Covered Entity Details

DSH220035W NORTH SHORE MEDICAL CENTER (Active) - information as of 5/2/2025 10:39:48 PM

Main Details

Name

NORTH SHORE MEDICAL CENTER

Subdivision Name

NSMC MRI Centennial

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220035W

Medicare Provider Number

220035

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/12/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/3/2016

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

North Shore Medical Center
Charles E Adams, Executive Director, Finance
(978) 354-4000

Primary Contact

Mass General Brigham - Boston, MA
Rafic Nehme, Enterprise Director
(617) 726-5125

Addresses

Street Address

4 Centennial Dr Suite# 104
Peabody, MA 01960-7929

Billing Address

North Shore Medical Center
81 Highland Avenue
Salem, MA 01970

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
MA	110026758B	1730121633

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
DSH220035AA	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Cardiovasc LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AB	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Endoscopy at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AC	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Primary Care at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AD	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Nephrology at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AE	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Nutrition at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035B	Child	DSH	NORTH SHORE MEDICAL CENTER	Union Hospital	500 LYNNFIELD STREET	LYNN	MA	Terminated
DSH220035C	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Angio Interv XRay	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035D	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Center for Pre-Op Evaluation	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035E	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Cardiac Rehabilitation	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035F	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Pain Clinic	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035G	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Pulmonary Rehabilitation	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035H	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Infusion Clinic	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035J	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Nuclear Cardiology	500 Lynnfield Street, South 1	Lynn	MA	Terminated
DSH220035K	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Respiratory Care/PFT	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035L	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union IV Therapy	500 Lynnfield Street, 2nd Floor	Lynn	MA	Terminated
DSH220035M	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union CT Scan	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035N	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Radioisotope	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035P	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Radiology / Diagnostic	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035Q	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Anesthesiology	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035R	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Recovery Room	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035S	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Operating Room	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035T	Child	DSH	NORTH SHORE MEDICAL CENTER	Union Hospital Emergency Room / Union Hospital Emergency Room	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035U	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC Outpatient Mental Health at Union Hospital / MH Hartman Hall Clinic	490 Lynnfield Street	Lynn	MA	Terminated
DSH220035V	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC Professional Services / MH Highland Hall Clinic	55 Highland Avenue	Salem	MA	Active
DSH220035W	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC MRI Centennial	4 Centennial Dr Suite# 104	Peabody	MA	Active
DSH220035X	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER I - SLM OP MH CLINIC LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035Y	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Rheum LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035Z	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Pulm LMV	480 LYNNFIELD ST	LYNN	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	McHatton, Ralph Michael Director Pharmacy North Shore Medical Center 9783542358	Nehme, Rafic Enterprise Director Mass General Brigham - Boston, MA 6177265125	9/5/2024 6:22 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 1:01:52 PM	9/5/2024 6:22:56 AM	9/5/2024 6:22 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 2:27:36 PM	9/6/2023 1:01:52 PM	9/6/2023 1:01 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 1:33:11 PM	9/8/2022 2:27:36 PM	9/8/2022 2:27 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 4:10:56 PM	8/25/2021 1:33:11 PM	8/25/2021 1:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1730121633	9/3/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/3/2020 4:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1730121633 ( )		9/3/2020 4:10 PM
Details	Last Recertification Date	Update	Recertification	11/7/2019 8:38:17 AM	9/3/2020 4:10:56 PM	9/3/2020 4:10 PM
Details	Last Recertification Date	Update	Recertification	9/11/2018 1:11:24 PM	11/7/2019 8:38:17 AM	11/7/2019 8:38 AM
Details	Last Recertification Date	Update	Recertification	11/14/2017 5:08:39 PM	9/11/2018 1:11:24 PM	9/11/2018 1:11 PM
Contacts	Primary Contact	Insert	Recertification		McHatton, Ralph Michael Director Pharmacy North Shore Medical Center 9783542358	11/14/2017 5:08 PM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/14/2017 5:08:39 PM	11/14/2017 5:08 PM
Contacts	Signed By	Update		Boemer, Sally Mason Senior Vice President of Finance 6177244537	Boemer, Sally Mason Senior Vice President of Finance Mass General Hospital 6177244537	10/12/2017 1:06 PM
Contacts	Authorizing Official	Insert	AO Change Request		Adams, Charles E Executive Director, Finance North Shore Medical Center 9783544000	10/3/2017 2:50 PM
Contacts	Signed By	Insert			Boemer, Sally Mason Senior Vice President of Finance 6177244537	8/8/2017 8:30 AM
Addresses	Main Address	Insert			4 Centennial Dr Suite# 104 Peabody, MA 01960-7929	7/17/2017 12:21 PM
Addresses	Billing Address	Insert			North Shore Medical Center 81 Highland Avenue Salem, MA 01970	7/17/2017 12:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/17/2017 12:20 PM
Medicaid Billing	Medicaid: Number	Insert			110026758B	7/17/2017 12:20 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/17/2017 12:20 PM
Medicaid Billing	NPI: Number	Insert			1730121633	7/17/2017 12:20 PM
Details	Last Recertification Date	Update			8/26/2016 12:00:00 AM	8/26/2016 1:57 PM
Dates	Participating Approval Date	Update			3/3/2016 12:00:00 AM	3/3/2016 5:08 PM
Details	State	Update		Pending	Active	3/3/2016 5:08 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/3/2016 5:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57244	DSH220035W	2/24/2016 12:56 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57244	1/12/2016 2:12 PM
Details	Last Recertification Date	Insert				1/12/2016 2:12 PM
Details	Grant Number	Insert				1/12/2016 2:12 PM
Details	340B ID	Insert				1/12/2016 2:12 PM
Details	Is Authorizing Official EHB Data	Insert				1/12/2016 2:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2016 2:12 PM
Details	Medicare Provider Number	Insert			220035	1/12/2016 2:12 PM
Details	Entity Name	Insert			NORTH SHORE MEDICAL CENTER	1/12/2016 2:12 PM
Details	Program Code	Insert			DSH	1/12/2016 2:12 PM
Details	Entity Subname	Insert			NSMC MRI Centennial	1/12/2016 2:12 PM
Dates	Participating Approval Date	Insert				1/12/2016 2:12 PM
Details	State	Insert			Pending	1/12/2016 2:12 PM
Dates	Registration Date	Insert			1/12/2016 12:00:00 AM	1/12/2016 2:12 PM
Dates	Signed By Date	Insert			1/12/2016 12:00:00 AM	1/12/2016 2:12 PM
Dates	Start Date	Insert				1/12/2016 2:12 PM
Terminations	Termination Comments	Insert				1/12/2016 2:12 PM
Terminations	Termination Date	Insert				1/12/2016 2:12 PM
Terminations	Termination Effective Date	Insert				1/12/2016 2:12 PM
Terminations	Termination Reason	Insert				1/12/2016 2:12 PM