Covered Entity Details

DSH440104AW Erlanger Health (Active) - information as of 4/25/2025 12:00:32 AM

Main Details

Name

Erlanger Health

Subdivision Name

Erlanger East Breast Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH440104AW

Medicare Provider Number

440104

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/8/2016

Last Recertification Date

9/9/2024

Contacts

Authorizing Official

Erlanger Health
Misty Brackett, VP Revenue Cycle
(423) 778-9775

Primary Contact

Erlanger Health System
Ngoc T. Le, 340B Program Coordinator
(423) 778-8194

Addresses

Street Address

1635 Gunbarrel Road
Suite 200
Chattanooga, TN 37421

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
AL	0440104	1154751931,1639264575,1861194086,1477256303
FL	0440104	1154751931,1639264575,1861194086,1477256303
GA	0440104	1154751931,1639264575,1861194086,1477256303
IL	0440104	1154751931,1639264575,1861194086,1477256303
IN	0440104	1154751931,1639264575,1861194086,1477256303
KY	0440104	1154751931,1639264575,1861194086,1477256303
MI	0440104	1154751931,1639264575,1861194086,1477256303
NY	0440104	1154751931,1639264575,1861194086,1477256303
NC	0440104	1154751931,1639264575,1861194086,1477256303
SC	0440104	1154751931,1639264575,1861194086,1477256303
TN	0440104	1154751931,1639264575,1861194086,1477256303
VA	0440104	1154751931,1639264575,1861194086,1477256303
WI	0440104	1154751931,1639264575,1861194086,1477256303

