Covered Entity Details

DSH160083X CATHOLIC HEALTH INITIATIVES - IOWA, CORP (Active) - information as of 6/3/2025 12:05:21 PM

Main Details

Name

CATHOLIC HEALTH INITIATIVES - IOWA, CORP

Subdivision Name

MercyOne West Des Moines Medical Center (3rd Floor Med Surg)

Type

Disproportionate Share Hospital

Rural

340B ID

DSH160083X

Medicare Provider Number

160083

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/13/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/6/2015

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

MercyOne
Terri Jane Donovan, Interim Chief Financial Officer
(515) 643-8212

Primary Contact

MercyOne
Jennifer Lynn Egbert, Market Director of Pharmacy
(304) 730-5888

Addresses

Street Address

1755 59th Place
West Des Moines, IA 50266

Billing Address
Same as Street Address

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
IA	060002,0600833	1538395975,1508964883
MO	011266400	1508964883,1538395975
AZ	29927	1508964883,1538395975
AR	114284105	1508964883,1538395975
CO	9000159864	1508964883,1538395975
IL	420680448001	1508964883,1538395975
MS	07580863	1508964883,1538395975
NE	10026115701	1508964883,1538395975
IN	300034708	1508964883,1538395975
CT	008106040	1508964883,1538395975
MN		1508964883,1538395975
NC		1508964883,1538395975

