Covered Entity Details

DSH330195AB LONG ISLAND JEWISH MEDICAL CENTER (Active) - information as of 4/30/2025 10:55:04 PM

Main Details

Name

LONG ISLAND JEWISH MEDICAL CENTER

Subdivision Name

Forest Hills Hospital / CAT Scan

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330195AB

Medicare Provider Number

330195

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

2/3/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/8/2016

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

102-01 66th Road
Forest Hills, NY 11375

Billing Address

LONG ISLAND JEWISH MEDICAL CENTER
270-05 76TH AVE
NEW HYDE PARK, NY 11040

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	LON0195N	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
AR	239739105	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
AZ	598210,085483	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
CA	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
CO	9000182281,44432577,9000166580	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
CT	008051182,008092821,3129401,008095457	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
DE	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
FL	092086000,003273000	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
GA	000105729A,399622993A,003239434A	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
ID	1316954449	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
IA	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
IL	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
IN	300031800	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
KY	01500040	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
LA	1747882	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MA	110026857C	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MD	283335200,453325900	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
ME	160670000	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MI	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MN	199217100,1316954449,273631400	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MO	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
MS	00096736	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NC	1285641514,1316954449,3300372	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NE	11224132600,10026583700	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NH	3104340,20002124	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NJ	4157303,8844500	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NM	A8435	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NV	001288387	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
OH	0608033	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
OK	100689170A	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
OR	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
PA	1007620400005,0014836270001,1007620400006	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
RI	OP30195	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
SC	10858B,12198B	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
TN	Q034252	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
TX	072485801,072505301	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
UT	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
VA	1285641514,1316954449	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
VT	0330195,0330372	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
WA	1285641514	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
WI	1285641514,100099880	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
WV	3910006997	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107
NY	05099885,04133506,3313980,00243903,02998887	1285641514,1982611190,1174530349,1174926406,1871024455,1346603107,1467695023

