Covered Entity Details

DSH310086D KENNEDY MEMORIAL HOSPITAL-UMC (Terminated) - information as of 4/27/2025 10:45:39 PM

Main Details

Name

KENNEDY MEMORIAL HOSPITAL-UMC

Subdivision Name

The Center for Wound Healing

Type

Disproportionate Share Hospital

Rural

340B ID

DSH310086D

Medicare Provider Number

310086

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/8/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/11/2016

Last Recertification Date

9/3/2024

Termination Date
Termination Reason

1/1/2025
DSH percentage below statutory minimum

Contacts

Authorizing Official

Kennedy Memorial Hospital - UMC
Stephen V DeStefano, Vice President Finance
(215) 587-3332

Primary Contact

Jefferson Health
Dustin Ottemiller, VP, Finance
(215) 503-5219

Addresses

Street Address

543 Egg Harbor Road
Sewell, NJ 08080

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
3/11/16 CE reinstated effective 4/1/16, was participating from 10/1/15 to 12/31/15, not participating from 1/1/2016 to 3/31/16	03/11/2016

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
NY	02995499	1386746592
PA	1007754140008,1007754140005,1007754140004	1386746592
DE	46501	1386746592
NJ	4140206	1386746592

Shipping Addresses

Shipping Address 1

Kennedy Memorial Hospital - UMC
435 Hurffville-Cross Keys Road
Turnersville, NJ 08012

