Covered Entity Details

DSH100017AC HALIFAX HEALTH MEDICAL CENTER (Active) - information as of 4/23/2025 10:54:33 PM

Main Details

Name

HALIFAX HEALTH MEDICAL CENTER

Subdivision Name

Halifax Health Port Orange Respiratory Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100017AC

Medicare Provider Number

100017

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2015

Participating Start Date

1/1/2016

Participating Approval Date

10/28/2015

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Halifax Hospital Medical Center
Alberto J Tineo, Chief Operating Officer
(386) 425-4073

Primary Contact

Halifax Health Medical Center
Crystal A Lue, Director, Reimbursement and Revenue
(386) 425-7382

Addresses

Street Address

1041 Dunlawton Ave
Port Orange, FL 32127

Billing Address

Halifax Medical Center
303 N CLYDE MORRIS BLVD
Daytona Beach, FL 32114

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
FL	061779211,010184200,010184204,029948100,106101100	1245283530,1811991227

Shipping Addresses

Shipping Address 1

Halifax Medical Center
303 N CLYDE MORRIS BLVD
Daytona Beach, FL 32114

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
DSH100017AA	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	HMC Pre-Op Test	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AB	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange SDS Ambulatory Unit	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AC	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange Respiratory Therapy	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AD	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange Radiology-Diagnostics	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AE	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange GI Services	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AF	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange Emergency Services	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AG	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange EKG & Halifax Port Orange Echocardiology	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AH	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange Neurodiagnostics	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AJ	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Port Orange Observation	1041 Dunlawton Ave	Port Orange	FL	Active
DSH100017AK	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	HMC 201 Neuroscience Center	201 N. Clyde Morris Blvd. , Suite 120	Daytona Beach	FL	Active
DSH100017AL	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Employee Med	Halifax Medical Center	Daytona Beach	FL	Terminated
DSH100017AM	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	HALIFAX HEALTH MEDICAL CENTER - Deltona Freestanding ED	3300 HALIFAX CROSSINGS BLVD	DELTONA	FL	Terminated
DSH100017AN	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Care for Women - FHC - Halifax Health - Care for Women	201 N Clyde Morris Blvd.	Daytona Beach	FL	Active
DSH100017B	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	HALIFAX HEALTH-TWIN LAKES SURGERY CENTER	1890 LPGA BLVD	DAYTONA BEACH	FL	Active
DSH100017C	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Professional Center	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017D	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Center for Oncology	1185 Dunlawton Ave. Suite 105	Port Orange	FL	Active
DSH100017E	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Center for Oncology	1688 W. Granada Blvd.	Ormond Beach	FL	Active
DSH100017F	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Community Clinic	303 North Clyde Morris Blvd.	Daytona Beach	FL	Terminated
DSH100017G	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Keech Pediatric Neighborhood Care	431 S. Keech St.	Daytona Beach	FL	Terminated
DSH100017H	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health Medical Center of Port Orange	1041 Dunlawton Ave	Port Orange	FL	Terminated
DSH100017J	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health - 201 Building	201 N. Clyde Morris	Daytona Beach	FL	Terminated
DSH100017K	Child	DSH	HALIFAX MEDICAL CENTER	Halifax Health - Care Now Deltona	2090 Saxon Boulevard,	Deltona	FL	Terminated
DSH100017L	Child	DSH	HALIFAX MEDICAL CENTER	Halifax Health Women's Care Now	325 Clyde Morris Blvd	Ormond Beach	FL	Terminated
DSH100017M	Child	DSH	HALIFAX MEDICAL CENTER	Halifax Health - Primary Care	1688 W. Granada Blvd.	Ormond Beach	FL	Terminated