Shipping Addresses

Shipping Address 1

Erlanger East
1751 Gunbarrel Road
Chattanooga, TN 37421

Shipping Address 2

Erlanger East Breast Center
1635 Gunbarrel Road
Suite 200
Chattanooga, TN 37421

Shipping Address 3

Erlanger Health
910 Blackford Street
Chattanooga, TN 37403

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
DSH440104A	Child	DSH	ERLANGER MEDICAL CENTER	ERLANGER EAST	1751 GUNBARREL ROAD	CHATTANOOGA	TN	Terminated
DSH440104AA	Child	DSH	Erlanger Health	Radiation Oncology	975 East Third Street	Chattanooga	TN	Active
DSH440104AB	Child	DSH	ERLANGER MEDICAL CENTER	EN - Nuclear Medicine	632 Morrison Springs Road	Chattanooga	TN	Terminated
DSH440104AC	Child	DSH	Erlanger Health	EN Respiratory Care	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104AD	Child	DSH	Erlanger Health	CH Surgery	910 Blackford Street	Chattanooga	TN	Active
DSH440104AE	Child	DSH	Erlanger Health	EN Emergency Department	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104AF	Child	DSH	Erlanger Health	EE - Emergency Room	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AG	Child	DSH	Erlanger Health	CH SACU	910 Blackford Street	Chattanooga	TN	Active
DSH440104AH	Child	DSH	ERLANGER MEDICAL CENTER	TCTCH Clinics	910 Blackford Street	Chattanooga	TN	Terminated
DSH440104AJ	Child	DSH	Erlanger Health	EE Radiology	1751 Gunbarrel Rd	Chattanooga	TN	Active
DSH440104AK	Child	DSH	Erlanger Health	Erlanger East Surgery	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AL	Child	DSH	Erlanger Health	EE Respiratory Care	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AM	Child	DSH	Erlanger Health	Ch - Recovery	910 Blackford Street	Chattanooga	TN	Active
DSH440104AN	Child	DSH	Erlanger Health	CH Respiratory Care	910 Blackford Street	Chattanooga	TN	Active
DSH440104AP	Child	DSH	Erlanger Health	Medical Mall-Nuclear Rad	979 East Third Street	Chattanooga	TN	Active
DSH440104AQ	Child	DSH	Erlanger Health	Medical Mall-CT	979 East Third Street	Chattanooga	TN	Active
DSH440104AR	Child	DSH	Erlanger Health	East Infusion	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AS	Child	DSH	Erlanger Health	UT Erlanger Women's Oncology Infusion Center	102 Central Avenue	Chattanooga	TN	Active
DSH440104AT	Child	DSH	Erlanger Health	Anesthesiology Children's Hospital	910 Blackford Street	CHATTANOOGA	TN	Active
DSH440104AU	Child	DSH	Erlanger Health	Otpt Radiology-Women's Service	979 East Third Street	Chattanooga	TN	Active
DSH440104AV	Child	DSH	Erlanger Health	Erlanger East Day Surgery	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AW	Child	DSH	Erlanger Health	Erlanger East Breast Center	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104AX	Child	DSH	Erlanger Health	Children's Hospital Ultrasound	910 Blackford Street	CHATTANOOGA	TN	Active
DSH440104AZ	Child	DSH	Erlanger Health	Erlanger East Post Anesthesia Care Unit	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104B	Child	DSH	Erlanger Health	Erlanger North Sleep Center	632 Morrison Springs Road	Chattanooga	TN	Terminated
DSH440104BA	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-Pediatric Electroencephalography	900 East Third Street	Chattanooga	TN	Active
DSH440104BE	Child	DSH	Erlanger Health	Anesthesiology Miller Eye Center	975 East Third Street	Chattanooga	TN	Active
DSH440104BJ	Child	DSH	Erlanger Health	Childrens Cardiology-Hosp Serv	910 Blackford Street	CHATTANOOGA	TN	Active
DSH440104BK	Child	DSH	Erlanger Health	Erlanger East Surgical Radiology	1751 Gunbarrel Rd	Chattanooga	TN	Active
DSH440104BL	Child	DSH	Erlanger Health	Neurosurgery-Hospital Service	979 East Third Street	Chattanooga	TN	Active
DSH440104BM	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (Lookout Mountain)	101 McFarland Road	Lookout Mountain	GA	Active
DSH440104BN	Child	DSH	Erlanger Health	UTEHN Hixson Family Medicine	1724 Hamill Road	Hixson	TN	Active
DSH440104BP	Child	DSH	ERLANGER MEDICAL CENTER	UT - Erlanger Cardiology Prac (Copper Basin)	144 Medical Center Drive	Copper Hill	TN	Terminated
DSH440104BQ	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (Sequatchie Valley)	16931 Rankin Ave.	Dunlap	TN	Active
DSH440104BR	Child	DSH	Erlanger Health	UT-Erl East Br Internal Med	1720 Gunbarrel Road	Chattanooga	TN	Active
