| Contacts | Authorizing Official | Update | Profile Change Request | Bartels, Dara Beth
Chief Executive Officer
Mile Bluff Medical Center
6088472992-6088472994 | Bartels, Dara Beth
Chief Executive Officer
Mile Bluff Medical Center
6088472992 | 4/10/2025 8:49 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2023 11:33:01 AM | 8/26/2024 10:22:45 AM | 8/26/2024 10:22 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2022 3:44:19 PM | 9/9/2023 11:33:01 AM | 9/9/2023 11:33 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2021 11:24:21 AM | 8/26/2022 3:44:19 PM | 8/26/2022 3:44 PM |
| Contacts | Authorizing Official | Update | Change Request | O'Keefe, James Michael
Chief Executive Officer
Mile Bluff Medical Center, Inc
6088472998 | Bartels, Dara Beth
Chief Executive Officer
Mile Bluff Medical Center
6088472992-6088472994 | 10/28/2021 7:35 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2020 12:01:56 PM | 8/18/2021 11:24:21 AM | 8/18/2021 11:24 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1447397492 ( ) | | 8/17/2020 12:01 PM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2019 12:51:05 PM | 8/17/2020 12:01:56 PM | 8/17/2020 12:01 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2018 10:00:17 AM | 8/20/2019 12:51:05 PM | 8/20/2019 12:51 PM |
| Contacts | Authorizing Official | Update | Change Request | Fish, Francis J.
CFO
Mile Bluff Medical Center
6088472992 | O'Keefe, James Michael
Chief Executive Officer
Mile Bluff Medical Center, Inc
6088472998 | 2/19/2019 10:43 AM |
| Details | Last Recertification Date | Update | Recertification | 11/9/2017 10:53:41 AM | 8/24/2018 10:00:17 AM | 8/24/2018 10:00 AM |
| Details | Entity Name | Update | Recertification | Mile Bluff Medical Center, Inc. | MILE BLUFF MEDICAL CENTER INC. | 11/9/2017 11:05 AM |
| Details | Last Recertification Date | Update | Recertification | 10/26/2017 1:11:15 PM | 11/9/2017 10:53:41 AM | 11/9/2017 10:53 AM |
| Details | Last Recertification Date | Update | Recertification | 8/12/2016 12:00:00 AM | 10/26/2017 1:11:15 PM | 10/26/2017 1:11 PM |
| Contacts | Authorizing Official | Update | | Fish, Francis J.
CFO
6088472992 | Fish, Francis J.
CFO
Mile Bluff Medical Center
6088472992 | 10/25/2017 12:09 PM |
| Contacts | Signed By | Update | | Fish, Francis J.
CFO
6088472992 | Fish, Francis J.
CFO
Mile Bluff Medical Center
6088472992 | 10/25/2017 12:09 PM |
| Contacts | Primary Contact | Update | | Griffis, Craig
Director of Pharmacy
6088471255 | Griffis, Craig William
Director of Pharmacy
Mile Bluff Medical Center
6088471255 | 10/10/2017 10:07 AM |
| Contacts | Authorizing Official | Insert | | | Fish, Francis J.
CFO
6088472992 | 8/10/2017 4:45 PM |
| Contacts | Signed By | Insert | | | Fish, Francis J.
CFO
6088472992 | 8/10/2017 4:45 PM |
| Addresses | Main Address | Insert | | |
1408 Wheelihan Avenue
Necedah, WI 54646 | 8/12/2016 3:02 PM |
| Contacts | Primary Contact | Update | | Snopek, Frank
Director of Pharmacy
6088471255 | Griffis, Craig
Director of Pharmacy
6088471255 | 8/12/2016 3:02 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1447397492 | 8/12/2016 3:02 PM |
| Details | Last Recertification Date | Update | | | 8/12/2016 12:00:00 AM | 8/12/2016 3:02 PM |
| Addresses | Billing Address | Insert | | | Mile Bluff Medical Center, Inc.
