| Details | Entity Name | Update | Change Request | SOUTH MIAMI HOSPITAL | South Miami Hospital | 3/20/2025 8:32 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2023 3:37:11 PM | 9/5/2024 2:02:30 PM | 9/5/2024 2:02 PM |
| Addresses | Billing Address | Update | Change Request | Coral Gables UCC
Baptist Health South Florida Accounts Payable
PO Box 29002
Miami, FL 33102 | Coral Gables UCC
Baptist Health South Florida Accounts Payable
8900 North Kendall Drive
Miami, FL 33176 | 6/17/2024 1:03 PM |
| Addresses | Billing Address | Update | Change Request | Coral Gables UCC - BHSF Accounts Payable
8900 North Kendall Drive
Miami, FL 33176-2197 | Coral Gables UCC
Baptist Health South Florida Accounts Payable
PO Box 29002
Miami, FL 33102 | 2/14/2024 1:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/20/2022 7:37:49 AM | 9/1/2023 3:37:11 PM | 9/1/2023 3:37 PM |
| Addresses | Shipping Address | Delete | Change Request | Baptist Health South Florida
Baptist Health Pharmacy Shared Services Center
9001 NW 33rd Street
Doral, FL 33172 | | 2/14/2023 7:05 AM |
| Addresses | Shipping Address | Insert | Change Request | | Baptist Health South Florida
Baptist Health Pharmacy Shared Services Center
14408 Commerce Way
Miami Lakes, FL 33016 | 2/14/2023 7:05 AM |
| Addresses | Shipping Address | Insert | Recertification | | South Miami Hospital
Urgent Care Center - Coral Gables
10 Giralda Avenue
100
Coral Gables, FL 33134 | 9/20/2022 7:37 AM |
| Addresses | Shipping Address | Insert | Recertification | | RedPharm Drug
6501 City West Pkwy
Eden Prairie, MN 55344 | 9/20/2022 7:37 AM |
| Addresses | Shipping Address | Insert | Recertification | | EPM Packaging Inc
210 E 4th Street
Lexington, NE 68850 | 9/20/2022 7:37 AM |
| Addresses | Shipping Address | Insert | Recertification | | Baptist Health South Florida
Baptist Health Pharmacy Shared Services Center
9001 NW 33rd Street
Doral, FL 33172 | 9/20/2022 7:37 AM |
| Addresses | Main Address | Update | Recertification |
10 Giralda Avenue
Suite 100
Coral Gables, FL 33134 |
10 Giralda Avenue
100
Coral Gables, FL 33134 | 9/20/2022 7:37 AM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2021 2:46:17 PM | 9/20/2022 7:37:49 AM | 9/20/2022 7:37 AM |
| Details | Entity Subname | Update | Recertification | Coral Gables UCC | Urgent Care Center - Coral Gables | 9/20/2022 7:37 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2020 6:39:46 PM | 9/11/2021 2:46:17 PM | 9/11/2021 2:46 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Camejo, Madeline
Vice President and Chief Pharmacy Officer
Baptist Health South Florida
7865951130 | Camejo, Madeline
Vice President and Chief Pharmacy Officer
Baptist Health South Florida
7866620801 | 9/10/2021 4:10 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | FL | 8/18/2020 6:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2019 9:50:58 AM | 8/18/2020 6:39:46 PM | 8/18/2020 6:39 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Marcelin, Halena Leah
Director, Pharmacy Business Affairs
Baptist Health South Florida
7866620785 | Marcelin, Halena Leah
Director, Pharmacy Business Affairs
Baptist Health South Florida
7866620805 | 5/27/2020 8:26 PM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2018 12:44:43 PM | 8/30/2019 9:50:58 AM | 8/30/2019 9:50 AM |
| Contacts | Primary Contact | Update | Recertification | Rouseff, Maribeth
Assistant VP
Baptist Health South Florida
7865963330 | Marcelin, Halena Leah
Director, Pharmacy Business Affairs
Baptist Health South Florida
7866620785 | 9/12/2018 12:44 PM |
| Details | Last Recertification Date | Update | Recertification | 12/6/2017 11:56:10 AM | 9/12/2018 12:44:43 PM | 9/12/2018 12:44 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Thomson Quintero, Suzzanne