DSH440104BS	Child	DSH	Erlanger Health	EE - Family Medicine	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104BT	Child	DSH	Erlanger Health	Academic Urology (East)	1755 Gunbarrel Road	Chattanooga	TN	Active
DSH440104BU	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (South)	60 Erlanger South Drive	Ringgold	GA	Active
DSH440104BV	Child	DSH	Erlanger Health	UT/EN Inst of Sports/Health	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104BW	Child	DSH	ERLANGER MEDICAL CENTER	UT/Erl Behavioural Health (North Neurobehavior & Memory Svcs)	632 Morrison Springs Road	Chattanooga	TN	Terminated
DSH440104BX	Child	DSH	ERLANGER MEDICAL CENTER	EN Multi-Specialty	632 Morrison Springs Road	Chattanooga	TN	Terminated
DSH440104BY	Child	DSH	Erlanger Health	UT/Erl Inst of Sports/Health UTC McKenzie	720 East 4th Street	Chattanooga	TN	Active
DSH440104BZ	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (Bledsoe)	121 Wheelertown Avenue	Pikeville	TN	Active
DSH440104C	Child	DSH	Erlanger Health	PACC Ambulatory Surgery	975 East Third Street	Chattanooga	TN	Active
DSH440104CA	Child	DSH	Erlanger Health	Pediatric Hospitalists	910 Blackford Street	Chattanooga	TN	Active
DSH440104CB	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Nephrology	900 East Third Street	Chattanooga	TN	Active
DSH440104CC	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center - CH Orthopedics	900 East Third Street	Chattanooga	TN	Active
DSH440104CD	Child	DSH	Erlanger Health	CH Critical Care	910 Blackford Street	Chattanooga	TN	Active
DSH440104CE	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Neurology	900 East Third Street	Chattanooga	TN	Active
DSH440104CF	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Psychology	900 East Third Street	Chattanooga	TN	Active
DSH440104CG	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Pulmonary	900 East Third Street	Chattanooga	TN	Active
DSH440104CH	Child	DSH	Erlanger Health	CH Oncology/Hema	910 Blackford Street	Chattanooga	TN	Active
DSH440104CJ	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH University Pediatrics	900 East Third Street	Chattanooga	TN	Active
DSH440104CK	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Endocrinology	900 East Third Street	Chattanooga	TN	Active
DSH440104CL	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Genetics	900 East Third Street	Chattanooga	TN	Active
DSH440104CM	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Cardiology	900 East Third Street	Chattanooga	TN	Active
DSH440104CN	Child	DSH	Erlanger Health	CH Infectious Disease	910 Blackford Street	Chattanooga	TN	Active
DSH440104CP	Child	DSH	ERLANGER MEDICAL CENTER	CH - Urgent Care Clinic	910 Blackford Street Ground Floor Massoud Building	Chattanooga	TN	Terminated
DSH440104CQ	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center- CH Healthy Eating Active Living Program	900 East Third Street	Chattanooga	TN	Active
DSH440104CR	Child	DSH	ERLANGER MEDICAL CENTER	Academic Urology (Spring Creek)	961 Spring Creek Road	Chattanooga	TN	Terminated
DSH440104CS	Child	DSH	Erlanger Health	BEH Enterostomal Therapy	975 East Third Street	Chattanooga	TN	Active
DSH440104CT	Child	DSH	Erlanger Health	Hospitalists	975 East Third Street	Chattanooga	TN	Active
DSH440104CU	Child	DSH	Erlanger Health	Interventional Radiology	975 East Third Street	Chattanooga	TN	Active
DSH440104CV	Child	DSH	Erlanger Health	Academic Internal Medicine	979 East Third Street	Chattanooga	TN	Active
DSH440104CW	Child	DSH	Erlanger Health	Southern Ortho Trauma	979 East Third Street	Chattanooga	TN	Active
DSH440104CX	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (Downtown)	979 East Third Street	Chattanooga	TN	Active
DSH440104CY	Child	DSH	Erlanger Health	Adult Gastroenterology	979 East Third Street	Chattanooga	TN	Active
DSH440104CZ	Child	DSH	Erlanger Health	UTEHN University Ortho	979 East Third Street	Chattanooga	TN	Active
DSH440104D	Child	DSH	Erlanger Health	Synagis Clinic	900 East Third Street	Chattanooga	TN	Active
DSH440104DA	Child	DSH	Erlanger Health	UTEHN Ortho South	979 East Third Street	Chattanooga	TN	Active
DSH440104DB	Child	DSH	ERLANGER MEDICAL CENTER	Ortho Residency Program	979 East Third Street	Chattanooga	TN	Terminated
DSH440104DC	Child	DSH	ERLANGER MEDICAL CENTER	CHATTANOOGA HAMILTON COUNTY HOS / Bariatrics	979 East Third Street	Chattanooga	TN	Terminated
DSH440104DD	Child	DSH	Erlanger Health	EMG Endocrinology	979 EAST THIRD STREET	CHATTANOOGA	TN	Active
