| Contacts | Authorizing Official | Update | Profile Change Request | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | Dalal, Hardik
SVP, Finance & System-wide Pharmacy Finance
Corewell Health
3127710810 | 2/24/2025 6:26 AM |
| Details | Entity Name | Update | Recertification | Botsford General Hospital d/b/a Beaumont Hospital - Farmington Hills | Botsford General Hospital d/b/a Corewell Health Farmington Hills Hospital | 9/5/2024 8:25 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 1:40:54 PM | 8/21/2024 7:35:52 AM | 8/21/2024 7:35 AM |
| Details | Entity Subname | Update | Recertification | BEAUMONT HOSPITAL, FARMINGTON HILLS, INFUSION CENTER (Dept# 743016) -Infusion Center TR | Corewell Health Farmington Hills Hospital Infusion Clinic - 44344 Dequindre Rd | 8/21/2024 7:35 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | Schaible, Thomas
Mgr, Pharmacy CHE
Corewell Health
9475221169 | 1/30/2024 8:36 AM |
| Contacts | Primary Contact | Update | PC Change Request | Schaible, Thomas
Manager 340B Pharmacy
Beaumont Hospital, Grosse Pointe
9475221169 | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | 1/10/2024 12:26 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | 12/13/2023 8:06 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 3:02:42 PM | 8/21/2023 1:40:54 PM | 8/21/2023 1:40 PM |
| Contacts | Primary Contact | Update | PC Change Request | Nastwold, Scott
Director, Pharmacy Services
Beaumont Health
2484718356 | Schaible, Thomas
Manager 340B Pharmacy
Beaumont Hospital, Grosse Pointe
9475221169 | 10/13/2022 11:25 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | 10/11/2022 10:05 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 9:45:42 AM | 8/29/2022 3:02:42 PM | 8/29/2022 3:02 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2020 4:08:15 PM | 8/27/2021 9:45:42 AM | 8/27/2021 9:45 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | 8/16/2021 8:47 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | MI | 8/31/2020 4:08 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2019 5:25:14 PM | 8/31/2020 4:08:15 PM | 8/31/2020 4:08 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
2482133338 | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | 6/2/2020 8:31 AM |
| Details | Entity Subname | Update | Change Request | Infusion Center - Troy | BEAUMONT HOSPITAL, FARMINGTON HILLS, INFUSION CENTER (Dept# 743016) -Infusion Center TR | 3/11/2020 9:06 AM |
| Details | Entity Name | Update | Change Request | BOTSFORD HOSPITAL | Botsford General Hospital d/b/a Beaumont Hospital - Farmington Hills | 3/11/2020 9:05 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 10:43:23 AM | 9/2/2019 5:25:14 PM | 9/2/2019 5:25 PM |
| Details | Last Recertification Date | Update | Recertification | 11/29/2017 2:51:19 PM | 8/16/2018 10:43:23 AM | 8/16/2018 10:43 AM |
| Contacts | Primary Contact | Update | Recertification | Nastwold, Scott
Director of Pharmacy
2484718356 | Nastwold, Scott
Director, Pharmacy Services
Beaumont Health
2484718356 | 11/29/2017 2:51 PM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2016 12:00:00 AM | 11/29/2017 2:51:19 PM | 11/29/2017 2:51 PM |
| Contacts | Authorizing Official | Update | | Wilson, Carolyn
Chief Operating Officer
2482133338 | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
2482133338 | 10/12/2017 10:32 AM |
| Contacts | Authorizing Official | Insert | | | Wilson, Carolyn
Chief Operating Officer
2482133338 | 7/3/2017 1:01 PM |
| Addresses | Main Address | Insert | | |
44344 Dequindre
Suite 230
Sterling Heights, MI 48314-1039 | 5/10/2017 5:54 PM |
| Addresses | Billing Address | Insert | | | Botsford General Hospital
PO Box 860163
Minneapolis, MN 55486-0163 | 5/10/2017 5:54 PM |
| Contacts | Signed By | Insert | | | LaCasse, Paul
President & Chief Executive Officer
2484718949 | 5/10/2017 5:54 PM |
| Contacts | Primary Contact | Insert | | | Nastwold, Scott
Director of Pharmacy
2484718356 | 5/10/2017 5:54 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1336183367 | 3/14/2017 11:14 AM |
| Details | Last Recertification Date | Update | | | 9/1/2016 12:00:00 AM | 9/1/2016 10:11 AM |
| Dates | Participating Approval Date | Update | | | 5/5/2016 12:00:00 AM | 5/5/2016 4:14 PM |
| Details | State | Update | | Pending | Active | 5/5/2016 4:14 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 5/5/2016 4:14 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_59972 | DSH230151G | 5/4/2016 10:23 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_59972 | 4/13/2016 10:14 AM |
| Details | Last Recertification Date | Insert | | | | 4/13/2016 10:14 AM |
| Details | Grant Number | Insert | | | | 4/13/2016 10:14 AM |
| Details | 340B ID | Insert | | | | 4/13/2016 10:14 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/13/2016 10:14 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/13/2016 10:14 AM |
| Details | Medicare Provider Number | Insert | | | 230151 | 4/13/2016 10:14 AM |
| Details | Entity Name | Insert | | | BOTSFORD HOSPITAL | 4/13/2016 10:14 AM |
| Details | Program Code | Insert | | | DSH | 4/13/2016 10:14 AM |
| Details | Entity Subname | Insert | | | Infusion Center - Troy | 4/13/2016 10:14 AM |
| Dates | Participating Approval Date | Insert | | | | 4/13/2016 10:14 AM |
| Details | State | Insert | | | Pending | 4/13/2016 10:14 AM |
| Dates | Registration Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 10:14 AM |
| Dates | Signed By Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 10:14 AM |
| Dates | Start Date | Insert | | | | 4/13/2016 10:14 AM |
| Terminations | Termination Comments | Insert | | | | 4/13/2016 10:14 AM |
| Terminations | Termination Date | Insert | | | | 4/13/2016 10:14 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/13/2016 10:14 AM |
| Terminations | Termination Reason | Insert | | | | 4/13/2016 10:14 AM |