DSH100017N	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Health- Eye Clinic	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017P	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Halifax Behavioral Services	841 Jimmy Ann Dr.	Daytona Beach	FL	Terminated
DSH100017Q	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Infusion Therapy	311 N Clyde Morris Blvd	Daytona Beach	FL	Active
DSH100017R	Child	DSH	HALIFAX MEDICAL CENTER	Center for Plastic and Cosmetic Surgery	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017S	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Center for Family & Sports Medicine	201 N. Clyde Morris Blvd. , Suite 110 and 200	Daytona Beach	FL	Active
DSH100017T	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Interventional Pain Service	201 N. Clyde Morris Blvd. , Suite 230	Daytona Beach	FL	Active
DSH100017U	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Same Day Surgery	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017V	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Center for Transplant Services	311 N Clyde Morris Blvd	Daytona Beach	FL	Active
DSH100017W	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Centers for Advanced Wound Healing	311 N Clyde Morris Blvd	Daytona Beach	FL	Active
DSH100017X	Child	DSH	HALIFAX MEDICAL CENTER	Centers for Urology, Centers for Female Pelvic Medicine	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017Y	Child	DSH	HALIFAX HEALTH MEDICAL CENTER	Center for Hand Surgery	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated
DSH100017Z	Child	DSH	HALIFAX MEDICAL CENTER	Center of Neurosciences, Neurosurgery	311 N Clyde Morris Blvd	Daytona Beach	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	3022431 (CT)		8/28/2024 12:38 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1766143 (LA)		8/28/2024 12:38 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 3:24:33 PM	8/28/2024 12:38:57 PM	8/28/2024 12:38 PM
Contacts	Primary Contact	Update	Group Change Request	Aldrich, Todd Robert Director of Finance Halifax Health 3864253615	Lue, Crystal A Director, Reimbursement and Revenue Halifax Health Medical Center 3864257382	2/6/2024 7:31 AM
Contacts	Authorizing Official	Update	Change Request	PEBURN, ERIC M. CFO Halifax Hospital Medical Center 3864254568	Tineo, Alberto J Chief Operating Officer Halifax Hospital Medical Center 3864254073	11/7/2023 7:44 AM
Contacts	Primary Contact	Update	Change Request	Squier, Richard Sr. Financial Analyst Halifax Health 3864254598	Aldrich, Todd Robert Director of Finance Halifax Health 3864253615	10/31/2023 8:47 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 10:56:53 AM	9/7/2023 3:24:33 PM	9/7/2023 3:24 PM
Contacts	Primary Contact	Update	Recertification	Lue, Crystal A Revenue and Cost Accounting Coordinator Halifax Health Medical Center 3864257206	Squier, Richard Sr. Financial Analyst Halifax Health 3864254598	9/16/2022 10:56 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 11:59:39 AM	9/16/2022 10:56:53 AM	9/16/2022 10:56 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 2:13:17 PM	9/3/2021 11:59:39 AM	9/3/2021 11:59 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1356358394 (FL)		7/15/2021 10:55 AM
Medicaid Billing	NPI: State	Update	Recertification		FL	9/8/2020 2:13 PM
Medicaid Billing	NPI: State	Update	Recertification		FL	9/8/2020 2:13 PM
Medicaid Billing	NPI: State	Update	Recertification		FL	9/8/2020 2:13 PM
Contacts	Primary Contact	Update	Recertification	Dowsett, Kern Reimbursement Specialist Halifax Health 3864254567	Lue, Crystal A Revenue and Cost Accounting Coordinator Halifax Health Medical Center 3864257206	9/8/2020 2:13 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 1:12:58 PM	9/8/2020 2:13:17 PM	9/8/2020 2:13 PM
Contacts	Authorizing Official	Update	Change Request	Lue, Crystal A Revenue and Cost Accounting Coordinator Halifax Health Medical Center 3864257206	PEBURN, ERIC M. CFO Halifax Hospital Medical Center 3864254568	7/28/2020 3:17 PM
Contacts	Authorizing Official	Update	AO Change Request	PEBURN, ERIC M. CFO Halifax Hospital Medical Center 3864254568	Lue, Crystal A Revenue and Cost Accounting Coordinator Halifax Health Medical Center 3864257206	7/2/2020 1:01 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 11:10:29 AM	9/9/2019 1:12:58 PM	9/9/2019 1:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3022431	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1766143	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	7/16/2019 12:29 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010184207 (FL)		4/9/2019 1:36 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010184208 (FL)		4/9/2019 1:36 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 2:03:29 PM	8/23/2018 11:10:29 AM	8/23/2018 11:10 AM