DSH440104DE	Child	DSH	ERLANGER MEDICAL CENTER	UT/Erl Behavioural Health	979 East Third Street	Chattanooga	TN	Terminated
DSH440104DF	Child	DSH	Erlanger Health	Southeast Regional Stroke Ctr	979 East Third Street	Chattanooga	TN	Active
DSH440104DG	Child	DSH	Erlanger Health	Academic Urology	979 East Third Street	Chattanooga	TN	Active
DSH440104DH	Child	DSH	Erlanger Health	UT/Erlanger Dermatology	979 East Third Street	Chattanooga	TN	Active
DSH440104DJ	Child	DSH	Erlanger Health	University Rheumatology	979 East Third Street	Chattanooga	TN	Active
DSH440104DK	Child	DSH	Erlanger Health	Univ Oncology & Hematology	979 East Third Street	Chattanooga	TN	Active
DSH440104DL	Child	DSH	Erlanger Health	EMG Women's Health Specialist	979 East Third Street	CHATTANOOGA	TN	Active
DSH440104DM	Child	DSH	Erlanger Health	UT/Erl Resp and Critical Care	979 East Third Street	Chattanooga	TN	Active
DSH440104DN	Child	DSH	Erlanger Health	IP Pulmonary/Critical Care	979 East Third Street	Chattanooga	TN	Active
DSH440104DP	Child	DSH	Erlanger Health	UT-Erl Primary and Athletic Health - Lookout Mtn	101 McFarland Road	Lookout Mountain	TN	Active
DSH440104DQ	Child	DSH	Erlanger Health	UT/Erl - Neurosurgery	979 East Third Street	Chattanooga	TN	Active
DSH440104DR	Child	DSH	Erlanger Health	WorkForce Clinic	1100 East Third Street	Chattanooga	TN	Terminated
DSH440104DS	Child	DSH	Erlanger Health	UT-ERL Primary and Athletic Health - Pineville Rd	1200 Pineville Road	Chattanooga	TN	Active
DSH440104DT	Child	DSH	Erlanger Health	UT - Erlanger Cardiology Prac (East)	1614 Gunbarrel Road	Chattanooga	TN	Active
DSH440104DU	Child	DSH	Erlanger Health	UT Erl Health and Wellness - Signal Mtn	2600 Taft Highway	Signal Mountain	TN	Active
DSH440104DV	Child	DSH	Erlanger Health	Erlanger South Family Practice - Ringgold/FO	60 Erlanger South Drive	Ringgold	GA	Active
DSH440104DW	Child	DSH	Erlanger Health	EN Sleep Center	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104DX	Child	DSH	ERLANGER MEDICAL CENTER	WorkForce Clinic at VW Drive	7380 Volkswagen Drive Ste 100	Chattanooga	TN	Terminated
DSH440104DY	Child	DSH	Erlanger Health	Erlanger Wellness Center at VW	7380 Volkswagen Drive	Chattanooga	TN	Active
DSH440104DZ	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH Gastroenterology	900 East Third Street	Chattanooga	TN	Active
DSH440104E	Child	DSH	Erlanger Health	Children's Hospital Radiology	910 Blackford Street	Chattanooga	TN	Active
DSH440104EA	Child	DSH	Erlanger Health	CH Lactation Clinic	910 Blackford Street	Chattanooga	TN	Active
DSH440104EB	Child	DSH	Erlanger Health	EE - Oncology Practice	1635 Gunbarrel Road	Chattanooga	TN	Terminated
DSH440104EC	Child	DSH	Erlanger Health	VW Inplant Clinic	8001 Volkswagen Drive	Chattanooga	TN	Active
DSH440104ED	Child	DSH	ERLANGER MEDICAL CENTER	Dalton Pediatrics / CH Gastroenterology	1008 Professional Blvd	Dalton	GA	Terminated
DSH440104EF	Child	DSH	Erlanger Health	Erlanger Inst for Clin Research / Oncology & Hematology	979 East Third Street	Chattanooga	TN	Active
DSH440104EG	Child	DSH	Erlanger Health	UT-Erl Chatt Bone & Joint	1809 Gunbarrel Rd	Chattanooga	TN	Active
DSH440104EH	Child	DSH	Erlanger Health	UT Erl- Radiation Oncology	979 East Third Street	Chattanooga	TN	Active
DSH440104EJ	Child	DSH	Erlanger Health	UT-ER-Prim Care at Marion Cty	520 East 12th Street	South Pittsburg	TN	Active
DSH440104EK	Child	DSH	Erlanger Health	Women's Oncology Practice	102 Central Avenue	Chattanooga	TN	Active
DSH440104EL	Child	DSH	ERLANGER MEDICAL CENTER	General Pediatrics - General Pediatrics East	1755 Gunbarrel Rd	Chattanooga	TN	Terminated
DSH440104EM	Child	DSH	Erlanger Health	CH Gastroenterology - CH Gastroenterology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EN	Child	DSH	Erlanger Health	Women's Institute Spec Health - Women's Institute Spec Health Hixson	1025 Executive Drive	Hixson	TN	Active
DSH440104EP	Child	DSH	Erlanger Health	Women's Institute Spec Health - Women's Institute Spec Health	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EQ	Child	DSH	Erlanger Health	CH Oncology - CH Oncology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104ER	Child	DSH	Erlanger Health	CH Neurology - CH Neurology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104ES	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-Children's Sleep Lab	900 East Third Street	Chattanooga	TN	Active
