Covered Entity Details

DSH070007D LAWRENCE & MEMORIAL HOSPITAL (Active) - information as of 6/8/2025 1:00:43 AM

Main Details

Name

LAWRENCE & MEMORIAL HOSPITAL

Subdivision Name

LMH EMERGENCY PEQUOT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070007D

Medicare Provider Number

070007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/1/2019

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Yale New Haven Health Services
Leeann Miller, Chief Pharmacy Officer
(203) 479-3000

Primary Contact

Yale New Haven Health System
Maria Da Silva, Senior Reimbursement Analyst
(203) 688-9332

Addresses

Street Address

52 Hazelnut Hill Road
Groton, CT 06340

Billing Address

LAWRENCE & MEMORIAL
365 MONTAUK AVENUE
NEW LONDON, CT 06320-3268

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 7/1/2016, terminated 2/28/2018. Reinstated 7/1/2019.	04/30/2019

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
CT	004041679,004024972	1073530879,1700092459
MA	110066612A,110066612B	1073530879,1700092459
NY	00410811	1073530879,1700092459
RI	1073530879	1073530879,1700092459

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	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH070007A	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M PEQUOT CT SCAN	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007AA	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CARDIOLOGY LIMB WATERFORD - Cardiovascular Disease	40 Boston Post Road	WATERFORD	CT	Active
DSH070007AB	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT REHAB SERVICES - Rehabilitation	52 Hazelnut Hill Road	Groton	CT	Active
DSH070007AC	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH FAIRE HARBOUR REHAB SERVICES - Rehabilitation	59 Faire Harbour	NEW LONDON	CT	Active
DSH070007AD	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER GYN ONC - GYN ONC Clinic	230 Waterford Parkway South	Waterford	CT	Active
DSH070007AE	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PODIATRY LIMB WATERFORD - Podiatry	40 Boston Post Road	Waterford	CT	Active
DSH070007AF	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH MED ONC URO MDC WATERFORD - Oncology and Urology	230 Waterford Parkway South	Waterford	CT	Active
DSH070007AG	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH VASCULAR SURG LIMB WATERFORD - Vascular Surgery	40 Boston Post Road	Waterford	CT	Active
DSH070007AH	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH Smilow Liver Clinic Waterford - Cancer	230 Waterford Pkwy S	Waterford	CT	Active
DSH070007AJ	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SMILOW HEAD & NECK WATERFORD - Cancer Center	230 Waterford Pkwy S	Waterford	CT	ToBeTerminated
DSH070007AK	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT PRE/POST - PRE and POST	52 Hazelnut Hill Road	Groton	CT	ToBeTerminated
DSH070007AL	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER ANTI COAG CLINIC - Clinic	230 Waterford Parkway South	WATERFORD	CT	Approved
DSH070007AM	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PODIATRY LIMB PRESERVATION - Wound Care clinic	52 Hazelnut Hill road	GROTON	CT	Approved
DSH070007B	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CROSSROADS CT SCAN	196 Parkway South, Suite 102	Waterford	CT	Terminated
DSH070007C	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CROSSROADS NUCLEAR MEDICINE	196 Parkway South Suite 102	Waterford	CT	Terminated
DSH070007D	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH EMERGENCY PEQUOT	52 Hazelnut Hill Road	Groton	CT	Active
DSH070007E	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads Mamo-Breast Imaging	196 Parkway South	Waterford	CT	Terminated
DSH070007F	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Mamo-Breast Imaging	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007G	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads MRI Services	196 Parkway South	Waterford	CT	Terminated
DSH070007H	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot MRI Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007J	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SLEEP LAB	224 Gold Star Highway	Groton	CT	Active
DSH070007K	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH WOUND CARE CENTER	40 Boston Post Road	Waterford	CT	Active
DSH070007L	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Waterfall Therapy Services	40 Boston Post Road	Waterford	CT	Terminated
DSH070007M	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads Radiology Services	196 Pakway South	Waterford	CT	Terminated
DSH070007N	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Flanders Therapy Services	339 Flanders Road	East Lyme	CT	Terminated
DSH070007P	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Therapy Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007Q	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Radiology Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007R	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT OR	52 Hazelnut Hill Road	Groton	CT	ToBeTerminated
DSH070007S	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER MED ONC	230 Waterford Parkway South	Waterford	CT	Active
DSH070007T	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CANCER CENTER - LMH CANCER CENTER RADIATION ONCOLOGY	230 WATERFORD PKWY South	WATERFORD	CT	Active
DSH070007U	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M PEQUOT HEALTH CENTER - LMH PEQUOT PERIOP SERVICES	52 HAZELNUT HILL RD	GROTON	CT	Active
DSH070007V	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PFT - PULMONARY FUNCTION TESTING SERVICES	365 MONTAUK AVENUE	NEW LONDON	CT	Terminated
DSH070007W	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH VASCULAR SURGERY LIMB PRESERVATION - VASCULAR LIMB SERVICE	52 HAZELNUT HILL ROAD	GROTON	CT	Terminated
DSH070007X	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SURGERY BREAST WATERFORD - BREAST SURGERY	230 WATERFORD PARKWAY SOUTH	WATERFORD	CT	Approved
DSH070007Y	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH FLANDERS REHAB SERVICES - Rehabilitation	339 Flanders Road	East Lyme	CT	Active