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	Last Updated On
Contract Detail	LONG ISLAND JEWISH MEDICAL CENTER AT HOM	VIVO HEALTH PHARMACY AT HOME	225 COMMUNITY DR STE 140	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	NORTH SHORE UNIVERSITY HOSPITAL	DBA VIVO HEALTH PHARMACY AT MANHASSET	300 COMMUNITY DRIVE	MANHASSET	NY	11030	11/20/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC	DBA: VIVO HEALTH PHARMACY AT CFAM	450 LAKEVILLE RD	LAKE SUCCESS	NY	11042	11/20/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC.	DBA: VIVO HEALTH SPECIALTY PHARMACY	225 COMMUNITY DR STE 100	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330195A	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - METHADONE CLINIC	75-59 263RD ST.	GLEN OAKS	NY	Active
DSH330195AA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital-Multi Speciality Clinic Rego Park / Ob/Gyn & Prenatal Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195AB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / CAT Scan	102-01 66th Road	Forest Hills	NY	Active
DSH330195AC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / MRI	102-01 66th Road	Forest Hills	NY	Active
DSH330195AD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Radiology	102-01 66th Road	Forest Hills	NY	Active
DSH330195AE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Interventional/Special Procedures	102-01 66th Road	Forest Hills	NY	Active
DSH330195AF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Endoscopy	102-01 66th Road	Forest Hills	NY	Active
DSH330195AG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Ambulatory Surgery	102-01 66th Road	Forest Hills	NY	Active
DSH330195AH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Emergency Deptartment	102-01 66th Road	Forest Hills	NY	Active
DSH330195AJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Institute - Great South Bay	440 East Main Street	Bayshore	NY	Active
DSH330195AK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SCHOOL BASED HC - John Adams	101-01 Rockaway Blvd	Ozone Park	NY	Active
DSH330195AL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Radiation Oncology	450 Lakeville Road	Lake Success	NY	Active
DSH330195AM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Project Outreach	600 Hempstead Turnpike	West Hempstead	NY	Active
DSH330195AN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Garden City Treatment Center	711 Stewart Avenue	Garden City	NY	Active
DSH330195AP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway Treatment Center	1600 Central Avenue	Far Rockaway	NY	Active
DSH330195AQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore-Radiology Diagnostic	440 East Main Street	Bay Shore	NY	Active
DSH330195AR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - Radioisotope	440 East Main Street	Bay Shore	NY	Active
DSH330195AS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - MRI	440 East Main Street	Bay Shore	NY	Active
DSH330195AT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJMC/ Medicine Specialties at Glen Oaks - Clinic	25611 Union Turnpike	Glen Oaks	NY	Active
DSH330195AU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Center - Cancer Treatment Services	270 Pulaski Rd.	Greenlawn	NY	Active
DSH330195AV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - August Martin - School-based Health Center	156-10 Baisley Blvd	Jamaica	NY	Active
DSH330195AW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / EHS - Employee Health Services	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195AX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Hearing and Speech Center - Clinic	430 Lakeville Road	New Hyde Park	NY	Active
DSH330195AY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Pre-Surgical Testing - Pre Surgical Testing	102-01 66th Road	Forest Hills	NY	Active
DSH330195AZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hospital / Women's Health - Ultrasound Diagnostic	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195B	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zuckerberg Cancer Center	450 LAKEVILLE ROAD	LAKE SUCCESS	NY	Active
DSH330195BA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / EKG/ECHO - Electrocardiology	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Personalized Recovery Oriented Services - All Other OASAS Programs O/P	205-07 Hillside Ave	Hollis	NY	Active
DSH330195BC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Lab - Laboratory	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Pre Surgical Testing - Pre Surgical Testing	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Martin Van Buren High School Clinic - Mental Health Clinic	230-17 Hillside Ave	Queens Village	NY	Active
DSH330195BF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP PSY/Social Work Svc Tran - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP Occupat Therapy Trans - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - DAERHS - ALL OTHER OASIS PROGRAMS	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - ELECTROCONVULSIVE THERAPY CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - MEDICAL SPECIALTIES CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - AMBULATORY CARE - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Psych Centers - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CTC CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CRISIS INTERVENTION - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Urology Clinic - Urology	95-25 Queens Boulevard 2nd floor	Rego Park	NY	Active
DSH330195BR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	BACKSTRETCH CLINIC AT BELMONT RACETRACK - Clinic	2150 HEMPSTEAD TURNPIKE COTTAGE 58C	BELMONT	NY	Active
DSH330195BS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Clinic - Peds Immunology	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195BT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital - OBS Check & Call - OBS Check & Call	102-01 66th Road	Forest Hills	NY	Active
DSH330195BU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Perinatal	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - OCD	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Early Treatment	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Bipolar	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - On Track	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - College Partnership	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195C	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - Franklin K Lane	999 Jamaica Ave	Brooklyn	NY	Active
DSH330195CA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Ketamine Infusion Services	75-59 263RD ST	GLEN OAKS	NY	Active
DSH330195CB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Queens Cancer Center	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195D	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	North Shore - LIJ Medical Group Urgent Care Center	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195E	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Recovery Room Ambulatory Surgery	450 Lakeville Rd	Lake Success	NY	Active
DSH330195F	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway HS Clinic SBHC	821 Bay 25th Street	Far Rockaway	NY	Active
DSH330195G	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Brian Picolo MS53 Clinic SBHC	1045 Nameoke Street	Far Rockaway	NY	Active
DSH330195H	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / General Pediatrics	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195J	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / Adolescent Medicine	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195K	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Eye Care Center	600 Northern Blvd	Great Neck	NY	Terminated
DSH330195L	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Medical Center LIJ Satellite Dialysis Center	220-22 Hillside Avenue	Queens Village	NY	Active
DSH330195M	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Nuclear Stress	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195N	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Cardiology Echo	102-01 66th Road	Forest Hills	NY	Active
DSH330195P	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Recovery Room	900 Franklin Ave	Valley Stream	NY	Active