DSH440104ET	Child	DSH	Erlanger Health	EE-Cath/IR Lab - EE-Cath/IR Lab	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EU	Child	DSH	Erlanger Health	HEAL Clinic - HEAL Clinic	1635 Gunbarrel Road	Chattanooga	TN	Terminated
DSH440104EV	Child	DSH	Erlanger Health	CH Endocrinology - CH Endocrinology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EW	Child	DSH	Erlanger Health	EE-GI Lab - EE-GI Lab	1755 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EX	Child	DSH	Erlanger Health	Ch Cardiology - CH Cardiology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104EY	Child	DSH	Erlanger Health	EE-Rehab Services - EE-Rehab Services	1751 Gunbarrel Rd	Chattanooga	TN	Active
DSH440104EZ	Child	DSH	Erlanger Health	EE-Labor & Delivery - EE-Labor & Delivery	1751 Gunbarrel Rd	Chattanooga	TN	Active
DSH440104F	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-Children's CT	900 East Third Street	Chattanooga	TN	Active
DSH440104FA	Child	DSH	Erlanger Health	CH Pulmonology - CH Pulmonology East	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FB	Child	DSH	Erlanger Health	Erlanger Center for Women - Erlanger Center for Women	7490 Zeigler Road	Chattanooga	TN	Active
DSH440104FC	Child	DSH	Erlanger Health	Acedemic Urology (Hixson) - Acedemic Urology (Hixson)	2158 Northgate Park	Chattanooga	TN	Active
DSH440104FD	Child	DSH	Erlanger Health	UT/ERL Institute of Sports and Health - Primary Care - Primary Care	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104FE	Child	DSH	Erlanger Health	CH Genetic Diagnostic Lab - Genetic Diagnostic Lab	910 Blackford Street	Chattanooga	TN	Active
DSH440104FF	Child	DSH	Erlanger Health	East Radiation Oncology - East Radiation Oncology	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FG	Child	DSH	Erlanger Health	Gastroenterology East Medical Office - EEH Gastroenterology	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FH	Child	DSH	Erlanger Health	Erlanger Palliative Services - Erlanger Palliative Services	979 East Third Street	Chattanooga	TN	Active
DSH440104FJ	Child	DSH	Erlanger Health	EEH Children's Cardiology Hospital Service - EEH Children's Cardiology	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FK	Child	DSH	Erlanger Health	Southeast Regional Stroke Center/Neurology East - EEH Neurology	1755 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FL	Child	DSH	Erlanger Health	Dermatology East Medical Office - EEH Dermatology	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FM	Child	DSH	Erlanger Health	Sports Medicine UT Family Practice - Sports Medicine UT Family Practie	1100 East Third Street	Chattanooga	TN	Active
DSH440104FN	Child	DSH	Erlanger Health	EN Cardiology	632 Morrison Spring Road	Chattanooga	TN	Active
DSH440104FP	Child	DSH	Erlanger Health	CH Orthopedics East Medical Office - EEH Children's Orthopedics	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FQ	Child	DSH	ERLANGER MEDICAL CENTER	Chattanooga Bone and Joint-Rhea - Ortho Rhea	9400 Rhea County Hwy	Dayton	TN	Terminated
DSH440104FR	Child	DSH	Erlanger Health	CH Genetics East Medical Office - EEH CH Genetics	1635 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FS	Child	DSH	Erlanger Health	Pediatric Urology Medical Mall - EMG Pediatric Urology	979 East Third Street	Chattanooga	TN	Active
DSH440104FT	Child	DSH	Erlanger Health	EEH Pediatric Urology - EEH Pediatric Urology	1755 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FU	Child	DSH	Erlanger Health	Orthopedics North - EN Orthopedics	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104FV	Child	DSH	Erlanger Health	Orthopedics Foot and Ankle - Medical Mall - Ortho Foot and Ankle - Medical Mall	979 East Third Street	Chattanooga	TN	Active
DSH440104FW	Child	DSH	Erlanger Health	UTEHN Ortho South on 3rd - UTEHN Orthopedics on 3rd	1100 East Third Street	Chattanooga	TN	Active
DSH440104FX	Child	DSH	Erlanger Health	EMG South Ortho Clnic-Ringgold/FO - EMG South Ortho Clinic-Ringgold/FO	60 Erlanger South Drive	Ringgold	GA	Active
DSH440104FY	Child	DSH	Erlanger Health	EE Anesthesiology - EE Anesthesiolgy	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104FZ	Child	DSH	Erlanger Health	ENH CV Rehab and Wellness - ENH CV Rehab and Wellness	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104G	Child	DSH	Erlanger Health	Children's ED	910 Blackford Street	Chattanooga	TN	Active
