Covered Entity Details

DSH060011BD DENVER HEALTH MEDICAL CENTER (Active) - information as of 4/30/2025 10:55:02 PM

Main Details

Name

DENVER HEALTH MEDICAL CENTER

Subdivision Name

Denver Health Pavilion L / Infectious Diseases

Type

Disproportionate Share Hospital

Rural

340B ID

DSH060011BD

Medicare Provider Number

060011

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/11/2016

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Denver Health and Hospital Authority
Kris Gaw, Chief Operating Officer
(303) 602-4985

Primary Contact

Denver Health and Hospital Authority
Nathalie Seoldo-Hinman, Admin Director of Pharmacy Services
(303) 602-9211

Addresses

Street Address

660 N Bannock St.
Denver, CO 80204

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
CO	05011002,03002334,28970845,77735072,03295003,03498441,03002631,03948502,7032382,28358562,39492788,9000171333,9000178555,05050083,49471091,05638598,05638382,05050117,05900139,05050091,05050133,82201722,17352380,11904241,05638770,92724728,33522731,39577856,05638812,05638804,05638846,05638788,05638796,30406871,05638820,94051721,52889564,84609354,9000154134,67630057	1689624686,1982627493,1033254925,1255470795,1285657528,1316960586,1720002181,1083637326,1174819197,1811328032,1164883955,1689624942,1467762435,1497305270,1285675371,1467877126,1316988413,1194766428,1326089400,1922049014,1801837810,1619918794,1336252287,1528337755,1467830778,1982626750,1427161371,1386714095,1144242900,1255353025,1366760498,1811196959,1376565143,1093737868,1326311655,1437171204,1184794893,1114341963,1538181318,1427155373,1629175153,1538266069,1124123427,1891891107,1033214333,1952699498,1306042502,1023464906,1215987987