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
DSH310086A	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY BEHAVIORAL HEALTH	454 HURFFVILLE CROSSKEYS RD	SEWELL	NJ	Terminated
DSH310086AA	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Medical Oncology Practice - Oncology	900 Medical Center Drive	Sewell	NJ	Terminated
DSH310086AB	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Medical Oncology Infusion - Oncology	900 Medical Center Drive	Sewell	NJ	Terminated
DSH310086AC	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC O/P Pet Scanning - Pet Scan	900 Medical Center Dr	Sewell	NJ	Terminated
DSH310086AD	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC Antenatal testing - Maternal Fetal Medicine	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086AF	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC Radiation Oncology - JWT Cancer Center-RADONC	900 Medical Center Dr	Sewell	NJ	Terminated
DSH310086AG	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC CT Scan - JWT CT	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086AJ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC EKG - JCH Heart Station	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AM	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC CT Scan - JCH CT	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AN	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC-Ultrasound - JWT US	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086AP	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Ultrasound - JCH ED US	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AQ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC O/P Imaging Ultrasound - JWT US 900 Medical Center	900 Medical Center Dr	Sewell	NJ	Terminated
DSH310086AR	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Ultrasound - JCH US	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AS	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Wound Care - JCH Wound Care	2211 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AT	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC EKG - JWT Heart Station	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086AU	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Behavioral Health ACC - JCH Crisis Services	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AV	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Operating Room - JCH GI	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AW	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC-MRI - JCH MRI	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AX	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	CHC Respiratory Therapy - JCH PFT Lab	2201 Chapel W Ave	Cherry Hill	NJ	Terminated
DSH310086AY	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC MRI - JWT MRI	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086AZ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC- OR Neurosurgery - JWT INR	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086B	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Kennedy Dialysis Center - Washington Township	300 Medical Center Drive	Sewell	NJ	Terminated
DSH310086BA	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC Nuclear Medicine - JWT NUC MED	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086BB	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	WTC Respiratory Therapy - JWT PFT Lab	435 Hurffville-Crosskeys Rd	Turnersville	NJ	Terminated
DSH310086BC	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	West Berlin Primary and Specialty Care - Family Health	301 Route 73 North	West Berlin	NJ	Terminated
DSH310086BD	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Dermatology	301 ROUTE 73 NORTH	WEST BERLIN	NJ	Terminated
DSH310086BE	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Plastic Surgery	301 ROUTE 73 NORTH	WEST BERLIN	NJ	Terminated
DSH310086BF	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - General Surgery	301 ROUTE 73 NORTH	WEST BERLIN	NJ	Terminated
DSH310086BG	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Bariatric Surgery	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BH	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Family Health	159 SOUTH BROAD STREET	WOODBURY	NJ	Terminated
DSH310086BJ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Infectious Disease	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BK	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - Endocrinology	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BL	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Medical Oncology Infusion-Cherry Hill - Oncology	2211 Chapel Ave	Cherry Hill	NJ	Terminated
DSH310086BM	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic-Fishpond Inf Dis - Infectious Disease	354 Hurffville-Crosskeys Rd	Sewell	NJ	Terminated
DSH310086BN	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic-FishPond Prim/Spec - Family Health	354 Hurffville-Crosskeys Rd	Sewell	NJ	Terminated
DSH310086BP	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Woodbury Behavioral Health	159 SOUTH BROAD STREET	WOODBURY	NJ	Terminated
DSH310086BQ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-West Berlin Neurology	301 ROUTE 73 NORTH	WEST BERLIN	NJ	Terminated
DSH310086BR	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Woodbury Surgery Bariatric	159 SOUTH BROAD STREET	WOODBURY	NJ	Terminated
DSH310086BS	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Voorhees Neurology	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BT	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Voorhees Pulmonary	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BU	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Woodbury Endo	159 SOUTH BROAD STREET	WOODBURY	NJ	Terminated
DSH310086BV	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY UNIVERSITY HOSPITAL, INC - HB Clinic-Voorhees Surgery Vascular	333 LAUREL OAK ROAD	VOORHEES	NJ	Terminated
DSH310086BW	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic Voorhees Beh. Hlth - Behavioral Health	333 Laurel Oak Rd	Voorhees	NJ	Terminated
DSH310086BX	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic Fishpond Endocrine - Endocrine	354 Hurffville-Crosskeys Rd	Sewell	NJ	Terminated
DSH310086BY	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic Voorhees Cardio - Cardiology	333 Laurel Oak Rd	Voorhees	NJ	Terminated
DSH310086BZ	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	HB Clinic Voorhees Neusurg - Neurosurgery	333 Laurel Oak Rd	Voorhees	NJ	Terminated