DSH440104GA	Child	DSH	Erlanger Health	EMG Women's Health Marion - EMG Women's Health Marion	520 East 12th Street	South Pittsburg	TN	Active
DSH440104GB	Child	DSH	Erlanger Health	Children's Kennedy Outpatient Center-CH OP Radiology - CH OP Radiology	900 East Third Street	Chattanooga	TN	Active
DSH440104GC	Child	DSH	Erlanger Health	EMG Children's Kennedy Outpatient Center -Adol Med - EMG Children's Kennedy Outpatient Center -Adol Med	900 East Third Street	Chattanooga	TN	Active
DSH440104GD	Child	DSH	Erlanger Health	EE Pre Admit Testing - EE Pre Admit Testing	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104GE	Child	DSH	Erlanger Health	EMG Cardiology Sports-3rd - EMG Cardiology Sports-3rd	1100 East Third Street	Chattanooga	TN	Active
DSH440104GF	Child	DSH	Erlanger Health	EMG Sports Health at South - EMG Sports Health at South	60 Erlanger South Drive	Ringgold	GA	Active
DSH440104GG	Child	DSH	Erlanger Health	EEH Pulmonary Proc Lab - EEH Pulmonary Proc Lab	1755 Gunbarrel Road	Chattanooga	TN	Active
DSH440104GH	Child	DSH	Erlanger Health	EEH CV CI Proc Lab - EEH CV CI Proc Lab-Hospital Service	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104GJ	Child	DSH	Erlanger Health	EMG Gastro South - EMG Gastro South -Ringgold/FO	60 Erlanger South Drive	Ringgold	GA	Active
DSH440104GK	Child	DSH	Erlanger Health	EEH POCT Lab - EEH POCT LAB/PFT	1751 Gunbarrel Road	Chattanooga	TN	Active
DSH440104GL	Child	DSH	Erlanger Health	EMG Prim Care-Soddy Daisy POB - EMG Prim Care-Soddy Daisy POB	9448 Dayton Pike	Soddy Daisy	TN	Active
DSH440104GM	Child	DSH	Erlanger Health	EMG Cleveland Pediatrics Endocrinology - EMG CH Endocrinology	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GN	Child	DSH	Erlanger Health	CH Sleep Lab - CH Sleep Lab	910 Blackford Street	Chattanooga	TN	Active
DSH440104GP	Child	DSH	Erlanger Health	EMG Urology at Cleveland - EMG Urology at Cleveland	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GQ	Child	DSH	Erlanger Health	EMG Orthopaedics Cleveland - EMG Orthopaedics Cleveland	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GR	Child	DSH	Erlanger Health	EMG Orthopaedics Rhea County - EMG Orthopaedics Rhea County	163 Walnut Grove Church Road	Dayton	TN	Active
DSH440104GS	Child	DSH	Erlanger Health	EMG Urology at Fertility Center - EMG Urology TFC	7407 Ziegler Road	Chattanooga	TN	Active
DSH440104GT	Child	DSH	Erlanger Health	EMG Cardiology Cleveland - EMG Cardiology Cleveland	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GU	Child	DSH	Erlanger Health	EMG Cardiology Rhea County - EMG Cardiology Rhea County	163 Walnut Grove Church Road	Dayton	TN	Active
DSH440104GV	Child	DSH	Erlanger Health	EMG Cleveland Pediatrics Urology - EMG CH Urology	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GW	Child	DSH	Erlanger Health	EMG CHE Craniofacial-Massoud - Craniofacial Program	910 Blackford Street	Chattanooga	TN	Active
DSH440104GX	Child	DSH	Erlanger Health	EMG Cardiology Marion County - EMG Cardiology Marion County	520 East 12th Street	South Pittsburg	TN	Active
DSH440104GY	Child	DSH	Erlanger Health	EMG Cleveland Pediatrics Cardiology - EMG CH Cardiology	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104GZ	Child	DSH	Erlanger Health	EMG Cleveland Pediatrics Gastroenterology - EMG Pediatric Gastroenterology	4312 Holiday Inn Express Way	Cleveland	TN	Active
DSH440104H	Child	DSH	Erlanger Health	North Radiology	632 Morrison Springs Road	Chattanooga	TN	Active
DSH440104HA	Child	DSH	Erlanger Health	UT Erlanger Cardiology Prac (VW) - Cardiology	7380 Volkswagon Drive	Chattanooga	TN	Active
DSH440104HB	Child	DSH	Erlanger Health	UT Erl Neurosurgery - EMG Neurology	979 East Third Street	Chattanooga	TN	Active
DSH440104HC	Child	DSH	Erlanger Health	Erl Prim Care Ringgold - Primary Care	6984 Nashville Street	Ringgold	GA	Active
DSH440104HD	Child	DSH	Erlanger Health	EMG Peds Aerodigestive - EMG CHE Aerodigestive Clinic-Mass	910 Blackford Street	Chattanooga	TN	Active
DSH440104HE	Child	DSH	Erlanger Health	Erl Pr Care Dalton Walnut Ave - Primary Care	1329 West Walnut Avenue	Dalton	GA	Active
DSH440104HF	Child	DSH	Erlanger Health	UT Erl H W Signal Mtn - Internal Medicine	579 Alexian Way	Signal Mountain	TN	Active