Chief Procurement Office and Corporate Vice President
Baptist Hospital Of Miami
7866627866 | Camejo, Madeline
Vice President and Chief Pharmacy Officer
Baptist Health South Florida
7865951130 | 8/27/2018 9:46 AM |
| Details | Last Recertification Date | Update | Recertification | 8/12/2016 12:00:00 AM | 12/6/2017 11:56:10 AM | 12/6/2017 11:56 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Rouseff, Maribeth
Assistant VP
Baptist Hospital of Miami, Inc
7865963330 | Rouseff, Maribeth
Assistant VP
Baptist Health South Florida
7865963330 | 11/21/2017 1:42 PM |
| Contacts | Authorizing Official | Update | AO Change Request | MENDEZ, LINCOLN
CEO
7866628848 | Thomson Quintero, Suzzanne
Chief Procurement Office and Corporate Vice President
Baptist Hospital Of Miami
7866627866 | 10/17/2017 12:23 PM |
| Contacts | Primary Contact | Update | | Rouseff, Maribeth
Assistant VP
7865963330 | Rouseff, Maribeth
Assistant VP
Baptist Hospital of Miami, Inc
7865963330 | 9/21/2017 10:45 AM |
| Contacts | Primary Contact | Insert | | | Rouseff, Maribeth
Assistant VP
7865963330 | 6/12/2017 11:16 AM |
| Addresses | Main Address | Insert | | |
10 Giralda Avenue
Suite 100
Coral Gables, FL 33134 | 8/12/2016 8:23 AM |
| Contacts | Authorizing Official | Insert | | | MENDEZ, LINCOLN
CEO
7866628848 | 8/12/2016 8:23 AM |
| Contacts | Signed By | Insert | | | MENDEZ, LINCOLN
CEO
7866628848 | 8/12/2016 8:23 AM |
| Details | Last Recertification Date | Update | | | 8/12/2016 12:00:00 AM | 8/12/2016 8:23 AM |
| Addresses | Billing Address | Insert | | | Coral Gables UCC - BHSF Accounts Payable
8900 North Kendall Drive
Miami, FL 33176-2197 | 6/30/2016 11:39 AM |
| Dates | Participating Approval Date | Update | | | 5/13/2016 12:00:00 AM | 5/13/2016 9:44 AM |
| Details | State | Update | | Pending | Active | 5/13/2016 9:44 AM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 5/13/2016 9:44 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_59993 | DSH100154B | 5/11/2016 2:53 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_59993 | 4/13/2016 11:32 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/13/2016 11:32 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 010058700 | 4/13/2016 11:32 AM |
| Medicaid Billing | Medicaid: State | Insert | | | FL | 4/13/2016 11:32 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1982688230 | 4/13/2016 11:32 AM |
| Details | Last Recertification Date | Insert | | | | 4/13/2016 11:32 AM |
| Details | Grant Number | Insert | | | | 4/13/2016 11:32 AM |
| Details | 340B ID | Insert | | | | 4/13/2016 11:32 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/13/2016 11:32 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/13/2016 11:32 AM |
| Details | Medicare Provider Number | Insert | | | 100154 | 4/13/2016 11:32 AM |
| Details | Entity Name | Insert | | | SOUTH MIAMI HOSPITAL | 4/13/2016 11:32 AM |
| Details | Program Code | Insert | | | DSH | 4/13/2016 11:32 AM |
| Details | Entity Subname | Insert | | | Coral Gables UCC | 4/13/2016 11:32 AM |
| Dates | Participating Approval Date | Insert | | | | 4/13/2016 11:32 AM |
| Details | State | Insert | | | Pending | 4/13/2016 11:32 AM |
| Dates | Registration Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 11:32 AM |
| Dates | Signed By Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 11:32 AM |
| Dates | Start Date | Insert | | | | 4/13/2016 11:32 AM |
| Terminations | Termination Comments | Insert | | | | 4/13/2016 11:32 AM |
| Terminations | Termination Date | Insert | | | | 4/13/2016 11:32 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/13/2016 11:32 AM |
| Terminations | Termination Reason | Insert | | | | 4/13/2016 11:32 AM |