Shipping Addresses

Shipping Address 1

Denver Health Outpatient Medical Center
660 N Bannock St.
Denver, CO 80204

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
DSH060011A	Child	DSH	DENVER HEALTH MEDICAL CENTER	DENVER HEALTH PRIMARY CARE	301 W. 6TH AVE	DENVER	CO	Active
DSH060011AA	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / North High School	2960 North Speer Blvd	Denver	CO	Active
DSH060011AB	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Martin Luther King Middle School	19535 East 46th Avenue	Denver	CO	Active
DSH060011AC	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Lake Middle School	1820 Lowell Blvd	Denver	CO	Active
DSH060011AD	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Kunsmiller Middle School	2250 South Quitman Way	Denver	CO	Active
DSH060011AE	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Kepner Middle School	911 Hazel Court	Denver	CO	Active
DSH060011AF	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / John F. Kennedy High School	2855 South Lamar Street	Denver	CO	Active
DSH060011AG	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Evie Garrett Dennis E-12 Campus	4800 Telluride Street	Denver	CO	Active
DSH060011AH	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Bruce Randolph Middle School	3955 Steele Street	Denver	CO	Active
DSH060011AJ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Park Hill / Family Medicine	4995 East 33rd Avenue	Denver	CO	Active
DSH060011AK	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Lincoln High School	2285 South Federal Blvd	Denver	CO	Active
DSH060011AL	Child	DSH	DENVER HEALTH MEDICAL CENTER	Park Hill / Laboratory	4995 East 33rd Avenue	Denver	CO	Active
DSH060011AM	Child	DSH	DENVER HEALTH MEDICAL CENTER	Montbello / Laboratory	12600 East Albrook Drive	Denver	CO	Active
DSH060011AN	Child	DSH	DENVER HEALTH MEDICAL CENTER	Montbello / Family Medicine	12600 East Albrook Drive	Denver	CO	Active
DSH060011AQ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Mental Health Centers of Denver	4455 East 12th Avenue	Denver	CO	Terminated
DSH060011AR	Child	DSH	DENVER HEALTH MEDICAL CENTER	Lowry / Laboratory	1001 Yosemite Street	Denver	CO	Active
DSH060011AS	Child	DSH	DENVER HEALTH MEDICAL CENTER	Lowry / Family Medicine	1001 Yosemite Street	Denver	CO	Active
DSH060011AT	Child	DSH	DENVER HEALTH MEDICAL CENTER	La Casa / Laboratory	4545 Navajo Street	Denver	CO	Active
DSH060011AU	Child	DSH	DENVER HEALTH MEDICAL CENTER	La Casa / Family Medicine	4545 Navajo Street	Denver	CO	Active
DSH060011AV	Child	DSH	DENVER HEALTH MEDICAL CENTER	Eastside / Women's Care Clinic	501 28th Street	Denver	CO	Active
DSH060011AW	Child	DSH	DENVER HEALTH MEDICAL CENTER	Eastside / Pediatric/Teen Clinic	501 28th Street	Denver	CO	Active
DSH060011AX	Child	DSH	DENVER HEALTH MEDICAL CENTER	Eastside / Laboratory	501 28th Street	Denver	CO	Active
DSH060011AY	Child	DSH	DENVER HEALTH MEDICAL CENTER	Eastside / Adult Clinic	501 28th Street	Denver	CO	Active
DSH060011AZ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion M / Radiology Diagnostic Imaging	723 Delaware Street	Denver	CO	ToBeTerminated
DSH060011B	Child	DSH	DENVER HEALTH MEDICAL CENTER	DENVER HEALTH MEDICAL CENTER I.D.	660 N Bannock St.	Denver	CO	Active
DSH060011BA	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion M / Anesthesiology	723 Delaware Street	Denver	CO	Terminated
DSH060011BB	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Neuro Psych	660 N Bannock St.	Denver	CO	Active
DSH060011BC	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion K / Behavioral Health	667 Bannock Street	Denver	CO	Active
DSH060011BD	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Infectious Diseases	660 N Bannock St.	Denver	CO	Active
DSH060011BE	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Radiology Ultrasound	301 W. 6th Avenue	Denver	CO	Terminated
DSH060011BF	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Radiology Diagnostic Imaging	301 W. 6th Avenue	Denver	CO	Terminated
DSH060011BG	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Radiology DEXA	301 W. 6th Avenue	Denver	CO	Terminated
DSH060011BH	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Pediatrics	301 W. 6th Avenue	Denver	CO	Active
DSH060011BJ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Laboratory	301 W. 6th Avenue	Denver	CO	Terminated
DSH060011BK	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Gerontology	301 W. 6th Avenue	Denver	CO	Active
DSH060011BL	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Family Medicine	301 W. 6th Avenue	Denver	CO	Active
DSH060011BM	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Internal Medicine	301 W. 6th Avenue	Denver	CO	Active
DSH060011BN	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Urology	660 N Bannock St.	Denver	CO	Active
DSH060011BP	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Rheumatology	660 N Bannock St.	Denver	CO	Active
DSH060011BQ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Pulmonary	660 N Bannock St.	Denver	CO	Active
DSH060011BR	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Neurology	660 N Bannock St.	Denver	CO	Active
DSH060011BS	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Physical Medicine & Rehabilitation	660 N Bannock St.	Denver	CO	Active
DSH060011BT	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Gastroenterology	660 N Bannock St.	Denver	CO	Active
DSH060011BU	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Otolaryngology	660 N Bannock St.	Denver	CO	Active
