Covered Entity Details

DSH070036F UCONN HEALTH (Active) - information as of 5/11/2025 11:44:44 PM

Main Details

Name

UCONN HEALTH

Subdivision Name

UConn Health Surgical Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070036F

Medicare Provider Number

070036

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/17/2015

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

UConn Health
Kevin Chamberlin, Associate Vice President and Chief Pharmacy Officer
(860) 679-2281

Primary Contact

UConn Health
F. Bahar Matusik, Director for 340B Services
(860) 480-9159

Addresses

Street Address

263 Farmington Avenue
UConn Musculoskeletal Institute, 2nd Level
Farmington, CT 06030

Billing Address

University of Connecticut Health Center
263 Farmington Avenue
Farmington, CT 06030

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
CT	004025250	1669466561,1902891682

Shipping Addresses

Shipping Address 1

University of Connecticut Health Center
263 Farmington Avenue
GPS: 120 Dowling Way, 2nd Floor
Farmington, CT 06030

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
DSH070036A	Child	DSH	UCONN HEALTH	Cardiology	11 South Road	Farmington	CT	Active
DSH070036B	Child	DSH	UCONN HEALTH	Dermatology	21 South Road	Farmington	CT	Active
DSH070036C	Child	DSH	UCONN HEALTH	Outpatient Psychiatry Service	10 Talcott Notch Rd	Farmington	CT	Active
DSH070036D	Child	DSH	UCONN HEALTH	Storrs Urgent Care	1 Royce Circle	Storrs	CT	Active
DSH070036E	Child	DSH	UCONN HEALTH	UCONN Health Medical Services / Cardiology	One Royce Circle	Storrs	CT	Active
DSH070036F	Child	DSH	UCONN HEALTH	UConn Health Surgical Center	263 Farmington Avenue	Farmington	CT	Active
DSH070036G	Child	DSH	UCONN HEALTH	Neag Cancer Center	263 Farmington Avenue	Farmington	CT	Active
DSH070036H	Child	DSH	UCONN HEALTH	CANTON / CANTON URGENT CARE	117 ALBANY TURNPIKE	CANTON	CT	Active
DSH070036J	Child	DSH	UCONN HEALTH	CANTON / CANTON DERMATOLOGY AND MOH'S SURGERY	117 ALBANY TURNPIKE	CANTON	CT	Active
DSH070036K	Child	DSH	UCONN HEALTH	UConn Health Musculoskeletal Institute MRI - MRI Imaging	263 Farmington Avenue	Farmington	CT	Active
DSH070036L	Child	DSH	UCONN HEALTH	UConn Health Musculoskeletal Institute Imaging - Ultrasound Imaging	263 Farmington Avenue	Farmington	CT	Active
DSH070036M	Child	DSH	UCONN HEALTH	UConn Health Musculoskeletal Institute CT SCAN - CAT Scan Imaging	263 Farmington Avenue	Farmington	CT	Active
DSH070036N	Child	DSH	UCONN HEALTH	UConn Health Musculoskeletal Institute Imaging - X-Ray Imaging	263 Farmington Avenue	Farmington	CT	Active
DSH070036P	Child	DSH	UCONN HEALTH	UConn Health Department of Infectious Disease - Infectious Diseases	263 Farmington Ave.	Farmington	CT	Active
DSH070036Q	Child	DSH	UCONN HEALTH	UConn Health Department of Osteoporosis - Osteoporosis	263 Farmington Ave.	Farmington	CT	Active
DSH070036R	Child	DSH	UCONN HEALTH	UConn Health Department of Endocrinology - Endocrinology	263 Farmington Ave.	Farmington	CT	Active
DSH070036S	Child	DSH	UCONN HEALTH	Cancer Center - Anticoagulation Clinic	11 South Road	Farmington	CT	Active
DSH070036T	Child	DSH	UCONN HEALTH	Radiology - Radiation Oncology	263 Farmington Avenue	Farmington	CT	Active
DSH070036U	Child	DSH	UCONN HEALTH	Diabetes Education - Diabetes Self-Management Education Program	263 Farmington Avenue	Farmington	CT	Active