DSH310086C	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Recovery Room	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086D	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	The Center for Wound Healing	543 Egg Harbor Road	Sewell	NJ	Terminated
DSH310086E	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY DIAGNOSTICE & TREATMENT CTR / MRI	900 MEDICAL CENTER DR	SEWELL	NJ	Terminated
DSH310086F	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY DIAGNOSTICE & TREATMENT CTR / CT Scan	900 MEDICAL CENTER DR	SEWELL	NJ	Terminated
DSH310086G	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / OP Psychiatric	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086H	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Recovery Room	435 HURFFVILLE CROSS KEYS RD	TURNERSVILLE	NJ	Terminated
DSH310086J	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Emergency Department	435 HURFFVILLE CROSS KEYS RD	TURNERSVILLE	NJ	Terminated
DSH310086K	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Operating Room	435 HURFFVILLE CROSS KEYS RD	TURNERSVILLE	NJ	Terminated
DSH310086L	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Kennedy Dialysis Center - Voorhees / OP Hemodialysis	201 Laurel Oak Road	Voorhees	NJ	Terminated
DSH310086M	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Emergency Room	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086N	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Anesthesiology	435 HURFFVILLE CROSS KEYS RD	TURNERSVILLE	NJ	Terminated
DSH310086P	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Anesthesiology	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086Q	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Operating Room	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086R	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY DIAGNOSTICE & TREATMENT CTR / Diagnostic Radiology	900 MEDICAL CENTER DR	SEWELL	NJ	Terminated
DSH310086S	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY DIAGNOSTIC & TREATMENT CTR	900 MEDICAL CENTER DR	SEWELL	NJ	Terminated
DSH310086T	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Diagnostic Radiology	435 HURFFVILLE CROSS KEYS RD	TURNERSVILLE	NJ	Terminated
DSH310086U	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	KENNEDY MEMORIAL HOSPITAL / Radiology Diagnostic	2201 CHAPEL W AVE	CHERRY HILL	NJ	Terminated
DSH310086V	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Family Health Center at Somerdale	1 SOMERDALE SQUARE	SOMERDALE	NJ	Terminated
DSH310086W	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Kennedy Surgical Center	540 Egg Harbor Road	Sewell	NJ	Terminated
DSH310086X	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Family Health Services at Washington Township	445 HURFVILLE CROSS KEYS ROAD	SEWELL	NJ	Terminated
DSH310086Y	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Home Health care	1099 White Horse Road	Voorhees	NJ	Terminated
DSH310086Z	Child	DSH	KENNEDY MEMORIAL HOSPITAL-UMC	Kennedy Dialysis Center - Voorhees / CPD Dialysis Home Care	201 Laurel Oak Road	Voorhees	NJ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/30/2024 12:00:00 AM	12/3/2024 11:05 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/3/2024 11:05 AM
Terminations	Termination Comments	Update	Termination Request		The most recently filed cost report (filed on 12/2/2024) showed a DSH percentage below the allowable threshold. Covered Entity has stopped purchasing 340B as of 11/30/2024.	12/3/2024 11:05 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	12/3/2024 11:05 AM
Terminations	Termination Effective Date	Update	Termination Request		12/2/2024 12:00:00 AM	12/3/2024 11:05 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	12/3/2024 11:05 AM
Contacts	Primary Contact	Update	Profile Change Request	Ottemiller, Dustin VP, Finance Thomas Jefferson University Hospitals, Inc. 2155035219	Ottemiller, Dustin VP, Finance Jefferson Health 2155035219	9/3/2024 11:17 AM
Contacts	Primary Contact	Update	Recertification	Swift, Brian G. Chief Pharmacy Officer Thomas Jefferson University Hospital 2159556736	Ottemiller, Dustin VP, Finance Thomas Jefferson University Hospitals, Inc. 2155035219	9/3/2024 8:16 AM
Details	Last Recertification Date	Update	Recertification	8/23/2023 11:23:48 AM	9/3/2024 8:16:53 AM	9/3/2024 8:16 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 11:11:29 AM	8/23/2023 11:23:48 AM	8/23/2023 11:23 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 9:53:38 AM	9/1/2022 11:11:29 AM	9/1/2022 11:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		46501	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007754140005	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007754140004	9/13/2021 9:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/13/2021 9:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1386746592	9/13/2021 9:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/13/2021 9:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1386746592	9/13/2021 9:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/13/2021 9:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1386746592	9/13/2021 9:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/13/2021 9:53 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 2:32:24 PM	9/13/2021 9:53:38 AM	9/13/2021 9:53 AM
Contacts	Authorizing Official	Update	AO Change Request	Graham, John W VP - Chief Administrative Officer Jefferson New Jersey 8565822661	DeStefano, Stephen V Vice President Finance Kennedy Memorial Hospital - UMC 2155873332	8/19/2021 1:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/17/2020 1:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		02995499	11/17/2020 1:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/17/2020 1:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/17/2020 1:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007754140008	11/17/2020 1:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/17/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1386746592	11/17/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	11/17/2020 1:37 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 10:05:17 AM	9/1/2020 2:32:24 PM	9/1/2020 2:32 PM
Contacts	Primary Contact	Update	Change Request	Bevenour, Kenneth John Corporate Director, Pharmacy Services Kennedy University Hospital 8563467319	Swift, Brian G. Chief Pharmacy Officer Thomas Jefferson University Hospital 2159556736	7/17/2020 10:17 AM