DSH060011BV	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Endocrinology	660 N Bannock St.	Denver	CO	Active
DSH060011BW	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Dermatology	660 N Bannock St.	Denver	CO	Active
DSH060011BX	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Cardiology	660 N Bannock St.	Denver	CO	Active
DSH060011BY	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Audiology Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011BZ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Vein Clinic	660 N Bannock St	Denver	CO	Active
DSH060011CA	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Vascular Surgery	660 N Bannock St.	Denver	CO	Active
DSH060011CB	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Vascular Surgery Lab	660 N Bannock St.	Denver	CO	Active
DSH060011CC	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion D / Infectious Disease	700 Delaware Street	Denver	CO	ToBeTerminated
DSH060011CD	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion D / Podiatry	700 Delaware Street	Denver	CO	Terminated
DSH060011CF	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Palliative Care	660 N Bannock St.	Denver	CO	Active
DSH060011CG	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Neurosurgery	660 N Bannock St.	Denver	CO	Active
DSH060011CH	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Oncology	660 N Bannock St.	Denver	CO	Active
DSH060011CJ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / General Surgery Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011CK	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Laboratory	660 N Bannock St.	Denver	CO	Active
DSH060011CL	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Sports Medicine	660 N Bannock St	Denver	CO	Active
DSH060011CM	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Breast Surgery	660 N Bannock St.	Denver	CO	Active
DSH060011CN	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Bariatrics	660 N Bannock St.	Denver	CO	Active
DSH060011CP	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Women's Care Clinic	790 Delaware Street	Denver	CO	Active
DSH060011CQ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Labor & Delivery PACU	790 Delaware Street	Denver	CO	Active
DSH060011CR	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Operating Room	790 Delaware Street	Denver	CO	Active
DSH060011CS	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Screening Room	790 Delaware Street	Denver	CO	Active
DSH060011CT	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Obstetric Ultrasound	790 Delaware Street	Denver	CO	Active
DSH060011CU	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westside / Women's Care Clinic	1100 Federal Blvd	Denver	CO	Active
DSH060011CV	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B / Speech Therapy	780 Delaware Street	Denver	CO	Active
DSH060011CW	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Ortho Radiology	660 N Bannock St.	Denver	CO	Active
DSH060011CX	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Labor & Deliver Operating Room	790 Delaware Street	Denver	CO	Active
DSH060011CY	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B-Correctional Care Medical Facility Radiology	780 Delaware Street	Denver	CO	Active
DSH060011CZ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westside / Adult Clinic	1100 Federal Blvd	Denver	CO	Active
DSH060011D	Child	DSH	DENVER HEALTH MEDICAL CENTER	DENVER HEALTH INFUSION CENTER	660 N Bannock St.	Denver	CO	Active
DSH060011DA	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B-Physical Therapy	780 Delaware Street	Denver	CO	Active
DSH060011DB	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Podiatry	660 N Bannock St.	Denver	CO	Active
DSH060011DC	Child	DSH	DENVER HEALTH MEDICAL CENTER	Family Crisis Center	405 South Platte River Drive	Denver	CO	Active
DSH060011DD	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L-Orthopedic Surgery	660 N Bannock St	Denver	CO	Active
DSH060011DE	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B-Occupational Therapy	780 Delaware Street	Denver	CO	Active
DSH060011DF	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Neurodiagnostic Lab	660 N Bannock St.	Denver	CO	Active
DSH060011DG	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Level One Physicians Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011DH	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion H / Neurodiagnostic Lab	605 Bannock Street	Denver	CO	Terminated
DSH060011DJ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Pulmonology	660 N Bannock St.	Denver	CO	Active
DSH060011DK	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Plastic Surgery	660 N Bannock St.	Denver	CO	Active
DSH060011DL	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion G / Intensive OP Medical Clinic	301 W 6th Ave	Denver	CO	Active
DSH060011DM	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Eye Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011DN	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Orthopedic Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011DP	Child	DSH	DENVER HEALTH MEDICAL CENTER	Winter Park Medical Center / Family Medicine	145 Parsenn Road	Winter Park	CO	Active
DSH060011DQ	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Montbello High School	5000 Crown Blvd	Denver	CO	Active
DSH060011DR	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Manual High School	1700 East 28th Avenue	Denver	CO	Active
