL Health -- Louisville	Mary & Elizabeth Hospital Lab - Lab	1850 Bluegrass Avenue	Louisville	KY	Active
DSH180040CX	Child	DSH	UofL Health -- Louisville	Medical Center East Lab - Lab	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040D	Child	DSH	UofL Health -- Louisville	DBA ST MARY'S SURGERY CENTER	1850 Bluegrass Ave	LOUISVILLE	KY	Active
DSH180040F	Child	DSH	UofL Health -- Louisville	MEDICAL CENTER SOUTHWEST	9700 STONESTREET ROAD	LOUISVILLE	KY	Terminated
DSH180040G	Child	DSH	UofL Health -- Louisville	MEDICAL CENTER NORTH EAST	2401 TERRA CROSSING BOULEVARD	LOUISVILLE	KY	Terminated
DSH180040H	Child	DSH	JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)	CANCER AND BLOOD SPECIALISTS, A SERVICE OF JEWISH HOSPITAL AND SAINT MARY'S HEALTHCARE	1460 BLUEGRASS AVE	LOUISVILLE	KY	Terminated
DSH180040J	Child	DSH	UofL Health -- Louisville	Medical Center East	3920 Dutchman's Lane	Louisville	KY	Terminated
DSH180040K	Child	DSH	UofL Health -- Louisville	Medical Center South	1903 West Hebron Lane	Shepherdsville	KY	Terminated
DSH180040L	Child	DSH	UofL Health -- Louisville	Medical Center South / Emergency Room Trauma	1903 West Hebron Lane	Shepherdsville	KY	Active
DSH180040M	Child	DSH	UofL Health -- Louisville	Medical Center East - Surgery Outpatient Care / Pod A	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040N	Child	DSH	UofL Health -- Louisville	Medical Center East / PACU	3920 Dutchman's Lane	Louisville	KY	Active
DSH180040P	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Transesophageal Echocardiography	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040Q	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Rm 9	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040R	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Rm 8	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040S	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Rm 7	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040T	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Rm 5	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040U	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Rm 2	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040V	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Core	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040W	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Angioplasty	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040X	Child	DSH	UofL Health -- Louisville	Rudd Heart and Lung Center / Cath Lab Pre-Op and Post-Op	201 Abraham Flexner Way	Louisville	KY	Active
DSH180040Y	Child	DSH	UofL Health -- Louisville	Jewish Hospital Hand Care Center / Pre-Op	225 Abraham Flexner Way	Louisville	KY	Active
DSH180040Z	Child	DSH	UofL Health -- Louisville	Jewish Hospital Hand Care Center / Surgery	225 Abraham Flexner Way	Louisville	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/25/2023 11:06:49 PM	8/31/2024 10:06:28 PM	8/31/2024 10:06 PM
Contacts	Authorizing Official	Update	Profile Change Request	Amsler, Steve Vice President of Operations University of Louisville Hospital 5025624122	Amsler, Steve Senior Vice President of Operations University of Louisville Hospital 5025624122	7/12/2024 9:19 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 10:27:07 AM	8/25/2023 11:06:49 PM	8/25/2023 11:06 PM
Addresses	Billing Address	Update	Change Request	Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202	University of Louisville Hospital 530 South Jackson Street Louisville, KY 40202	4/14/2023 2:18 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300023268 (IN)		11/10/2022 8:40 AM
Details	Last Recertification Date	Update	Recertification	9/8/2021 11:11:07 PM	8/29/2022 10:27:07 AM	8/29/2022 10:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Fink, Robert Michael System Director, Pharmacy Services UofL Health 5022175095	Fink, Robert Michael System Vice President, Pharmacy Services UofL Health 5025623211	4/11/2022 3:09 PM
Details	Last Recertification Date	Update	Recertification	9/13/2020 11:30:43 PM	9/8/2021 11:11:07 PM	9/8/2021 11:11 PM
Details	Entity Name	Update	Change Request	UofL Health -- Lousiville	UofL Health -- Louisville	10/20/2020 9:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/14/2020 11:14 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300038900	10/14/2020 11:14 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	10/14/2020 11:14 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	180040 (KY)		9/13/2020 11:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1275539587 ( )		9/13/2020 11:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1073678330 ( )		9/13/2020 11:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1639711294 ( )		9/13/2020 11:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1639711294	9/13/2020 11:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/13/2020 11:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1639711294	9/13/2020 11:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/13/2020 11:30 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 10:47:13 AM	9/13/2020 11:30:43 PM	9/13/2020 11:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01022367	7/15/2020 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	7/15/2020 10:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300023268	7/15/2020 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	7/15/2020 10:24 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1639711294	7/15/2020 10:24 AM
