| Contacts | Primary Contact | Update | Recertification | Mattingly, Michelle
Director of Pharmacy
Flaget Memorial Hospital
5023505232 | Mattingly, Michelle E
Director of Pharmacy
Flaget Memorial Hospital
5023505232 | 8/29/2024 3:03 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2023 10:34:18 AM | 8/29/2024 3:03:52 PM | 8/29/2024 3:03 PM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2022 12:21:41 PM | 8/16/2023 10:34:18 AM | 8/16/2023 10:34 AM |
| Addresses | Billing Address | Update | Change Request | Catholic Health Initiative
11045 E Lansing Cir
Englewood, CO 80112-5909 | Catholic Health Initiative
P.O. Box 2400
Phoenix, AZ 85002 | 7/24/2023 3:33 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2021 3:27:20 PM | 9/1/2022 12:21:41 PM | 9/1/2022 12:21 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2020 3:53:56 PM | 8/23/2021 3:27:20 PM | 8/23/2021 3:27 PM |
| Addresses | Main Address | Update | Change Request |
4359 New Shepherdsville Road
Bardstown, KY 40004 |
4359 New Shepherdsville Road
Suite 225
Bardstown, KY 40004 | 6/23/2021 2:47 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1871588772 ( ) | | 8/27/2020 3:53 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1871588772 | 8/27/2020 3:53 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | KY | 8/27/2020 3:53 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2019 1:24:16 PM | 8/27/2020 3:53:56 PM | 8/27/2020 3:53 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2018 2:34:41 PM | 8/23/2019 1:24:16 PM | 8/23/2019 1:24 PM |
| Addresses | Shipping Address | Insert | Change Request | | Flaget Mem Hosp, St Joseph 340B
5100115 720030 Member of KY One
4305 New Shepherdsville Rd
Bardstown, KY 40004-1299 | 4/23/2019 8:36 AM |
| Addresses | Billing Address | Update | Change Request | Flaget Memorial Hospital
4305 New Shepherdsville Road
Bardstown, KY 40004 | Catholic Health Initiative
11045 E Lansing Cir
Englewood, CO 80112-5909 | 4/23/2019 8:36 AM |
| Addresses | Shipping Address | Delete | Change Request | Flaget Memorial Hospital
4305 New Shepherdsville Road
Bardstown, KY 40004 | | 4/23/2019 8:36 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/13/2019 5:05 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 01000017 | 3/13/2019 5:05 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 3/13/2019 5:05 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1871588772 | 3/13/2019 5:05 PM |
| Contacts | Authorizing Official | Update | Change Request | Vancise, Richard J
VP-Hospital Operations
Flaget Memorial Hospital
5023505456 | Nolan, Jennifer C
President
Flaget Memorial Hospital
5023505044 | 11/9/2018 9:11 AM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 7:59:34 AM | 8/27/2018 2:34:41 PM | 8/27/2018 2:34 PM |
| Contacts | Authorizing Official | Update | Change Request | Goss, Norma
VP Patient Care Services/ CNO
Flaget Memorial Hospital
5023505048 | Vancise, Richard J
VP-Hospital Operations
Flaget Memorial Hospital
5023505456 | 3/29/2018 11:07 AM |
| Details | Last Recertification Date | Update | Recertification | 10/24/2017 1:16:53 PM | 11/3/2017 7:59:34 AM | 11/3/2017 7:59 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2016 12:00:00 AM | 10/24/2017 1:16:53 PM | 10/24/2017 1:16 PM |
| Contacts | Primary Contact | Update | | Mattingly, Michelle
Director of Pharmacy
5023505232 | Mattingly, Michelle
Director of Pharmacy
Flaget Memorial Hospital
5023505232 | 10/13/2017 2:20 PM |
| Contacts | Authorizing Official | Update | | Goss, Norma
VP Patient Care Services/ CNO
5023505048 | Goss, Norma
VP Patient Care Services/ CNO
Flaget Memorial Hospital
5023505048 | 10/10/2017 12:13 PM |
| Contacts | Authorizing Official | Update | | Goss, Norma
VP Patient Care Services/ CNO
5023505048 | Goss, Norma
VP Patient Care Services/ CNO
5023505048 | 9/11/2017 3:29 PM |
| Addresses | Main Address | Insert | | |
4359 New Shepherdsville Road
Bardstown, KY 40004 | 11/23/2016 11:43 AM |
| Addresses | Billing Address | Insert | | | Flaget Memorial Hospital
4305 New Shepherdsville Road
Bardstown, KY 40004 | 11/23/2016 11:43 AM |
| Addresses | Shipping Address | Insert | | | Flaget Memorial Hospital
4305 New Shepherdsville Road
Bardstown, KY 40004 | 11/23/2016 11:43 AM |
| Contacts | Primary Contact | Insert | | | Mattingly, Michelle
Director of Pharmacy
5023505232 | 11/23/2016 11:43 AM |
| Contacts | Authorizing Official | Insert | | | Goss, Norma
VP Patient Care Services/ CNO
5023505048 | 11/23/2016 11:43 AM |
| Contacts | Signed By | Insert | | | Downs, Sue
Hospital President
5023505044 | 11/23/2016 11:43 AM |
| Details | Last Recertification Date | Update | | | 8/23/2016 12:00:00 AM | 8/23/2016 3:55 PM |
| Dates | Participating Approval Date | Update | | | 3/3/2016 12:00:00 AM | 3/3/2016 10:53 AM |
| Details | State | Update | | Pending | Active | 3/3/2016 10:53 AM |
| Dates | Start Date | Update | | | 4/1/2016 12:00:00 AM | 3/3/2016 10:53 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_58157 | DSH180025A | 2/18/2016 8:42 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_58157 | 1/15/2016 9:34 AM |
| Details | Last Recertification Date | Insert | | | | 1/15/2016 9:34 AM |
| Details | Grant Number | Insert | | | | 1/15/2016 9:34 AM |
| Details | 340B ID | Insert | | | | 1/15/2016 9:34 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/15/2016 9:34 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/15/2016 9:34 AM |
| Details | Medicare Provider Number | Insert | | | 180025 | 1/15/2016 9:34 AM |
| Details | Entity Name | Insert | | | ST. JOE. - FLAGET | 1/15/2016 9:34 AM |
| Details | Program Code | Insert | | | DSH | 1/15/2016 9:34 AM |
| Details | Entity Subname | Insert | | | Flaget Memorial Hospital Sleep Lab | 1/15/2016 9:34 AM |
| Dates | Participating Approval Date | Insert | | | | 1/15/2016 9:34 AM |
| Details | State | Insert | | | Pending | 1/15/2016 9:34 AM |
| Dates | Registration Date | Insert | | | 1/15/2016 12:00:00 AM | 1/15/2016 9:34 AM |
| Dates | Signed By Date | Insert | | | 1/15/2016 12:00:00 AM | 1/15/2016 9:34 AM |
| Dates | Start Date | Insert | | | | 1/15/2016 9:34 AM |
| Terminations | Termination Comments | Insert | | | | 1/15/2016 9:34 AM |
| Terminations | Termination Date | Insert | | | | 1/15/2016 9:34 AM |
| Terminations | Termination Effective Date | Insert | | | | 1/15/2016 9:34 AM |
| Terminations | Termination Reason | Insert | | | | 1/15/2016 9:34 AM |