DSH440104HG	Child	DSH	Erlanger Health	Erl Prim Care Cleveland - Primary Care	4312 Holiday Inn Expressway NW	Cleveland	TN	Active
DSH440104J	Child	DSH	Erlanger Health	Plaza Radiology	979 East Third Street	Chattanooga	TN	Active
DSH440104K	Child	DSH	Erlanger Health	Children's Oncology Center	910 Blackford Street	Chattanooga	TN	Active
DSH440104L	Child	DSH	Erlanger Health	Infusion Center	975 East Third Street	Chattanooga	TN	Active
DSH440104M	Child	DSH	Erlanger Health	Infusion Center-University Oncology	979 East Third Street	Chattanooga	TN	Active
DSH440104N	Child	DSH	Erlanger Health	Miller Eye Center	975 East Third Street	Chattanooga	TN	Active
DSH440104P	Child	DSH	Erlanger Health	Wound Care Center	975 East Third Street	Chattanooga	TN	Active
DSH440104Q	Child	DSH	Erlanger Health	Ch Gastrointerology - Hospital Service	910 Blackford Street	Chattanooga	TN	Active
DSH440104R	Child	DSH	Erlanger Health	East Cardiology Practice Hospital Service	1614 Gunbarrel Road	Chattanooga	TN	Active
DSH440104S	Child	DSH	Erlanger Health	UT Cardiology Erlanger Hospital Service	979 East Third Street	Chattanooga	TN	Active
DSH440104T	Child	DSH	Erlanger Health	Renal Dialysis	975 East Third Street	Chattanooga	TN	Active
DSH440104U	Child	DSH	Erlanger Health	Cardiac Cath Lab	975 East Third Street	Chattanooga	TN	Active
DSH440104V	Child	DSH	Erlanger Health	GI Laboratory	975 East Third Street	Chattanooga	TN	Active
DSH440104W	Child	DSH	Erlanger Health	UT Family Medicine	1100 East Third Street	Chattanooga	TN	Active
DSH440104X	Child	DSH	Erlanger Health	University Medical Associates	975 East Third Street	Chattanooga	TN	Active
DSH440104Y	Child	DSH	Erlanger Health	Kidney Transplant Clinic	979 East Third Street	Chattanooga	TN	Active
DSH440104Z	Child	DSH	Erlanger Health	East Imaging	1751 Gunbarrel Road	Chattanooga	TN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Recertification		Erlanger Health 910 Blackford Street Chattanooga, TN 37403	9/9/2024 7:55 AM
Details	Last Recertification Date	Update	Recertification	9/9/2023 11:53:59 AM	9/9/2024 7:55:14 AM	9/9/2024 7:55 AM
Details	Entity Name	Update	Recertification	ERLANGER MEDICAL CENTER	Erlanger Health	9/18/2023 7:29 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 2:12:30 PM	9/9/2023 11:53:59 AM	9/9/2023 11:53 AM
Contacts	Authorizing Official	Update	Change Request	Spady, Christopher Scott Vice President, Revenue Cycle Erlanger Health System 4237784786	Brackett, Misty VP Revenue Cycle Erlanger Health 4237789775	7/5/2023 3:55 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		TN	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		TN	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861194086	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	6/23/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477256303	6/23/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	6/23/2023 1:46 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 3:00:57 PM	9/16/2022 2:12:30 PM	9/16/2022 2:12 PM
Details	Last Recertification Date	Update	Recertification	9/7/2020 10:06:43 AM	9/10/2021 3:00:57 PM	9/10/2021 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0440104	6/14/2021 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154751931	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	6/14/2021 5:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639264575	6/14/2021 5:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	6/14/2021 5:52 PM
Contacts	Authorizing Official	Update	AO Change Request	TABOR, BRITTON J. CFO Erlanger Health System 4237787729	Spady, Christopher Scott Vice President, Revenue Cycle Erlanger Health System 4237784786	5/5/2021 4:17 PM
Addresses	Shipping Address	Delete	Recertification	Erlanger East Breast Center 1635 Gunbarrel Road Suite 300 Chattanooga, TN 37421		9/7/2020 10:06 AM
Addresses	Shipping Address	Delete	Recertification	Erlanger East Breast Center 1751 Gunbarrel Rd. Chattanooga, TN 37421		9/7/2020 10:06 AM
Addresses	Shipping Address	Insert	Recertification		Erlanger East 1751 Gunbarrel Road Chattanooga, TN 37421	9/7/2020 10:06 AM
Addresses	Shipping Address	Insert	Recertification		Erlanger East Breast Center 1635 Gunbarrel Road Suite 200 Chattanooga, TN 37421	9/7/2020 10:06 AM
Addresses	Main Address	Update	Recertification	1635 Gunbarrel Road Suite 300 Chattanooga, TN 37421	1635 Gunbarrel Road Suite 200 Chattanooga, TN 37421	9/7/2020 10:06 AM