DSH070036V	Child	DSH	UCONN HEALTH	Outpatient Psychiatry Service - Supportive Care BH/ Health Psychology	263 Farmington Avenue	Farmington	CT	Active
DSH070036W	Child	DSH	UCONN HEALTH	Neag Comprehensive Cancer Center - Oncology and Supportive Care	263 Farmington Avenue	Farmington	CT	Active
DSH070036X	Child	DSH	UCONN HEALTH	UConn Health - Medication Therapy Management Clinic	263 Farmington Avenue	Farmington	CT	Active
DSH070036Y	Child	DSH	UCONN HEALTH	Diagnostic Radiology - OPPV XRAY IMAGING	263 Farmington Avenue	Farmington	CT	Active
DSH070036Z	Child	DSH	UCONN HEALTH	Mammography - OPPV MAMMO IMAGING	263 Farmington Avenue	Farmington	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 11:52:35 AM	8/21/2024 12:26:07 PM	8/21/2024 12:26 PM
Contacts	Primary Contact	Update	Profile Change Request	Matusik, F. Bahar Associate Pharmacy Director UConn Health 8604809159	Matusik, F. Bahar Director for 340B Services UConn Health 8604809159	12/5/2023 9:41 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 9:42:47 AM	8/18/2023 11:52:35 AM	8/18/2023 11:52 AM
Contacts	Authorizing Official	Update	Change Request	Geoghegan, Jeffrey P. CFO UConn Health 8606793162	Chamberlin, Kevin Associate Vice President and Chief Pharmacy Officer UConn Health 8606792281	5/9/2023 1:01 PM
Contacts	Authorizing Official	Update	Change Request	Metcalf, Kimberly AVP Pharmacy and Ancillary Services UConn Health 8606797943	Geoghegan, Jeffrey P. CFO UConn Health 8606793162	9/7/2022 7:15 AM
Contacts	Signed By	Update	Change Request	Geoghegan, Jeffrey P. CFO 8606793162	Geoghegan, Jeffrey P. CFO UConn Health 8606793162	9/6/2022 9:57 AM
Details	Last Recertification Date	Update	Recertification	9/5/2021 11:01:20 AM	8/31/2022 9:42:47 AM	8/31/2022 9:42 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 12:31:05 AM	9/5/2021 11:01:20 AM	9/5/2021 11:01 AM
Addresses	Shipping Address	Delete	Change Request	University of Connecticut Health Center 263 Farmington Avenue Farmington, CT 06030		6/21/2021 8:25 AM
Addresses	Shipping Address	Insert	Change Request		University of Connecticut Health Center 263 Farmington Avenue GPS: 120 Dowling Way, 2nd Floor Farmington, CT 06030	6/21/2021 8:25 AM
Contacts	Authorizing Official	Update	Profile Change Request	Metcalf, Kimberly Senior Director Hospital Operations UConn Health 8606797943	Metcalf, Kimberly AVP Pharmacy and Ancillary Services UConn Health 8606797943	1/19/2021 3:43 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 7:49:55 AM	9/8/2020 12:31:05 AM	9/8/2020 12:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/19/2020 9:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		004025250	8/19/2020 9:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	8/19/2020 9:46 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4025250 (CT)		8/19/2020 9:46 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1902891682 ( )		8/19/2020 9:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669466561	8/19/2020 9:46 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	8/19/2020 9:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1902891682	8/19/2020 9:46 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	8/19/2020 9:46 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1669466561 ( )		8/19/2020 9:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1902891682	4/17/2020 8:44 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 12:29:58 PM	8/28/2019 7:49:55 AM	8/28/2019 7:49 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 9:40:23 AM	8/21/2018 12:29:58 PM	8/21/2018 12:29 PM