DSH060011DS	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Outpatient Behavioral Health Services	660 N Bannock St.	Denver	CO	Active
DSH060011DT	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion K / Methadone	667 Bannock Street	Denver	CO	Active
DSH060011DU	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion K / Suboxone	667 Bannock Street	Denver	CO	Active
DSH060011DV	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion K / Substance Abuse Disorder Services	667 Bannock Street	Denver	CO	Terminated
DSH060011DW	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Nephrology	660 N Bannock St.	Denver	CO	Active
DSH060011DX	Child	DSH	DENVER HEALTH MEDICAL CENTER	Substance Abuse Treatment Education & Prevention	301 W. 6th Avenue	Denver	CO	Active
DSH060011DY	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion M / Child/Adolescent Psych	723 Delaware Street	Denver	CO	ToBeTerminated
DSH060011DZ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Women's Mobile Clinic	777 Bannock Street	Denver	CO	Active
DSH060011E	Child	DSH	DENVER HEALTH MEDICAL CENTER	EASTSIDE NEIGHBORHOOD HEALTH CENTER	501 28TH ST.	DENVER	CO	Active
DSH060011EA	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / 4C Medical/Surgical	790 Delaware Street	Denver	CO	Active
DSH060011EB	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Pediatric Intensive Care Unit	790 Delaware Street	Denver	CO	Active
DSH060011EC	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B / Progressive Care Unit	780 Delaware Street	Denver	CO	Active
DSH060011ED	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B / 4B Medical/Surgical	780 Delaware Street	Denver	CO	Active
DSH060011EE	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B / Correctional Care Medical Facility Ob Beds	780 Delaware Street	Denver	CO	Active
DSH060011EF	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion B / Medical Intensive Care Unit (MICU)	780 Delaware Street	Denver	CO	Active
DSH060011EG	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Mom/Baby Unit	790 Delaware Street	Denver	CO	Active
DSH060011EH	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Neonatology	790 Delaware Street	Denver	CO	ToBeTerminated
DSH060011EJ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Pediatrics	790 Delaware Street	Denver	CO	Active
DSH060011EK	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Florence Crittenton High School	55 S. Zuni Street	Denver	CO	Active
DSH060011EL	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Travel & Immunization Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011EM	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Tuberculosis Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011EN	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Sexually Transmitted Diseases Clinic	660 N Bannock St.	Denver	CO	Active
DSH060011EP	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Adult Urgent Care	660 N Bannock St.	Denver	CO	Terminated
DSH060011EQ	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion C / Labor & Delivery - Labor & Delivery	790 Delaware Street	Denver	CO	Active
DSH060011ER	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L / Electrophysiology - Electrophysiology	660 N Bannock St	Denver	CO	Active
DSH060011ES	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pavilion L GYN/ONC - GYN/ONC	660 N Bannock St.	Denver	CO	ToBeTerminated
DSH060011F	Child	DSH	DENVER HEALTH MEDICAL CENTER	WESTSIDE NEIGHBORHOOD HEALTH CENTER	1100 FEDERAL BOULEVARD	DENVER	CO	Active
DSH060011G	Child	DSH	DENVER HEALTH MEDICAL CENTER	LA CASA-QUIGG NEWTON HEALTH CENTER	4545 NAVAJO	DENVER	CO	Active
DSH060011H	Child	DSH	DENVER HEALTH MEDICAL CENTER	Winter Park Medical Center	145 Parsenn Rd	Winter Park	CO	Active
DSH060011J	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pav L Pre OP/PACU	660 N Bannock St.	Denver	CO	Active
DSH060011K	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pav L Operating Room	660 N Bannock St.	Denver	CO	Active
DSH060011L	Child	DSH	DENVER HEALTH MEDICAL CENTER	Denver Health Pav L GI Lab	660 N Bannock St.	Denver	CO	Active
DSH060011M	Child	DSH	DENVER HEALTH MEDICAL CENTER	Montbello Family Health Station	12600 E. Albrook Drive	Denver	CO	Active
DSH060011N	Child	DSH	DENVER HEALTH MEDICAL CENTER	Lowry Family Health Center	1001 Yosemite St	DENVER	CO	Active
DSH060011P	Child	DSH	DENVER HEALTH MEDICAL CENTER	Winter Park Medical Center / Radiology	145 Parsenn Road	Winter Park	CO	Active
DSH060011Q	Child	DSH	DENVER HEALTH MEDICAL CENTER	Winter Park Medical Center / Emergency	145 Parsenn Road	Winter Park	CO	Active
DSH060011R	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westwood / Laboratory	4320 Alaska Place	Denver	CO	Active
DSH060011S	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westwood / Family Medicine	4320 Alaska Place	Denver	CO	Active
DSH060011T	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westside / Pediatric/Teen Clinic	1100 Federal Blvd	Denver	CO	Active
DSH060011U	Child	DSH	DENVER HEALTH MEDICAL CENTER	Westside / Laboratory	1100 Federal Blvd	Denver	CO	Active
DSH060011V	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / West High School	951 Elati Street	Denver	CO	Active
DSH060011W	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Thomas Jefferson High School	3950 South Holly Street	Denver	CO	Active
DSH060011X	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / South High School	1700 East Louisiana Avenue	Denver	CO	Active