Shipping Addresses

Same as Street Address

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
DSH160083A	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CENTER	1755 59th Place	WEST DES MOINES	IA	Terminated
DSH160083AA	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	Mercy North Surgery Clinic	800 E. First Street	Ankeny	IA	Terminated
DSH160083AB	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Ankeny Endoscopy	800 E 1st St	Ankeny	IA	Active
DSH160083AC	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (4th Floor ICU)	1755 59th Place	West Des Moines	IA	Active
DSH160083AD	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (5th Floor Med/Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083AE	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (4th Floor Med/Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083AF	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES INTERNAL MED - Internal Medicine	411 LAUREL ST	DES MOINES	IA	Terminated
DSH160083AG	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES DIABETES AND EN - Diabetes and Endocrinology Care	411 LAUREL ST SUITE 3262	DES MOINES	IA	Active
DSH160083AH	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES NEUROPSYCHOLOGY - Neuropsychology	1111 6TH AVE EAST TOWER STE B1	DES MOINES	IA	Active
DSH160083AJ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES NEUROSURGERY - Neurosurgery	1111 6TH AVE EAST TOWER STE B1	DES MOINES	IA	Active
DSH160083AK	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES SURGICAL GROUP - Surgical Group	411 LAUREL ST SUITE 2100	DES MOINES	IA	Active
DSH160083AL	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES PULMONARY INFEC - Pulmonary and Infectious Disease Care	411 LAUREL ST	DES MOINES	IA	Active
DSH160083AM	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH Heart Failure-Laurel)	411 LAUREL ST STE 1225	DES MOINES	IA	Active
DSH160083AN	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH Heart Failure-West University)	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083AP	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Iowa Heart Center Des Moines (IH-SV Surg-Laurel) - Iowa Heart Center (IH-SV Surg-Laurel)	411 Laurel St STE A250	Des Moines	IA	Active
DSH160083AQ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Arry Srvcs-West Univeristy)	5880 UNIVERSITY AVE SUITE 112	WEST DES MOINES	IA	Active
DSH160083AR	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Cardiac Rehab-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AS	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Clinic Srvs-West University)	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083AT	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-IV Structural-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AU	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Clinic Srvs-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AV	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-PV Surg-West University)	5880 UNIVERSITY AVE SUITE 103	WEST DES MOINES	IA	Active
DSH160083AW	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH IOWA CORP - Iowa Heart Center (IH-Arry Srvcs-Laurel)	411 LAUREL ST STE A250	DES MOINES	IA	Active
DSH160083AX	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - Iowa Heart Center (IH-Vein Ctr-West University)	5880 UNIVERSITY AVE SUITE 103	WEST DES MOINES	IA	Active
DSH160083AY	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Radiology-Diagnostic	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083AZ	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Cardiac Rehab	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BA	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MWL Bariatric Program	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BB	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MercyOne West Des Moines Birthing Center	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BC	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE WEST DES MOINES MEDICAL CE - MercyOne West Des Moines Labor and Birthing Center	1755 59TH PL	WEST DES MOINES	IA	Active
DSH160083BD	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	CATHOLIC HEALTH INITIATIVES-IOWA CO - IH-Prevention and Wellness Clinic	5880 UNIVERSITY AVE SUITE 102	WEST DES MOINES	IA	Active
DSH160083BE	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	Mercyone Des Moines Cancer & Infusion Care - Newton - Infusion Center	204 N 4th Ave E	Newton	IA	Active
DSH160083C	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Cancer Care	411 LAUREL ST	DES MOINES	IA	Active
DSH160083D	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Ambulatory Surgery	411 LAUREL ST	DES MOINES	IA	Active
DSH160083E	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE CLIVE SLEEP CENTER	1449 NW 128th ST	CLIVE	IA	Active
DSH160083G	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES FIRST STEP RECOVERY	1750 48TH ST	DES MOINES	IA	Terminated
DSH160083H	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY WEST RADIOLOGY	1601 NW 114TH ST	CLIVE	IA	Terminated
DSH160083J	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE DES MOINES CARDIAC & PULMONARY PREVENTION AND REHABILITATION	411 Laurel St	DES MOINES	IA	Active
DSH160083L	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne Des Moines Outpatient Cardiac Testing	411 Laurel St	DES MOINES	IA	Active
DSH160083M	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Outpatient Cardiac Testing	5880 UNIVERSITY AVE	WEST DES MOINES	IA	Active
DSH160083Q	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY RADIOLOGY CENTER	12495 UNIVERSITY AVE	CLIVE	IA	Terminated
DSH160083R	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE RIVERSIDE REHABILITATION	501 SW 7th St.	DES MOINES	IA	Active
DSH160083T	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCY ATRIUM IMAGING SUITE	411 LAUREL ST.	DES MOINES	IA	Terminated
DSH160083U	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MERCYONE CLIVE ENDOSCOPY	1601 NW 114TH ST	CLIVE	IA	Active
DSH160083V	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Emergency Room)	1755 59th Place	West Des Moines	IA	Active
DSH160083W	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Cath Lab)	1755 59th Place	West Des Moines	IA	Active
DSH160083X	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (3rd Floor Med Surg)	1755 59th Place	West Des Moines	IA	Active
DSH160083Y	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Surgery)	1755 59th Place	West Des Moines	IA	Active
DSH160083Z	Child	DSH	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	MercyOne West Des Moines Medical Center (Recovery Room-PACU)	1755 59th Place	West Des Moines	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	McVey, Kevin Patrick Interim Director of Pharmacy Catholic Health Initiatives 5156432934	Egbert, Jennifer Lynn Market Director of Pharmacy MercyOne 3047305888	9/3/2024 7:26 PM
Details	Last Recertification Date	Update	Recertification	8/17/2023 10:14:58 AM	9/3/2024 7:26:52 PM	9/3/2024 7:26 PM
Contacts	Authorizing Official	Update	AO Change Request	Roettger, Jodie Lynn Interim Chief Financial Officer MercyOne 5153589267	Donovan, Terri Jane Interim Chief Financial Officer MercyOne 5156438212	2/5/2024 7:34 AM
