Covered Entity Details

DSH050360G MARIN GENERAL HOSPITAL (Terminated) - information as of 5/7/2025 10:47:59 PM

Main Details

Name

MARIN GENERAL HOSPITAL

Subdivision Name

2 Bon Air Cardiovascular Testing

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050360G

Medicare Provider Number

050360

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/13/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/18/2016

Last Recertification Date

Termination Date
Termination Reason

4/1/2016
Other

Contacts

Authorizing Official

Marin General Hospital
Elizabeth Lasnier, Controller
(415) 925-7449

Primary Contact

Marin General Hospital
Michael Sillman, Director of Pharmacy
(415) 925-7867

Addresses

Street Address

2 Bon Air Rd
Suite 140
Greenbrae, CA 94904

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
CA	MSM003606
		1396725677

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
DSH050360A	Child	DSH	MARIN GENERAL HOSPITAL	RADIATION ONCOLOGY	1350 S. ELISEO DR	GREENBRAE	CA	Terminated
DSH050360B	Child	DSH	MARIN GENERAL HOSPITAL	Marin Outpatient Imaging Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360C	Child	DSH	MARIN GENERAL HOSPITAL	Eliseo Vascular Testing	1100 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360D	Child	DSH	MARIN GENERAL HOSPITAL	BRADEN DIABETES CENTER	1100 S ELISEO DR 2	GREENBRAE	CA	Terminated
DSH050360E	Child	DSH	MARIN GENERAL HOSPITAL	Breast Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360F	Child	DSH	MARIN GENERAL HOSPITAL	75 Rowland Vascular and Cardiovascular Testing	75 Rowland Way	Novato	CA	Terminated
DSH050360G	Child	DSH	MARIN GENERAL HOSPITAL	2 Bon Air Cardiovascular Testing	2 Bon Air Rd	Greenbrae	CA	Terminated
DSH050360H	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT PHYSICAL THERAPY - MARINHEALTH OUTPATIENT PHYSICAL THERAPY	1350 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360J	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH VASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Active
DSH050360K	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE	2 BON AIR ROAD	LARKSPUR	CA	Active
DSH050360L	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH UROLOGY	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360M	Child	DSH	MARIN GENERAL HOSPITAL	BREAST HEALTH CENTER - MARINHEALTH BREAST HEALTH CENTER	100A DRAKES LANDING RD	GREENBRAE	CA	Terminated
DSH050360N	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - IMAGING	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360P	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT MRI	1260 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360Q	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE - MARINHEALTH CARDIOVASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Terminated
DSH050360R	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH BRADEN DIABETES CENTER - BRADEN DIABETES CENTER	1100 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360S	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	75 Rowland Way	NOVATO	CA	Terminated
DSH050360T	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	2 BON AIR ROAD	LARKSPUR	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Eckhart, Megan Marie 340B Coordinator Marin General Hospital 4159257884	Lasnier, Elizabeth Controller Marin General Hospital 4159257449	1/15/2020 12:41 PM
Contacts	Authorizing Official	Update	AO Change Request	Wells, Beverly Assistant Controller MarinHealth 4159257437	Eckhart, Megan Marie 340B Coordinator Marin General Hospital 4159257884	12/16/2019 8:07 AM
Contacts	Authorizing Official	Update	Change Request	Noonan, Jean Controller Marin General Hospital 4159257449	Wells, Beverly Assistant Controller MarinHealth 4159257437	8/8/2019 7:17 AM
Contacts	Authorizing Official	Update	Change Request	McManus, James Chief Financial Officer Marin General Hospital 4159252095	Noonan, Jean Controller Marin General Hospital 4159257449	4/3/2019 3:23 PM
Contacts	Authorizing Official	Update		McManus, James Chief Financial Officer 4159252095	McManus, James Chief Financial Officer Marin General Hospital 4159252095	10/9/2017 9:07 PM
Contacts	Signed By	Update		McManus, James Chief Financial Officer 4159252095	McManus, James Chief Financial Officer Marin General Hospital 4159252095	10/9/2017 9:07 PM
Contacts	Primary Contact	Update		Sillman, Michael Director of Pharmacy 4159257867	Sillman, Michael Director of Pharmacy Marin General Hospital 4159257867	9/28/2017 12:52 PM
Contacts	Authorizing Official	Insert			McManus, James Chief Financial Officer 4159252095	1/13/2017 3:25 PM
Contacts	Signed By	Insert			McManus, James Chief Financial Officer 4159252095	1/13/2017 3:25 PM
Contacts	Primary Contact	Insert			Sillman, Michael Director of Pharmacy 4159257867	10/20/2016 2:49 PM
Addresses	Main Address	Insert			2 Bon Air Rd Suite 140 Greenbrae, CA 94904	3/31/2016 10:42 PM
Dates	Last Date That 340B Drugs Purchased	Update			3/31/2016 12:00:00 AM	3/31/2016 10:42 PM
Details	State	Update		Active	Terminated	3/31/2016 10:42 PM
Terminations	Termination Comments	Update			3/31/16 OPA terminated based on review of termination request that was submitted on 3/31/16 but not yet "accepted" by the AO	3/31/2016 10:42 PM
Terminations	Termination Date	Update			4/1/2016 12:00:00 AM	3/31/2016 10:42 PM
Terminations	Termination Effective Date	Update			4/1/2016 12:00:00 AM	3/31/2016 10:42 PM
Terminations	Termination Reason	Update			Other	3/31/2016 10:42 PM
Dates	Participating Approval Date	Update			2/18/2016 12:00:00 AM	2/18/2016 2:23 PM
Details	State	Update		Pending	Active	2/18/2016 2:23 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/18/2016 2:23 PM
Details	340B ID	Update		DEL-DSH050360D	DSH050360G	2/8/2016 2:04 PM
Details	State	Update		Rejected	Pending	2/8/2016 2:04 PM
Details	340B ID	Update		DSH050360D	DEL-DSH050360D	2/2/2016 4:00 PM
Details	State	Update		Pending	Rejected	2/2/2016 4:00 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57749	DSH050360D	1/29/2016 11:52 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57749	1/13/2016 6:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/13/2016 6:04 PM
Medicaid Billing	Medicaid: Number	Insert			MSM003606	1/13/2016 6:04 PM
Medicaid Billing	Medicaid: State	Insert			CA	1/13/2016 6:04 PM
Medicaid Billing	NPI: Number	Insert			1396725677	1/13/2016 6:04 PM
Details	Last Recertification Date	Insert				1/13/2016 6:04 PM
Details	Grant Number	Insert				1/13/2016 6:04 PM
Details	340B ID	Insert				1/13/2016 6:04 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 6:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 6:04 PM
Details	Medicare Provider Number	Insert			050360	1/13/2016 6:04 PM
Details	Entity Name	Insert			MARIN GENERAL HOSPITAL	1/13/2016 6:04 PM
Details	Program Code	Insert			DSH	1/13/2016 6:04 PM
Details	Entity Subname	Insert			2 Bon Air Cardiovascular Testing	1/13/2016 6:04 PM
Dates	Participating Approval Date	Insert				1/13/2016 6:04 PM
Details	State	Insert			Pending	1/13/2016 6:04 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 6:04 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 6:04 PM
Dates	Start Date	Insert				1/13/2016 6:04 PM
Terminations	Termination Comments	Insert				1/13/2016 6:04 PM
Terminations	Termination Date	Insert				1/13/2016 6:04 PM
Terminations	Termination Effective Date	Insert				1/13/2016 6:04 PM
Terminations	Termination Reason	Insert				1/13/2016 6:04 PM