DSH060011Y	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Rachel Noel Middle School	5290 Kittredge Street	Denver	CO	Active
DSH060011Z	Child	DSH	DENVER HEALTH MEDICAL CENTER	School-Based Medical Services / Place Bridge Academy School	7125 Cherry Creek Drive North	Denver	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/1/2023 4:06:34 PM	8/19/2024 7:50:55 PM	8/19/2024 7:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000171333	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000178555	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05050083	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		49471091	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638598	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638382	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05050117	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05900139	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05050091	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05050133	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		82201722	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		17352380	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		11904241	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638770	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		92724728	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		33522731	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		39577856	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638812	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638804	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638846	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638788	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638796	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30406871	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05638820	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		94051721	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		52889564	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		84609354	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000154134	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		67630057	11/14/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1689624942	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467762435	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1497305270	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1285675371	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467877126	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316988413	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1194766428	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326089400	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1922049014	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1801837810	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619918794	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1336252287	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1528337755	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467830778	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982626750	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427161371	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1386714095	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144242900	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1255353025	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1366760498	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1811196959	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1376565143	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1093737868	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326311655	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1437171204	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1184794893	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1114341963	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1538181318	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427155373	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1629175153	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1538266069	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1124123427	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1891891107	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1033214333	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1952699498	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1306042502	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1023464906	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1215987987	11/14/2023 11:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	11/14/2023 11:34 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 10:29:13 AM	9/1/2023 4:06:34 PM	9/1/2023 4:06 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 12:50:34 PM	8/29/2022 10:29:13 AM	8/29/2022 10:29 AM
Details	Last Recertification Date	Update	Recertification	8/19/2020 11:28:59 AM	8/25/2021 12:50:34 PM	8/25/2021 12:50 PM
Addresses	Shipping Address	Delete	Change Request	Denver Health Acute Pharmacy 790 Delaware St Denver, CO 80204		4/14/2021 4:18 PM
Addresses	Shipping Address	Insert	Change Request		Denver Health Outpatient Medical Center 660 N Bannock St. Denver, CO 80204	4/14/2021 4:18 PM
Addresses	Main Address	Update	Change Request	605 Bannock Street Denver, CO 80204	660 N Bannock St. Denver, CO 80204	4/14/2021 4:18 PM