DSH330195Q	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Radiology	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195R	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / HYPERBARIC OXYGEN THERAPY	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195S	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Wound Care	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195T	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Ambulatory Surgery	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195U	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Emergency Department	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195V	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Internal Medicine	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195W	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / General Surgery	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195X	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Cardiology	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195Y	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Wound Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195Z	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills-Rego Park Multi-Specialty Clinic / Podiatry	95-25 Queens Blvd	Rego Park	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Change Request	b (SC)		10/21/2024 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/3/2024 10:01 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		3313980	10/3/2024 10:01 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	10/3/2024 10:01 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467695023	10/3/2024 10:01 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	10/3/2024 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05099885	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		04133506	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	10/1/2024 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	03313980 (NY)		9/26/2024 2:00 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	05431874 (NY)		9/26/2024 2:00 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04634960 (NY)		9/26/2024 2:00 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04633703 (NY)		9/26/2024 2:00 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1669854832 (NY)		9/26/2024 2:00 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730523549 (NY)		9/26/2024 2:00 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1851807929 (NY)		9/26/2024 2:00 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1467695023 (NY)		9/26/2024 2:00 PM
Details	Last Recertification Date	Update	Recertification	8/23/2023 11:47:15 AM	8/19/2024 3:47:44 PM	8/19/2024 3:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		008095457	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CT	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007620400006	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	2/28/2024 2:56 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1528075108 (CA)		12/28/2023 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1528075108 (DE)		12/28/2023 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1528075108 (IA)		12/28/2023 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1528075108 (MI)		12/28/2023 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1528075108 (VA)		12/28/2023 2:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03313980	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05431874	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04634960	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04633703	12/13/2023 1:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669854832	12/13/2023 1:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730523549	12/13/2023 1:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851807929	12/13/2023 1:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1467695023	12/13/2023 1:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/13/2023 1:09 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (AL)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (AR)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (AZ)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (CA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (CO)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (CT)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (DE)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (FL)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (GA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (ID)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (IA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (IL)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (IN)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (KY)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (LA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MD)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (ME)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MI)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MN)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MO)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (MS)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NC)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NE)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NH)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NJ)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NM)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (NV)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (OH)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (OK)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (OR)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (PA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (RI)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (SC)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (TN)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (TX)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (UT)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (VA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (VT)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (WA)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (WI)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457369381 (WV)		10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285641514	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982611190	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174530349	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174926406	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871024455	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346603107	10/12/2023 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/12/2023 1:56 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 2:27:07 PM	8/23/2023 11:47:15 AM	8/23/2023 11:47 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457369381 (KS)		5/10/2023 3:46 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100446570A (KS)		5/10/2023 3:39 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 10:47:54 AM	8/31/2022 2:27:07 PM	8/31/2022 2:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003129407 (CT)		2/11/2022 2:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/11/2022 2:49 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3129401	2/11/2022 2:49 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	2/11/2022 2:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		LON0195N	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		239739105	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		598210	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		085483	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528075108	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000182281	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		44432577	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000166580	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003129407	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008051182	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008092821	