Details	Entity Name	Update	Change Request	JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)	UofL Health -- Lousiville	11/20/2019 6:54 AM
Contacts	Primary Contact	Update	Change Request	AlSorougi, Mustafa Pharmacy Manager JHSMH 5025608317	Fink, Robert Michael System Director, Pharmacy Services UofL Health 5022175095	11/19/2019 9:39 AM
Contacts	Authorizing Official	Update	AO Change Request	Holton, Colleen Chief Financial Officer JHSMH 5025874170	Amsler, Steve Vice President of Operations University of Louisville Hospital 5025624122	10/29/2019 11:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 10:47 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		180040	8/29/2019 10:47 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	8/29/2019 10:47 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 9:23:32 AM	8/29/2019 10:47:13 AM	8/29/2019 10:47 AM
Contacts	Primary Contact	Update	Profile Change Request	AlSorougi, Mustafa Pharmacist-Coordinator JHSMH 5025608317	AlSorougi, Mustafa Pharmacy Manager JHSMH 5025608317	6/7/2019 4:16 PM
Contacts	Authorizing Official	Update	AO Change Request	Clagg, John D. Vice President, Financial Analytics and Support kentuckyone health 5025608357	Holton, Colleen Chief Financial Officer JHSMH 5025874170	5/22/2019 3:40 PM
Contacts	Signed By	Update	Profile Change Request	Holton, Colleen Divisional VP Finance JHSMH 5025874170	Holton, Colleen Chief Financial Officer JHSMH 5025874170	5/22/2019 10:03 AM
Contacts	Signed By	Update		Holton, Colleen Divisional VP Finance 5025874170	Holton, Colleen Divisional VP Finance JHSMH 5025874170	5/22/2019 9:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1275539587	3/11/2019 2:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073678330	3/11/2019 2:29 PM
Details	Last Recertification Date	Update	Recertification	11/13/2017 9:35:20 AM	8/15/2018 9:23:32 AM	8/15/2018 9:23 AM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/13/2017 9:35:20 AM	11/13/2017 9:35 AM
Contacts	Primary Contact	Update	Change Request	Martin, Pat Asst Director of Pharmacy 5025874761	AlSorougi, Mustafa Pharmacist-Coordinator JHSMH 5025608317	10/19/2017 10:42 AM
Contacts	Authorizing Official	Update		Clagg, John D. Vice President, Financial Analytics and Support 5025608357	Clagg, John D. Vice President, Financial Analytics and Support kentuckyone health 5025608357	10/19/2017 10:13 AM
Contacts	Authorizing Official	Update		Steltenpohl, Bob VP Finance Fiscal Services 5025874691	Clagg, John D. Vice President, Financial Analytics and Support 5025608357	8/3/2017 8:46 AM
Contacts	Signed By	Insert			Holton, Colleen Divisional VP Finance 5025874170	8/3/2017 8:46 AM
Addresses	Main Address	Insert			225 Abraham Flexner Way Louisville, KY 40202	7/21/2017 7:26 PM
Addresses	Billing Address	Insert			Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202	7/21/2017 7:26 PM
Addresses	Shipping Address	Insert			Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202	7/21/2017 7:26 PM
Contacts	Primary Contact	Insert			Martin, Pat Asst Director of Pharmacy 5025874761	4/19/2017 9:02 AM
Contacts	Authorizing Official	Insert			Steltenpohl, Bob VP Finance Fiscal Services 5025874691	4/19/2017 9:02 AM
Details	Last Recertification Date	Update			8/19/2016 12:00:00 AM	8/19/2016 1:14 PM
Details	Entity Subname	Update		Jewish Hospital Outpatient Care Center / Jewish Hospital Outpatient Care Center Surgery	Jewish Hospital Outpatient Care Center / Surgery	11/17/2015 12:35 PM
Dates	Participating Approval Date	Update			11/17/2015 12:00:00 AM	11/17/2015 12:35 PM
Details	State	Update		Pending	Active	11/17/2015 12:35 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/17/2015 12:35 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_55141	DSH180040AE	11/6/2015 7:21 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_55141	10/13/2015 9:06 AM
Details	Last Recertification Date	Insert				10/13/2015 9:06 AM
Details	Grant Number	Insert				10/13/2015 9:06 AM
Details	340B ID	Insert				10/13/2015 9:06 AM
Details	Is Authorizing Official EHB Data	Insert				10/13/2015 9:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/13/2015 9:06 AM
Details	Medicare Provider Number	Insert			180040	10/13/2015 9:06 AM
Details	Entity Name	Insert			JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)	10/13/2015 9:06 AM
Details	Program Code	Insert			DSH	10/13/2015 9:06 AM
Details	Entity Subname	Insert			Jewish Hospital Outpatient Care Center / Jewish Hospital Outpatient Care Center Surgery	10/13/2015 9:06 AM
Dates	Participating Approval Date	Insert				10/13/2015 9:06 AM
Details	State	Insert			Pending	10/13/2015 9:06 AM
Dates	Registration Date	Insert			10/13/2015 12:00:00 AM	10/13/2015 9:06 AM
Dates	Signed By Date	Insert			10/13/2015 12:00:00 AM	10/13/2015 9:06 AM
Dates	Start Date	Insert				10/13/2015 9:06 AM
Terminations	Termination Comments	Insert				10/13/2015 9:06 AM
Terminations	Termination Date	Insert				10/13/2015 9:06 AM
Terminations	Termination Effective Date	Insert				10/13/2015 9:06 AM
Terminations	Termination Reason	Insert				10/13/2015 9:06 AM