| Details | Last Recertification Date | Update | Recertification | 9/7/2023 8:26:46 AM | 8/29/2024 2:20:02 PM | 8/29/2024 2:20 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 1:52:25 PM | 9/7/2023 8:26:46 AM | 9/7/2023 8:26 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2021 11:34:19 AM | 9/12/2022 1:52:25 PM | 9/12/2022 1:52 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2020 1:24:45 PM | 8/24/2021 11:34:19 AM | 8/24/2021 11:34 AM |
| Addresses | Main Address | Update | Change Request |
51 Tennis Way
East Dorset, VT 05701 |
51 Tennis Way
East Dorset, VT 05253 | 10/30/2020 12:44 PM |
| Addresses | Billing Address | Update | Change Request | Rutland Regional Medical Center
160 Allen St
Rutland, VT 05253 | Rutland Regional Medical Center
160 Allen St
Rutland, VT 05701 | 10/30/2020 12:44 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1720042203 ( ) | | 8/31/2020 1:24 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1720042203 | 8/31/2020 1:24 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | VT | 8/31/2020 1:24 PM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2019 10:16:29 AM | 8/31/2020 1:24:45 PM | 8/31/2020 1:24 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 2/26/2020 9:37 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 470005 | 2/26/2020 9:37 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | VT | 2/26/2020 9:37 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1720042203 | 2/26/2020 9:37 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 |
| Addresses | Billing Address | Update | Recertification | Rutland Regional Medical Center
160 Allen St
Rutland, VT 05701 | Rutland Regional Medical Center
160 Allen St
Rutland, VT 05253 | 8/28/2019 10:16 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2018 3:33:18 PM | 8/28/2019 10:16:29 AM | 8/28/2019 10:16 AM |
| Addresses | Billing Address | Update | Recertification | Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701 | Rutland Regional Medical Center
160 Allen St
Rutland, VT 05701 | 9/10/2018 3:33 PM |
| Details | Last Recertification Date | Update | Recertification | 11/6/2017 12:56:46 PM | 9/10/2018 3:33:18 PM | 9/10/2018 3:33 PM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2016 12:00:00 AM | 11/6/2017 12:56:46 PM | 11/6/2017 12:56 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 | | |
51 Tennis Way
East Dorset, VT 05701 | 4/28/2017 6:10 PM |
| Addresses | Billing Address | Insert | | | Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701 | 4/28/2017 6:10 PM |
| Addresses | Shipping Address | Insert | | | Rutland Regional Medical Center
160 Allen 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 10:23 AM |
| Dates | Participating Approval Date | Update | | | 4/26/2016 12:00:00 AM | 4/26/2016 4:31 PM |
| Details | State | Update | | Pending | Active | 4/26/2016 4:31 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/26/2016 4:31 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_58709 | DSH470005K | 4/4/2016 9:03 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_58709 | 4/1/2016 11:23 AM |
| Details | Last Recertification Date | Insert | | | | 4/1/2016 11:23 AM |
| Details | Grant Number | Insert | | | | 4/1/2016 11:23 AM |
| Details | 340B ID | Insert | | | | 4/1/2016 11:23 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/1/2016 11:23 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/1/2016 11:23 AM |
| Details | Medicare Provider Number | Insert | | | 470005 | 4/1/2016 11:23 AM |
| Details | Entity Name | Insert | | | RUTLAND REGIONAL MEDICAL CENTER | 4/1/2016 11:23 AM |
| Details | Program Code | Insert | | | DSH | 4/1/2016 11:23 AM |
| Details | Entity Subname | Insert | | | East Dorset Medical Campus / ENT | 4/1/2016 11:23 AM |
| Dates | Participating Approval Date | Insert | | | | 4/1/2016 11:23 AM |
| Details | State | Insert | | | Pending | 4/1/2016 11:23 AM |
| Dates | Registration Date | Insert | | | 4/1/2016 12:00:00 AM | 4/1/2016 11:23 AM |
| Dates | Signed By Date | Insert | | | 4/1/2016 12:00:00 AM | 4/1/2016 11:23 AM |
| Dates | Start Date | Insert | | | | 4/1/2016 11:23 AM |
| Terminations | Termination Comments | Insert | | | | 4/1/2016 11:23 AM |
| Terminations | Termination Date | Insert | | | | 4/1/2016 11:23 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/1/2016 11:23 AM |
| Terminations | Termination Reason | Insert | | | | 4/1/2016 11:23 AM |