Contacts	Primary Contact	Update	Recertification	McVey, Kevin interim PIC Catholic Health Initiatives, Iowa Corp 5156432934	McVey, Kevin Patrick Interim Director of Pharmacy Catholic Health Initiatives 5156432934	8/17/2023 10:14 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 6:50:38 AM	8/17/2023 10:14:58 AM	8/17/2023 10:14 AM
Contacts	Authorizing Official	Update	Change Request	Rubin, Randall Senior Vice President Chief Financial Officer Catholic Health Initiatives, Iowa Corp. 5156432860	Roettger, Jodie Lynn Interim Chief Financial Officer MercyOne 5153589267	6/22/2023 1:09 PM
Contacts	Primary Contact	Update	Recertification	Jordan, Candace Marie Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	McVey, Kevin interim PIC Catholic Health Initiatives, Iowa Corp 5156432934	9/6/2022 6:50 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 9:36:23 AM	9/6/2022 6:50:38 AM	9/6/2022 6:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/8/2022 2:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008106040	4/8/2022 2:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	4/8/2022 2:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	4/8/2022 2:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/8/2022 2:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	4/8/2022 2:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/8/2022 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		29927	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		114284105	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000159864	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		420680448001	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		07580863	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026115701	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300034708	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508964883	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	1/13/2022 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	1/13/2022 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	1/13/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2021 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		011266400	8/27/2021 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	8/27/2021 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2021 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0600833	8/27/2021 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	8/27/2021 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508964883	8/27/2021 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/27/2021 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508964883	8/27/2021 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/27/2021 9:36 AM
Details	Last Recertification Date	Update	Recertification	9/9/2020 12:35:19 PM	8/27/2021 9:36:23 AM	8/27/2021 9:36 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1538395975 ( )		9/9/2020 12:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1538395975	9/9/2020 12:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 12:35 PM
Contacts	Primary Contact	Update	Recertification	Young, Gregory A. DIRECTOR OF PHARMACY Catholice Health Initiatives, Iowa Corp. 5152473262	Jordan, Candace Marie Mkt Director of Pharmacy Catholic Health Initiatives, Iowa Corp 5152473262	9/9/2020 12:35 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 9:17:37 AM	9/9/2020 12:35:19 PM	9/9/2020 12:35 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 10:15:33 AM	9/3/2019 9:17:37 AM	9/3/2019 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/10/2019 3:42 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		060002	7/10/2019 3:42 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	7/10/2019 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538395975	7/10/2019 3:42 PM
Details	Entity Subname	Update	Change Request	West Lakes (3rd Floor Med Surg)	MercyOne West Des Moines Medical Center (3rd Floor Med Surg)	6/4/2019 10:37 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 1:50:46 PM	8/24/2018 10:15:33 AM	8/24/2018 10:15 AM
Contacts	Authorizing Official	Update	Change Request	Wegner, Michael A. SENIOR VP-CFO Mercy Medical Center 5152474291	Rubin, Randall Senior Vice President Chief Financial Officer Catholic Health Initiatives, Iowa Corp. 5156432860	3/1/2018 9:37 AM
Details	Entity Name	Update	Recertification	MERCY MEDICAL CENTER-DES MOINES	CATHOLIC HEALTH INITIATIVES - IOWA, CORP	11/9/2017 1:54 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/9/2017 1:50:46 PM	11/9/2017 1:50 PM
Contacts	Authorizing Official	Update		Wegner, Michael A. SENIOR VP-CFO 5152474291	Wegner, Michael A. SENIOR VP-CFO Mercy Medical Center 5152474291	10/2/2017 3:26 PM
Contacts	Signed By	Update		Wegner, Michael A. SENIOR VP-CFO 5152474291	Wegner, Michael A. SENIOR VP-CFO Mercy Medical Center 5152474291	10/2/2017 3:26 PM
Contacts	Primary Contact	Update		Young, Gregory A. DIRECTOR OF PHARMACY 5152473262	Young, Gregory A. DIRECTOR OF PHARMACY Catholice Health Initiatives, Iowa Corp. 5152473262	10/2/2017 1:05 PM
Contacts	Authorizing Official	Insert			Wegner, Michael A. SENIOR VP-CFO 5152474291	7/20/2017 9:17 AM
Contacts	Signed By	Insert			Wegner, Michael A. SENIOR VP-CFO 5152474291	7/20/2017 9:17 AM
Contacts	Primary Contact	Insert			Young, Gregory A. DIRECTOR OF PHARMACY 5152473262	6/30/2017 11:02 AM
Addresses	Main Address	Insert			1755 59th Place West Des Moines, IA 50266	11/4/2016 3:04 PM
Details	Entity Subname	Update		West Lakes (Birthing Center)	West Lakes (3rd Floor Med Surg)	11/4/2016 3:04 PM
Details	Last Recertification Date	Update			8/17/2016 12:00:00 AM	8/17/2016 3:27 PM
Dates	Participating Approval Date	Update			11/6/2015 12:00:00 AM	11/6/2015 12:36 PM
Details	State	Update		Pending	Active	11/6/2015 12:36 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/6/2015 12:36 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_55349	DSH160083X	11/3/2015 9:06 AM
Details	Entity Subname	Update		Mercy Medical Center West Lakes (Birthing Center)	West Lakes (Birthing Center)	11/3/2015 9:06 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_55349	10/13/2015 3:49 PM
Details	Last Recertification Date	Insert				10/13/2015 3:49 PM
Details	Grant Number	Insert				10/13/2015 3:49 PM
Details	340B ID	Insert				10/13/2015 3:49 PM
Details	Is Authorizing Official EHB Data	Insert				10/13/2015 3:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/13/2015 3:49 PM
Details	Medicare Provider Number	Insert			160083	10/13/2015 3:49 PM
Details	Entity Name	Insert			MERCY MEDICAL CENTER-DES MOINES	10/13/2015 3:49 PM
Details	Program Code	Insert			DSH	10/13/2015 3:49 PM
Details	Entity Subname	Insert			Mercy Medical Center West Lakes (Birthing Center)	10/13/2015 3:49 PM
Dates	Participating Approval Date	Insert				10/13/2015 3:49 PM
Details	State	Insert			Pending	10/13/2015 3:49 PM
Dates	Registration Date	Insert			10/13/2015 12:00:00 AM	10/13/2015 3:49 PM
Dates	Signed By Date	Insert			10/13/2015 12:00:00 AM	10/13/2015 3:49 PM
Dates	Start Date	Insert				10/13/2015 3:49 PM
Terminations	Termination Comments	Insert				10/13/2015 3:49 PM
Terminations	Termination Date	Insert				10/13/2015 3:49 PM
Terminations	Termination Effective Date	Insert				10/13/2015 3:49 PM
Terminations	Termination Reason	Insert				10/13/2015 3:49 PM