Details	Entity Subname	Update	Change Request	Denver Health Pavilion H / Infectious Diseases	Denver Health Pavilion L / Infectious Diseases	4/14/2021 4:18 PM
Contacts	Authorizing Official	Update	Change Request	Membel, Bradford Associate CFO Denver Health and Hospial Authority 3036027083	Gaw, Kris Chief Operating Officer Denver Health and Hospital Authority 3036024985	12/1/2020 7:58 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/19/2020 11:28 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 6:44:33 PM	8/19/2020 11:28:59 AM	8/19/2020 11:28 AM
Contacts	Authorizing Official	Update	Change Request	BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY Denver Health 3036024964	Membel, Bradford Associate CFO Denver Health and Hospial Authority 3036027083	7/27/2020 1:00 PM
Addresses	Shipping Address	Insert	Change Request		Denver Health Acute Pharmacy 790 Delaware St Denver, CO 80204	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05011002	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03002334	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		28970845	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		77735072	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03295003	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03498441	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03002631	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03948502	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7032382	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		28358562	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		39492788	1/28/2020 10:22 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1255470795	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1285657528	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1316960586	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720002181	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1083637326	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1174819197	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1811328032	1/28/2020 10:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1164883955	1/28/2020 10:22 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 4:30:56 PM	9/9/2019 6:44:33 PM	9/9/2019 6:44 PM
Contacts	Primary Contact	Update	Change Request	Kurtz, Andrew Director of Ambulatory Pharmacy Denver Health and Hospital Authority 3036028535	Seoldo-Hinman, Nathalie Admin Director of Pharmacy Services Denver Health and Hospital Authority 3036029211	2/1/2019 10:49 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1982627493	9/6/2018 4:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033254925	9/6/2018 4:30 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 11:56:42 AM	9/6/2018 4:30:56 PM	9/6/2018 4:30 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	12/5/2017 11:56:42 AM	12/5/2017 11:56 AM
Contacts	Authorizing Official	Update		BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY 3036024964	BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY Denver Health 3036024964	10/12/2017 4:00 PM
Contacts	Signed By	Update		BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY 3036024964	BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY Denver Health 3036024964	10/12/2017 4:00 PM
Contacts	Primary Contact	Update		Kurtz, Andrew Director of Ambulatory Pharmacy 3036028535	Kurtz, Andrew Director of Ambulatory Pharmacy Denver Health and Hospital Authority 3036028535	9/18/2017 5:43 PM
Contacts	Primary Contact	Insert			Kurtz, Andrew Director of Ambulatory Pharmacy 3036028535	7/27/2017 10:50 AM
Contacts	Authorizing Official	Insert			BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY 3036024964	7/27/2017 10:50 AM
Contacts	Signed By	Insert			BURNETTE, PEG CFO, DENVER HEALTH AND HOSPITAL AUTHORITY 3036024964	7/27/2017 10:50 AM
Addresses	Main Address	Insert			605 Bannock Street Denver, CO 80204	7/21/2017 5:01 PM
Details	Last Recertification Date	Update			9/6/2016 12:00:00 AM	9/6/2016 5:49 PM
Dates	Participating Approval Date	Update			3/11/2016 12:00:00 AM	3/11/2016 1:24 PM
Details	State	Update		Pending	Active	3/11/2016 1:24 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/11/2016 1:24 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57615	DSH060011BD	1/22/2016 9:42 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57615	1/13/2016 3:52 PM
Medicaid Billing	NPI: Number	Insert			1689624686	1/13/2016 3:52 PM
Details	Last Recertification Date	Insert				1/13/2016 3:52 PM
Details	Grant Number	Insert				1/13/2016 3:52 PM
Details	340B ID	Insert				1/13/2016 3:52 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 3:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 3:52 PM
Details	Medicare Provider Number	Insert			060011	1/13/2016 3:52 PM
Details	Entity Name	Insert			DENVER HEALTH MEDICAL CENTER	1/13/2016 3:52 PM
Details	Program Code	Insert			DSH	1/13/2016 3:52 PM
Details	Entity Subname	Insert			Denver Health Pavilion H / Infectious Diseases	1/13/2016 3:52 PM
Dates	Participating Approval Date	Insert				1/13/2016 3:52 PM
Details	State	Insert			Pending	1/13/2016 3:52 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 3:52 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 3:52 PM
Dates	Start Date	Insert				1/13/2016 3:52 PM
Terminations	Termination Comments	Insert				1/13/2016 3:52 PM
Terminations	Termination Date	Insert				1/13/2016 3:52 PM
Terminations	Termination Effective Date	Insert				1/13/2016 3:52 PM
Terminations	Termination Reason	Insert				1/13/2016 3:52 PM