Covered Entity Details

DSH470005C RUTLAND REGIONAL MEDICAL CENTER (Active) - information as of 4/29/2025 11:59:43 PM

Main Details

Name

RUTLAND REGIONAL MEDICAL CENTER

Subdivision Name

Rutland Regional General Surgery

Type

Disproportionate Share Hospital

Rural

340B ID

DSH470005C

Medicare Provider Number

470005

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/1/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/14/2016

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Rutland Regional Medical Center
Jennifer Bertrand, CFO
(802) 747-1601

Primary Contact

Rutland Regional Medical Center
Jonathan Reynolds, VP Clinical Services
(802) 772-2634

Addresses

Street Address

6 Commons St
Rutland, VT 05701

Billing Address

Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701

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
VT	470005	1720042203

Shipping Addresses

Shipping Address 1

Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH470005A	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Heart Center	12 Commons St	Rutland	VT	Active
DSH470005B	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Regional Behavioral Health	1 Commons St	Rutland	VT	Active
DSH470005C	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Regional General Surgery	6 Commons St	Rutland	VT	Active
DSH470005D	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Regional Digestive Services	1 Albert Cree Dr	Rutland	VT	Active
DSH470005E	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Regional Diabetes and Endocrinology Center	8 Albert Cree Dr	Rutland	VT	Active
DSH470005F	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Vermont Orthopaedic Clinic	3 Albert Cree Drive	Rutland	VT	Terminated
DSH470005G	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Marble Valley Eye Care	1 Albert Cree Dr	Rutland	VT	Active
DSH470005H	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Women's Healthcare	147 Allen St	Rutland	VT	Active
DSH470005J	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Marble Valley Urology	145 Allen St	Rutland	VT	Active
DSH470005K	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	East Dorset Medical Campus / ENT	51 Tennis Way	East Dorset	VT	Active
DSH470005L	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	ENT & Audiology	69 Allen Street	Rutland	VT	Terminated
DSH470005M	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	East Dorset Medical Campus / Women's Health	51 Tennis Way	East Dorset	VT	Active
DSH470005N	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	East Dorset Medical Campus / Orthopaedics	51 Tennis Way	East Dorset	VT	Active
DSH470005P	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	East Dorset Medical Campus / General Surgery	51 Tennis Way	East Dorset	VT	Terminated
DSH470005Q	Child	DSH	RUTLAND REGIONAL MEDICAL CENTER	Rutland Regional Neurology Center	1 Albert Cree Dr	Rutland	VT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/7/2023 8:27:58 AM	8/29/2024 2:24:48 PM	8/29/2024 2:24 PM
Contacts	Authorizing Official	Update	Change Request	Fox, Judi K CFO Rutland Regional Medical Center 8027471632	Bertrand, Jennifer CFO Rutland Regional Medical Center 8027471601	1/10/2024 8:10 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 1:51:51 PM	9/7/2023 8:27:58 AM	9/7/2023 8:27 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 11:35:39 AM	9/12/2022 1:51:51 PM	9/12/2022 1:51 PM
Details	Last Recertification Date	Update	Recertification	8/31/2020 1:13:52 PM	8/24/2021 11:35:39 AM	8/24/2021 11:35 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1720042203 ( )		8/31/2020 1:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1720042203	8/31/2020 1:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/31/2020 1:13 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 10:13:09 AM	8/31/2020 1:13:52 PM	8/31/2020 1:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/26/2020 9:40 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		470005	2/26/2020 9:40 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	2/26/2020 9:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720042203	2/26/2020 9:40 AM
Contacts	Primary Contact	Update	Profile Change Request	Reynolds, Jonathan Director of Pharmacy Rutland Regional Medical Center 8027722634	Reynolds, Jonathan VP Clinical Services Rutland Regional Medical Center 8027722634	10/15/2019 4:47 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 3:28:26 PM	8/28/2019 10:13:09 AM	8/28/2019 10:13 AM
Details	Last Recertification Date	Update	Recertification	11/8/2017 2:12:31 PM	9/10/2018 3:28:26 PM	9/10/2018 3:28 PM
Addresses	Billing Address	Insert	Recertification		Rutland Regional Medical Center 160 Allen Street Rutland, VT 05701	11/8/2017 2:12 PM
Addresses	Shipping Address	Insert	Recertification		Rutland Regional Medical Center 160 Allen Street Rutland, VT 05701	11/8/2017 2:12 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/8/2017 2:12:31 PM	11/8/2017 2:12 PM
Contacts	Authorizing Official	Update		Fox, Judi CFO 8027471632	Fox, Judi K CFO Rutland Regional Medical Center 8027471632	10/13/2017 11:29 AM
Contacts	Primary Contact	Update		Reynolds, Jonathan Director of Pharmacy 8027722634	Reynolds, Jonathan Director of Pharmacy Rutland Regional Medical Center 8027722634	9/25/2017 9:17 AM
Contacts	Authorizing Official	Insert			Fox, Judi CFO 8027471632	7/11/2017 1:33 PM
Addresses	Main Address	Insert			6 Commons St Rutland, VT 05701	4/28/2017 6:10 PM
Contacts	Signed By	Insert			OGORZALEK, EDWARD CFO 8027471610	4/28/2017 6:10 PM
Contacts	Primary Contact	Insert			Reynolds, Jonathan Director of Pharmacy 8027722634	4/28/2017 6:10 PM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 10:22 AM
Dates	Participating Approval Date	Update			4/14/2016 12:00:00 AM	4/14/2016 2:17 PM
Details	State	Update		Pending	Active	4/14/2016 2:17 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/14/2016 2:17 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58679	DSH470005C	4/1/2016 3:14 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58679	4/1/2016 10:31 AM
Details	Last Recertification Date	Insert				4/1/2016 10:31 AM
Details	Grant Number	Insert				4/1/2016 10:31 AM
Details	340B ID	Insert				4/1/2016 10:31 AM
Details	Is Authorizing Official EHB Data	Insert				4/1/2016 10:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/1/2016 10:31 AM
Details	Medicare Provider Number	Insert			470005	4/1/2016 10:31 AM
Details	Entity Name	Insert			RUTLAND REGIONAL MEDICAL CENTER	4/1/2016 10:31 AM
Details	Program Code	Insert			DSH	4/1/2016 10:31 AM
Details	Entity Subname	Insert			Rutland Regional General Surgery	4/1/2016 10:31 AM
Dates	Participating Approval Date	Insert				4/1/2016 10:31 AM
Details	State	Insert			Pending	4/1/2016 10:31 AM
Dates	Registration Date	Insert			4/1/2016 12:00:00 AM	4/1/2016 10:31 AM
Dates	Signed By Date	Insert			4/1/2016 12:00:00 AM	4/1/2016 10:31 AM
Dates	Start Date	Insert				4/1/2016 10:31 AM
Terminations	Termination Comments	Insert				4/1/2016 10:31 AM
Terminations	Termination Date	Insert				4/1/2016 10:31 AM
Terminations	Termination Effective Date	Insert				4/1/2016 10:31 AM
Terminations	Termination Reason	Insert				4/1/2016 10:31 AM