Contacts	Authorizing Official	Update	AO Change Request	Alliano, Kimberly VP of Finance Kennedy Health System 8566615184	Graham, John W VP - Chief Administrative Officer Jefferson New Jersey 8565822661	3/27/2020 5:29 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 8:37:24 AM	9/11/2019 10:05:17 AM	9/11/2019 10:05 AM
Contacts	Primary Contact	Update	Change Request	Kelley, Janet F 340B Program Coordinator Jefferson 6097744823	Bevenour, Kenneth John Corporate Director, Pharmacy Services Kennedy University Hospital 8563467319	8/2/2019 9:07 AM
Contacts	Primary Contact	Update	Change Request	Struckus, Ronald Corporate Director of Financial Services and Reimbursement Kennedy Health System 8566615377	Kelley, Janet F 340B Program Coordinator Jefferson 6097744823	7/9/2019 10:02 AM
Addresses	Shipping Address	Insert	Change Request		Kennedy Memorial Hospital - UMC 435 Hurffville-Cross Keys Road Turnersville, NJ 08012	2/13/2019 6:57 AM
Contacts	Primary Contact	Update	Change Request	Struckus, Ronald Corporate Director of Financial Services & Reimbursement Kennedy Health System 8566615377	Struckus, Ronald Corporate Director of Financial Services and Reimbursement Kennedy Health System 8566615377	2/13/2019 6:57 AM
Contacts	Authorizing Official	Update	Change Request	Zirbser, Glenn Senior Vice President/CFO Kennedy Health 8565665269	Alliano, Kimberly VP of Finance Kennedy Health System 8566615184	2/6/2019 6:56 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 4:08:43 PM	9/10/2018 8:37:24 AM	9/10/2018 8:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/4/2018 8:34 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4140206	1/4/2018 8:34 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	1/4/2018 8:34 AM
Details	Entity Name	Update	Recertification	KENNEDY MEMORIAL HOSPITALS - UMC	KENNEDY MEMORIAL HOSPITAL-UMC	11/7/2017 9:17 AM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/6/2017 4:08:43 PM	11/6/2017 4:08 PM
Contacts	Authorizing Official	Update		Zirbser, Glenn Senior Vice President/CFO 8565665269	Zirbser, Glenn Senior Vice President/CFO Kennedy Health 8565665269	11/6/2017 3:57 PM
Contacts	Primary Contact	Update		Struckus, Ronald Corporate Director of Financial Services & Reimbursement 8566615377	Struckus, Ronald Corporate Director of Financial Services & Reimbursement Kennedy Health System 8566615377	9/18/2017 4:20 PM
Addresses	Main Address	Insert			543 Egg Harbor Road Sewell, NJ 08080	6/5/2017 6:32 PM
Contacts	Authorizing Official	Update		Terrinoni, Gary Executive Vice President of Administration & CFO 8565665269	Zirbser, Glenn Senior Vice President/CFO 8565665269	6/5/2017 6:32 PM
Contacts	Primary Contact	Update		Alliano, Kim VP Finance 8566615184	Struckus, Ronald Corporate Director of Financial Services & Reimbursement 8566615377	6/5/2017 6:32 PM
Contacts	Signed By	Update		Terrinoni, Gary Executive Vice President of Administration & CFO 8565665269	Maher, Edward Interim CFO 8566615217	6/5/2017 6:32 PM
Details	Last Recertification Date	Update			8/31/2016 12:00:00 AM	8/31/2016 4:31 PM
Dates	Last Date That 340B Drugs Purchased	Update		10/1/2015 12:00:00 AM		3/11/2016 11:33 AM
Dates	Participating Approval Date	Update		8/12/2015 12:00:00 AM	3/11/2016 12:00:00 AM	3/11/2016 11:33 AM
Details	State	Update		Terminated	Active	3/11/2016 11:33 AM
Dates	Registration Date	Update		7/15/2015 12:00:00 AM	1/8/2016 12:00:00 AM	3/11/2016 11:33 AM
Dates	Signed By Date	Update		7/15/2015 12:00:00 AM	1/8/2016 12:00:00 AM	3/11/2016 11:33 AM
Dates	Start Date	Update		10/1/2015 12:00:00 AM	4/1/2016 12:00:00 AM	3/11/2016 11:33 AM
Terminations	Termination Comments	Update		Kennedy was not ready for implementation and purchased drugs under GPO		3/11/2016 11:33 AM
Terminations	Termination Date	Update		1/1/2016 12:00:00 AM		3/11/2016 11:33 AM
Terminations	Termination Effective Date	Update		10/1/2015 12:00:00 AM		3/11/2016 11:33 AM
Terminations	Termination Reason	Update		Site closure		3/11/2016 11:33 AM
Details	Comments Public	Insert			3/11/16 CE reinstated effective 4/1/16, was participating from 10/1/15 to 12/31/15, not participating from 1/1/2016 to 3/31/16	3/11/2016 11:33 AM
Contacts	Authorizing Official	Insert			Terrinoni, Gary Executive Vice President of Administration & CFO 8565665269	12/3/2015 12:10 PM
Contacts	Signed By	Insert			Terrinoni, Gary Executive Vice President of Administration & CFO 8565665269	12/3/2015 12:10 PM
Contacts	Primary Contact	Insert			Alliano, Kim VP Finance 8566615184	12/3/2015 12:10 PM
Dates	Last Date That 340B Drugs Purchased	Update			10/1/2015 12:00:00 AM	12/3/2015 11:59 AM
Details	State	Update		Active	Terminated	12/3/2015 11:59 AM
Terminations	Termination Comments	Update			Kennedy was not ready for implementation and purchased drugs under GPO	12/3/2015 11:59 AM
Terminations	Termination Date	Update			1/1/2016 12:00:00 AM	12/3/2015 11:59 AM
Terminations	Termination Effective Date	Update			10/1/2015 12:00:00 AM	12/3/2015 11:59 AM
Terminations	Termination Reason	Update			Site closure	12/3/2015 11:59 AM
Dates	Participating Approval Date	Update			8/12/2015 12:00:00 AM	8/12/2015 1:19 PM
Details	State	Update		Pending	Active	8/12/2015 1:19 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	8/12/2015 1:19 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53896	DSH310086D	8/12/2015 12:44 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53896	7/15/2015 1:38 PM
Details	Last Recertification Date	Insert				7/15/2015 1:38 PM
Details	Grant Number	Insert				7/15/2015 1:38 PM
Details	340B ID	Insert				7/15/2015 1:38 PM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 1:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 1:38 PM
Details	Medicare Provider Number	Insert			310086	7/15/2015 1:38 PM
Details	Entity Name	Insert			KENNEDY MEMORIAL HOSPITALS - UMC	7/15/2015 1:38 PM
Details	Program Code	Insert			DSH	7/15/2015 1:38 PM
Details	Entity Subname	Insert			The Center for Wound Healing	7/15/2015 1:38 PM
Dates	Participating Approval Date	Insert				7/15/2015 1:38 PM
Details	State	Insert			Pending	7/15/2015 1:38 PM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 1:38 PM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 1:38 PM
Dates	Start Date	Insert				7/15/2015 1:38 PM
Terminations	Termination Comments	Insert				7/15/2015 1:38 PM
Terminations	Termination Date	Insert				7/15/2015 1:38 PM
Terminations	Termination Effective Date	Insert				7/15/2015 1:38 PM
Terminations	Termination Reason	Insert				7/15/2015 1:38 PM