1050 Division Street
Mauston, WI 53948 | 2/18/2016 2:52 PM |
| Details | Last Recertification Date | Update | | 9/10/2015 12:00:00 AM | | 2/18/2016 2:52 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 10/1/2015 12:00:00 AM | | 2/18/2016 2:52 PM |
| Details | Entity Subname | Update | | Necedah Family Medical Center | Necedah Family Medical Center / Family Practice, Obstetrics, Podiatry, Radiology | 2/18/2016 2:52 PM |
| Dates | Participating Approval Date | Update | | 10/25/2013 12:00:00 AM | 2/18/2016 12:00:00 AM | 2/18/2016 2:52 PM |
| Details | State | Update | | Terminated | Active | 2/18/2016 2:52 PM |
| Dates | Registration Date | Update | | 10/2/2013 12:00:00 AM | 1/5/2016 12:00:00 AM | 2/18/2016 2:52 PM |
| Dates | Signed By Date | Update | | 10/2/2013 12:00:00 AM | 1/5/2016 12:00:00 AM | 2/18/2016 2:52 PM |
| Dates | Start Date | Update | | 1/1/2014 12:00:00 AM | 4/1/2016 12:00:00 AM | 2/18/2016 2:52 PM |
| Terminations | Termination Date | Update | | 10/1/2015 12:00:00 AM | | 2/18/2016 2:52 PM |
| Terminations | Termination Effective Date | Update | | 10/1/2015 12:00:00 AM | | 2/18/2016 2:52 PM |
| Terminations | Termination Reason | Update | | Failure to recertify | | 2/18/2016 2:52 PM |
| Contacts | Primary Contact | Insert | | | Snopek, Frank
Director of Pharmacy
6088471255 | 9/10/2015 8:58 AM |
| Details | Last Recertification Date | Update | | 8/20/2014 12:00:00 AM | 9/10/2015 12:00:00 AM | 9/10/2015 8:58 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 10/1/2015 12:00:00 AM | 9/10/2015 8:58 AM |
| Details | State | Update | | Active | Terminated | 9/10/2015 8:58 AM |
| Terminations | Termination Date | Update | | | 10/1/2015 12:00:00 AM | 9/10/2015 8:58 AM |
| Terminations | Termination Effective Date | Update | | | 10/1/2015 12:00:00 AM | 9/10/2015 8:58 AM |
| Terminations | Termination Reason | Update | | | Failure to recertify | 9/10/2015 8:58 AM |
| Details | Last Recertification Date | Update | | | 8/20/2014 12:00:00 AM | 8/20/2014 2:54 PM |
| Dates | Participating Approval Date | Update | | | 10/25/2013 12:00:00 AM | 10/25/2013 2:22 PM |
| Details | State | Update | | Pending | Active | 10/25/2013 2:22 PM |
| Dates | Start Date | Update | | | 1/1/2014 12:00:00 AM | 10/25/2013 2:22 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | SCH520109-02 | 10/23/2013 5:27 PM |
| Details | Last Recertification Date | Insert | | | | 10/2/2013 11:37 AM |
| Details | Grant Number | Insert | | | | 10/2/2013 11:37 AM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 10/2/2013 11:37 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/2/2013 11:37 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/2/2013 11:37 AM |
| Details | Medicare Provider Number | Insert | | | 520109 | 10/2/2013 11:37 AM |
| Details | Entity Name | Insert | | | Mile Bluff Medical Center, Inc. | 10/2/2013 11:37 AM |
| Details | Program Code | Insert | | | SCH | 10/2/2013 11:37 AM |
| Details | Entity Subname | Insert | | | Necedah Family Medical Center | 10/2/2013 11:37 AM |
| Dates | Participating Approval Date | Insert | | | | 10/2/2013 11:37 AM |
| Details | State | Insert | | | Pending | 10/2/2013 11:37 AM |
| Dates | Registration Date | Insert | | | 10/2/2013 12:00:00 AM | 10/2/2013 11:37 AM |
| Dates | Signed By Date | Insert | | | 10/2/2013 12:00:00 AM | 10/2/2013 11:37 AM |
| Dates | Start Date | Insert | | | | 10/2/2013 11:37 AM |
| Terminations | Termination Comments | Insert | | | | 10/2/2013 11:37 AM |
| Terminations | Termination Date | Insert | | | | 10/2/2013 11:37 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/2/2013 11:37 AM |
| Terminations | Termination Reason | Insert | | | | 10/2/2013 11:37 AM |