Covered Entity Details

SCH520109-04 MILE BLUFF MEDICAL CENTER INC. (Active) - information as of 5/6/2025 11:13:41 PM

Main Details

Name

MILE BLUFF MEDICAL CENTER INC.

Subdivision Name

MILE BLUFF MEDICAL CENTER INC / Mile Bluff Clinic

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH520109-04

Medicare Provider Number

520109

Outpatient Facility Provider Number

528549

Additional Details

Current Program Status

Active

Registration Date

1/6/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/16/2016

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Mile Bluff Medical Center
Dara Beth Bartels, Chief Executive Officer
(608) 847-2992

Primary Contact

Mile Bluff Medical Center
Craig William Griffis, Director of Pharmacy
(608) 847-1255

Addresses

Street Address

1040 DIVISION ST
MAUSTON, WI 53948-1931

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
WI	1104700	1568487411

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
SCH520109-01	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	Elroy Family Medical Center / Family Practice, OB, Podiatry	1515 Academy Street	Elroy	WI	Active
SCH520109-02	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	Necedah Family Medical Center / Family Practice, Obstetrics, Podiatry, Radiology	1408 Wheelihan Avenue	Necedah	WI	Active
SCH520109-03	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	Mile Bluff Dialysis Center	1040 Division Street	Mauston	WI	Active
SCH520109-04	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	MILE BLUFF MEDICAL CENTER INC / Mile Bluff Clinic	1040 DIVISION ST	MAUSTON	WI	Active
SCH520109-05	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	MILE BLUFF MEDICAL CENTER INC / New Lisbon Family Medicine	901W BRIDGE ST	NEW LISBON	WI	Active
SCH520109-06	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	Wisconsin Dells Dialysis Center - Dialysis	28 Commerce Street	Wisconsin Dells	WI	Active
SCH520109-07	Child	SCH	MILE BLUFF MEDICAL CENTER INC.	Delton Family Medical Center - Family Practice	28 Commerce Street	Wisconsin Dells	WI	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2024 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1104700	8/26/2024 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/26/2024 10:24 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568487411	8/26/2024 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/26/2024 10:24 AM
Details	Last Recertification Date	Update	Recertification	9/9/2023 11:33:58 AM	8/26/2024 10:24:07 AM	8/26/2024 10:24 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 3:43:26 PM	9/9/2023 11:33:58 AM	9/9/2023 11:33 AM
Details	Last Recertification Date	Update	Recertification	8/18/2021 11:25:40 AM	8/26/2022 3:43:26 PM	8/26/2022 3:43 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 12:02:20 PM	8/18/2021 11:25:40 AM	8/18/2021 11:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1881930527 ( )		8/17/2020 12:02 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 10:11:58 AM	8/17/2020 12:02:20 PM	8/17/2020 12:02 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 9:59:01 AM	8/20/2019 10:11:58 AM	8/20/2019 10:11 AM
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 10:53:07 AM	8/24/2018 9:59:01 AM	8/24/2018 9:59 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	8/12/2016 12:00:00 AM	11/9/2017 10:53:07 AM	11/9/2017 10:53 AM
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			1040 DIVISION ST MAUSTON, WI 53948-1931	8/12/2016 3:02 PM
Contacts	Primary Contact	Insert			Griffis, Craig Director of Pharmacy 6088471255	8/12/2016 3:02 PM
Medicaid Billing	NPI: Number	Insert			1881930527	8/12/2016 3:02 PM
Details	Last Recertification Date	Update			8/12/2016 12:00:00 AM	8/12/2016 3:02 PM
Dates	Participating Approval Date	Update			2/16/2016 12:00:00 AM	2/16/2016 5:44 PM
Details	State	Update		Pending	Active	2/16/2016 5:44 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/16/2016 5:44 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_56719	SCH520109-04	1/8/2016 3:22 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_56719	1/6/2016 2:26 PM
Details	Last Recertification Date	Insert				1/6/2016 2:26 PM
Details	Grant Number	Insert				1/6/2016 2:26 PM
Details	340B ID	Insert				1/6/2016 2:26 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2016 2:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2016 2:26 PM
Details	Medicare Provider Number	Insert			520109	1/6/2016 2:26 PM
Details	Entity Name	Insert			MILE BLUFF MEDICAL CENTER INC.	1/6/2016 2:26 PM
Details	Program Code	Insert			SCH	1/6/2016 2:26 PM
Details	Entity Subname	Insert			MILE BLUFF MEDICAL CENTER INC / Mile Bluff Clinic	1/6/2016 2:26 PM
Dates	Participating Approval Date	Insert				1/6/2016 2:26 PM
Details	State	Insert			Pending	1/6/2016 2:26 PM
Dates	Registration Date	Insert			1/6/2016 12:00:00 AM	1/6/2016 2:26 PM
Dates	Signed By Date	Insert			1/6/2016 12:00:00 AM	1/6/2016 2:26 PM
Dates	Start Date	Insert				1/6/2016 2:26 PM
Terminations	Termination Comments	Insert				1/6/2016 2:26 PM
Terminations	Termination Date	Insert				1/6/2016 2:26 PM
Terminations	Termination Effective Date	Insert				1/6/2016 2:26 PM
Terminations	Termination Reason	Insert				1/6/2016 2:26 PM