Contacts	Primary Contact	Update	Recertification	Metcalf, Kimberly Senior Director Hospital Operations 8606797943	Matusik, F. Bahar Associate Pharmacy Director UConn Health 8604809159	11/6/2017 9:40 AM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/6/2017 9:40:23 AM	11/6/2017 9:40 AM
Contacts	Authorizing Official	Update	Change Request	Geoghegan, Jeffrey P. CFO 8606793162	Metcalf, Kimberly Senior Director Hospital Operations UConn Health 8606797943	10/10/2017 11:49 AM
Addresses	Main Address	Insert			263 Farmington Avenue UConn Musculoskeletal Institute, 2nd Level Farmington, CT 06030	8/10/2017 2:49 PM
Addresses	Billing Address	Insert			University of Connecticut Health Center 263 Farmington Avenue Farmington, CT 06030	8/10/2017 2:49 PM
Addresses	Shipping Address	Insert			University of Connecticut Health Center 263 Farmington Avenue Farmington, CT 06030	8/10/2017 2:49 PM
Contacts	Authorizing Official	Insert			Geoghegan, Jeffrey P. CFO 8606793162	8/10/2017 2:49 PM
Contacts	Signed By	Insert			Geoghegan, Jeffrey P. CFO 8606793162	8/10/2017 2:49 PM
Contacts	Primary Contact	Update		Mitchell, Cassandra Chief Clinical Revenue Cycle Officer 8606792916	Metcalf, Kimberly Senior Director Hospital Operations 8606797943	8/10/2017 2:49 PM
Details	Entity Name	Update		JOHN DEMPSEY HOSPITAL	UCONN HEALTH	8/10/2017 2:48 PM
Contacts	Primary Contact	Insert			Mitchell, Cassandra Chief Clinical Revenue Cycle Officer 8606792916	3/21/2017 12:47 PM
Details	Last Recertification Date	Update			9/1/2016 12:00:00 AM	9/1/2016 9:02 AM
Dates	Participating Approval Date	Update			11/17/2015 12:00:00 AM	11/17/2015 5:24 PM
Details	State	Update		Pending	Active	11/17/2015 5:24 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/17/2015 5:24 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_55644	DSH070036F	11/2/2015 2:45 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_55644	10/14/2015 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:23 PM
Medicaid Billing	Medicaid: Number	Insert			4025250	10/14/2015 3:23 PM
Medicaid Billing	Medicaid: State	Insert			CT	10/14/2015 3:23 PM
Medicaid Billing	NPI: Number	Insert			1669466561	10/14/2015 3:23 PM
Details	Last Recertification Date	Insert				10/14/2015 3:23 PM
Details	Grant Number	Insert				10/14/2015 3:23 PM
Details	340B ID	Insert				10/14/2015 3:23 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2015 3:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2015 3:23 PM
Details	Medicare Provider Number	Insert			070036	10/14/2015 3:23 PM
Details	Entity Name	Insert			JOHN DEMPSEY HOSPITAL	10/14/2015 3:23 PM
Details	Program Code	Insert			DSH	10/14/2015 3:23 PM
Details	Entity Subname	Insert			UConn Health Surgical Center	10/14/2015 3:23 PM
Dates	Participating Approval Date	Insert				10/14/2015 3:23 PM
Details	State	Insert			Pending	10/14/2015 3:23 PM
Dates	Registration Date	Insert			10/14/2015 12:00:00 AM	10/14/2015 3:23 PM
Dates	Signed By Date	Insert			10/14/2015 12:00:00 AM	10/14/2015 3:23 PM
Dates	Start Date	Insert				10/14/2015 3:23 PM
Terminations	Termination Comments	Insert				10/14/2015 3:23 PM
Terminations	Termination Date	Insert				10/14/2015 3:23 PM
Terminations	Termination Effective Date	Insert				10/14/2015 3:23 PM
Terminations	Termination Reason	Insert				10/14/2015 3:23 PM