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528075108	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092086000	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003273000	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000105729A	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		399622993A	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003239434A	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1316954449	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528075108	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300031800	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100446570A	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01500040	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1747882	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110026857C	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		283335200	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		453325900	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		160670000	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528075108	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		199217100	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1316954449	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		273631400	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00096736	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1316954449	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3300372	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11224132600	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026583700	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3104340	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		20002124	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4157303	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		8844500	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		A8435	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		001288387	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0608033	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100689170A	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007620400005	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0014836270001	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		OP30195	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10858B	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12198B	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		b	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q034252	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		072485801	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		072505301	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1316954449	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528075108	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0330195	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0330372	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285641514	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100099880	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3910006997	11/2/2021 11:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		DE	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		ID	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		KS	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		MS	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NE	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NH	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		NV	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		OR	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		UT	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		VT	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		WA	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	11/2/2021 11:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457369381	11/2/2021 11:28 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	11/2/2021 11:28 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 10:00:01 AM	8/24/2021 10:47:54 AM	8/24/2021 10:47 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1285641514	9/4/2020 10:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/4/2020 10:00 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285641514 ( )		9/4/2020 10:00 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 10:56:28 AM	9/4/2020 10:00:01 AM	9/4/2020 10:00 AM
Details	Last Recertification Date	Update	Recertification	9/5/2018 1:53:44 PM	9/5/2019 10:56:28 AM	9/5/2019 10:56 AM
Details	Last Recertification Date	Update	Recertification	12/1/2017 2:46:39 PM	9/5/2018 1:53:44 PM	9/5/2018 1:53 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5168766061	Cusack, Michele L SVP & CFO Northwell Health 5163216058	1/19/2018 2:42 PM
Contacts	Authorizing Official	Update	AO Change Request	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	Cusack, Michele L SVP & CFO Northwell Health 5168766061	1/9/2018 3:20 PM
Contacts	Authorizing Official	Update	AO Change Request	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	12/4/2017 1:31 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	12/1/2017 2:46:39 PM	12/1/2017 2:46 PM
Contacts	Authorizing Official	Update		SHAPIRO, ROBERT SR. VP & CFO 5164658162	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	11/30/2017 11:47 AM
Contacts	Signed By	Update		SHAPIRO, ROBERT SR. VP & CFO 5164658162	SHAPIRO, ROBERT S. SR. VP & CFO Northwell Health 5164658162	11/30/2017 11:47 AM
Contacts	Primary Contact	Update		Stefas, Onisis VP of Pharmacy Operations 5167195720	Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	10/12/2017 1:11 PM
Contacts	Primary Contact	Insert			Stefas, Onisis VP of Pharmacy Operations 5167195720	7/25/2017 12:32 PM
Contacts	Authorizing Official	Insert			SHAPIRO, ROBERT SR. VP & CFO 5164658162	7/25/2017 12:32 PM
Contacts	Signed By	Insert			SHAPIRO, ROBERT SR. VP & CFO 5164658162	7/25/2017 12:32 PM
Addresses	Main Address	Insert			102-01 66th Road Forest Hills, NY 11375	7/25/2017 12:32 PM
Addresses	Billing Address	Insert			LONG ISLAND JEWISH MEDICAL CENTER 270-05 76TH AVE NEW HYDE PARK, NY 11040	7/25/2017 12:32 PM
Details	Last Recertification Date	Update			8/31/2016 12:00:00 AM	8/31/2016 3:00 PM
Dates	Participating Approval Date	Update			3/8/2016 12:00:00 AM	3/8/2016 12:45 PM
Details	State	Update		Pending	Active	3/8/2016 12:45 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/8/2016 12:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58529	DSH330195AB	2/18/2016 9:09 AM
Details	Entity Subname	Update		Forest Hills Hospital / Forest Hills-CAT Scan	Forest Hills Hospital / CAT Scan	2/18/2016 9:09 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58529	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: Number	Insert			00243903	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: State	Insert			NY	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: Number	Insert			02998887	2/3/2016 3:32 PM
Medicaid Billing	Medicaid: State	Insert			NY	2/3/2016 3:32 PM
Medicaid Billing	NPI: Number	Insert			1285641514	2/3/2016 3:32 PM
Details	Last Recertification Date	Insert				2/3/2016 3:32 PM
Details	Grant Number	Insert				2/3/2016 3:32 PM
Details	340B ID	Insert				2/3/2016 3:32 PM
Details	Is Authorizing Official EHB Data	Insert				2/3/2016 3:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert				2/3/2016 3:32 PM
Details	Medicare Provider Number	Insert			330195	2/3/2016 3:32 PM
Details	Entity Name	Insert			LONG ISLAND JEWISH MEDICAL CENTER	2/3/2016 3:32 PM
Details	Program Code	Insert			DSH	2/3/2016 3:32 PM
Details	Entity Subname	Insert			Forest Hills Hospital / Forest Hills-CAT Scan	2/3/2016 3:32 PM
Dates	Participating Approval Date	Insert				2/3/2016 3:32 PM
Details	State	Insert			Pending	2/3/2016 3:32 PM
Dates	Registration Date	Insert			2/3/2016 12:00:00 AM	2/3/2016 3:32 PM
Dates	Signed By Date	Insert			2/3/2016 12:00:00 AM	2/3/2016 3:32 PM
Dates	Start Date	Insert				2/3/2016 3:32 PM
Terminations	Termination Comments	Insert				2/3/2016 3:32 PM
Terminations	Termination Date	Insert				2/3/2016 3:32 PM
Terminations	Termination Effective Date	Insert				2/3/2016 3:32 PM
Terminations	Termination Reason	Insert				2/3/2016 3:32 PM