Contacts	Authorizing Official	Update	New Registration	PEBURN, ERIC CFO Halifax Hospital Medical Center 3864254568	PEBURN, ERIC M. CFO Halifax Hospital Medical Center 3864254568	7/3/2018 11:18 AM
Contacts	Signed By	Update	New Registration	PEBURN, ERIC CFO Halifax Hospital Medical Center 3864254568	PEBURN, ERIC M. CFO Halifax Hospital Medical Center 3864254568	7/3/2018 11:18 AM
Details	Entity Name	Update	Recertification	HALIFAX MEDICAL CENTER	HALIFAX HEALTH MEDICAL CENTER	12/4/2017 2:06 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	12/4/2017 2:03:29 PM	12/4/2017 2:03 PM
Contacts	Primary Contact	Update	Profile Change Request	Dowsett, Kern Reimbursement Specialist halifax health 3862264567	Dowsett, Kern Reimbursement Specialist Halifax Health 3864254567	10/26/2017 11:16 AM
Contacts	Primary Contact	Update		Dowsett, Kern Reimbursement Specialist 3862264567	Dowsett, Kern Reimbursement Specialist halifax health 3862264567	9/29/2017 11:03 AM
Contacts	Authorizing Official	Update		PEBURN, ERIC CFO 3864254568	PEBURN, ERIC CFO Halifax Hospital Medical Center 3864254568	9/27/2017 1:20 PM
Contacts	Signed By	Update		PEBURN, ERIC CFO 3864254568	PEBURN, ERIC CFO Halifax Hospital Medical Center 3864254568	9/27/2017 1:20 PM
Contacts	Authorizing Official	Insert			PEBURN, ERIC CFO 3864254568	6/30/2017 10:28 AM
Contacts	Signed By	Insert			PEBURN, ERIC CFO 3864254568	6/30/2017 10:28 AM
Contacts	Primary Contact	Insert			Dowsett, Kern Reimbursement Specialist 3862264567	6/15/2017 11:50 AM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 3:53 PM
Addresses	Main Address	Insert			1041 Dunlawton Ave Port Orange, FL 32127	8/30/2016 3:53 PM
Addresses	Billing Address	Insert			Halifax Medical Center 303 N CLYDE MORRIS BLVD Daytona Beach, FL 32114	5/3/2016 11:26 AM
Addresses	Shipping Address	Insert			Halifax Medical Center 303 N CLYDE MORRIS BLVD Daytona Beach, FL 32114	5/3/2016 11:26 AM
Dates	Participating Approval Date	Update			10/28/2015 12:00:00 AM	10/28/2015 12:08 PM
Details	State	Update		Pending	Active	10/28/2015 12:08 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	10/28/2015 12:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_55676	DSH100017AC	10/22/2015 3:54 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_55676	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			061779211	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			010184200	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			010184204	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			010184207	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			010184208	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			029948100	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: Number	Insert			106101100	10/14/2015 3:45 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/14/2015 3:45 PM
Medicaid Billing	NPI: Number	Insert			1245283530	10/14/2015 3:45 PM
Medicaid Billing	NPI: Number	Insert			1811991227	10/14/2015 3:45 PM
Medicaid Billing	NPI: Number	Insert			1356358394	10/14/2015 3:45 PM
Details	Last Recertification Date	Insert				10/14/2015 3:45 PM
Details	Grant Number	Insert				10/14/2015 3:45 PM
Details	340B ID	Insert				10/14/2015 3:45 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2015 3:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2015 3:45 PM
Details	Medicare Provider Number	Insert			100017	10/14/2015 3:45 PM
Details	Entity Name	Insert			HALIFAX MEDICAL CENTER	10/14/2015 3:45 PM
Details	Program Code	Insert			DSH	10/14/2015 3:45 PM
Details	Entity Subname	Insert			Halifax Health Port Orange Respiratory Therapy	10/14/2015 3:45 PM
Dates	Participating Approval Date	Insert				10/14/2015 3:45 PM
Details	State	Insert			Pending	10/14/2015 3:45 PM
Dates	Registration Date	Insert			10/14/2015 12:00:00 AM	10/14/2015 3:45 PM
Dates	Signed By Date	Insert			10/14/2015 12:00:00 AM	10/14/2015 3:45 PM
Dates	Start Date	Insert				10/14/2015 3:45 PM
Terminations	Termination Comments	Insert				10/14/2015 3:45 PM
Terminations	Termination Date	Insert				10/14/2015 3:45 PM
Terminations	Termination Effective Date	Insert				10/14/2015 3:45 PM
Terminations	Termination Reason	Insert				10/14/2015 3:45 PM