Details	Last Recertification Date	Update	Recertification	9/11/2019 2:13:26 PM	9/7/2020 10:06:43 AM	9/7/2020 10:06 AM
Addresses	Shipping Address	Delete	Recertification	Erlanger East Breast Center 1635 Gunbarrel Road Chattanooga, TN 37421		9/11/2019 2:13 PM
Addresses	Shipping Address	Insert	Recertification		Erlanger East Breast Center 1635 Gunbarrel Road Suite 300 Chattanooga, TN 37421	9/11/2019 2:13 PM
Addresses	Main Address	Update	Recertification	1635 Gunbarrel Road Chattanooga, TN 37421	1635 Gunbarrel Road Suite 300 Chattanooga, TN 37421	9/11/2019 2:13 PM
Details	Last Recertification Date	Update	Recertification	8/29/2018 3:44:10 PM	9/11/2019 2:13:26 PM	9/11/2019 2:13 PM
Addresses	Shipping Address	Insert	Change Request		Erlanger East Breast Center 1635 Gunbarrel Road Chattanooga, TN 37421	4/18/2019 7:02 AM
Addresses	Main Address	Update	Change Request	1751 Gunbarrel Rd Suite G10 Chattanooga, TN 37421	1635 Gunbarrel Road Chattanooga, TN 37421	4/18/2019 7:02 AM
Details	Entity Subname	Update	Change Request	Erlanger East Breast Center	Erlanger East Breast Center	4/18/2019 7:02 AM
Addresses	Main Address	Update	Recertification	1751 Gunbarrel Rd Suite G10 Chattanooga, TN 37421	1751 Gunbarrel Rd Suite G10 Chattanooga, TN 37421	8/29/2018 3:44 PM
Contacts	Primary Contact	Update	Recertification	Friedman, Julia 340B Program Coordinator Erlanger Health System 4237788194	Le, Ngoc T. 340B Program Coordinator Erlanger Health System 4237788194	8/29/2018 3:44 PM
Details	Last Recertification Date	Update	Recertification	11/14/2017 1:43:14 PM	8/29/2018 3:44:10 PM	8/29/2018 3:44 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/14/2017 1:43:14 PM	11/14/2017 1:43 PM
Contacts	Authorizing Official	Update		TABOR, BRITTON J. CFO 4237787729	TABOR, BRITTON J. CFO Erlanger Health System 4237787729	9/19/2017 7:41 PM
Contacts	Signed By	Update		TABOR, BRITTON J. CFO 4237787729	TABOR, BRITTON J. CFO Erlanger Health System 4237787729	9/19/2017 7:41 PM
Contacts	Primary Contact	Update		Friedman, Julia 340B Program Coordinator 4237788194	Friedman, Julia 340B Program Coordinator Erlanger Health System 4237788194	9/19/2017 1:51 PM
Contacts	Authorizing Official	Insert			TABOR, BRITTON J. CFO 4237787729	7/16/2017 1:20 PM
Contacts	Signed By	Insert			TABOR, BRITTON J. CFO 4237787729	7/16/2017 1:20 PM
Contacts	Primary Contact	Insert			Friedman, Julia 340B Program Coordinator 4237788194	5/1/2017 1:48 PM
Addresses	Main Address	Insert			1751 Gunbarrel Rd Suite G10 Chattanooga, TN 37421	5/1/2017 1:48 PM
Addresses	Shipping Address	Insert			Erlanger East Breast Center 1751 Gunbarrel Rd. Chattanooga, TN 37421	5/1/2017 1:48 PM
Details	Last Recertification Date	Update			8/15/2016 12:00:00 AM	8/15/2016 5:14 PM
Dates	Participating Approval Date	Update			3/8/2016 12:00:00 AM	3/8/2016 10:28 AM
Details	State	Update		Pending	Active	3/8/2016 10:28 AM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/8/2016 10:28 AM
Details	340B ID	Update		DSH440104BD	DSH440104AW	2/22/2016 9:51 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57651	DSH440104BD	1/26/2016 12:36 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57651	1/13/2016 4:19 PM
Details	Last Recertification Date	Insert				1/13/2016 4:19 PM
Details	Grant Number	Insert				1/13/2016 4:19 PM
Details	340B ID	Insert				1/13/2016 4:19 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 4:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 4:19 PM
Details	Medicare Provider Number	Insert			440104	1/13/2016 4:19 PM
Details	Entity Name	Insert			ERLANGER MEDICAL CENTER	1/13/2016 4:19 PM
Details	Program Code	Insert			DSH	1/13/2016 4:19 PM
Details	Entity Subname	Insert			Erlanger East Breast Center	1/13/2016 4:19 PM
Dates	Participating Approval Date	Insert				1/13/2016 4:19 PM
Details	State	Insert			Pending	1/13/2016 4:19 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 4:19 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 4:19 PM
Dates	Start Date	Insert				1/13/2016 4:19 PM
Terminations	Termination Comments	Insert				1/13/2016 4:19 PM
Terminations	Termination Date	Insert				1/13/2016 4:19 PM
Terminations	Termination Effective Date	Insert				1/13/2016 4:19 PM
Terminations	Termination Reason	Insert				1/13/2016 4:19 PM