DSH070007Z	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH WATERFALL REHABILITATION - Rehabilitation	40 Boston Post Road	Waterford	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/31/2023 12:45:54 PM	9/5/2024 5:52:34 PM	9/5/2024 5:52 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 2:16:40 PM	8/31/2023 12:45:54 PM	8/31/2023 12:45 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	51106144 (AK)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	004167 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (CA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9000161963 (CO)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	023456500 (FL)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003194255A (GA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	060646704002 (IL)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	01260157 (KY)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1761826 (LA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (ME)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	011409703 (MO)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (NC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10026753600 (NE)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4079302 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	85286737 (NM)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0038944 (OH)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10463A (SC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10410B (SC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	81130700 (WI)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300041719 (IN)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (AK)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (CA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (CA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (CO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (CO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (FL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (FL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (GA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (GA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (IL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (IL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (KY)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (KY)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (LA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (LA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (ME)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (ME)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (MO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (MO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NE)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NE)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NM)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NM)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (OH)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (OH)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (SC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (SC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (WI)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (WI)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (AK)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (IN)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (IN)		6/5/2023 9:49 AM
Contacts	Authorizing Official	Update	Change Request	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	Miller, Leeann Chief Pharmacy Officer Yale New Haven Health Services 2034793000	10/17/2022 8:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1073530879 (WI)		9/14/2022 2:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2022 2:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		81130700	9/14/2022 2:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/14/2022 2:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2022 2:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300041719	9/14/2022 2:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/14/2022 2:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/14/2022 2:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/14/2022 2:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/14/2022 2:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/14/2022 2:16 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 5:25:26 PM	9/14/2022 2:16:40 PM	9/14/2022 2:16 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 7:17:50 AM	9/10/2021 5:25:26 PM	9/10/2021 5:25 PM
Contacts	Primary Contact	Update	Change Request	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	Da Silva, Maria Senior Reimbursement Analyst Yale New Haven Health System 2036889332	3/15/2021 8:42 AM
Contacts	Authorizing Official	Update	Change Request	Payne, Douglas Director, Reimbursement Yale New Haven Health System Yale New Haven Health System 2036884878	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	3/12/2021 12:21 PM
Contacts	Primary Contact	Update	Profile Change Request	Messina, Mary G Senior Manager, Regulatory Reimbursement Yale New Haven Health System 2036888543	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	3/11/2021 2:38 PM
Addresses	Billing Address	Update	Recertification	LAWRENCE & MEMORIAL 365 MONTAUK AVENUE NEW LONDON, CT 06320-4700	LAWRENCE & MEMORIAL 365 MONTAUK AVENUE NEW LONDON, CT 06320-3268	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		51106144	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		004167	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000161963	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		023456500	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003194255A	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		060646704002	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01260157	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1761826	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110066612A	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110066612B	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		011409703	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10026753600	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NE	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4079302	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		85286737	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00410811	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0038944	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10463A	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10410B	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Update	Recertification		AK	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/9/2020 7:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/9/2020 7:17 AM
Medicaid Billing	NPI: State	Update	Recertification		AK	9/9/2020 7:17 AM
Details	Last Recertification Date	Update	Recertification	9/10/2019 4:20:25 PM	9/9/2020 7:17:50 AM	9/9/2020 7:17 AM
Details	Entity Subname	Update	Recertification	PEQUOT EMERGENCY ROOM	LMH EMERGENCY PEQUOT	9/9/2020 7:17 AM
Details	Last Recertification Date	Update	Recertification		9/10/2019 4:20:25 PM	9/10/2019 4:20 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Addresses	Billing Address	Insert	Reinstatement		LAWRENCE & MEMORIAL 365 MONTAUK AVENUE NEW LONDON, CT 06320-4700	5/1/2019 8:53 AM
Contacts	Authorizing Official	Update	Reinstatement	Van Essendelft, Seth CFO Lawrence + Memorial Hospital 8604420711-2211	Payne, Douglas Director, Reimbursement Yale New Haven Health System Yale New Haven Health System 2036884878	5/1/2019 8:53 AM
Contacts	Signed By	Update	Reinstatement	Morris, J. xbvx HRSA 2315698541	Payne, Douglas Director, Reimbursement Yale New Haven Health System Yale New Haven Health System 2036884878	5/1/2019 8:53 AM
Dates	Participating Approval Date	Update	Reinstatement		5/1/2019 8:53:07 AM	5/1/2019 8:53 AM
Details	State	Update	Reinstatement	Pending	Approved	5/1/2019 8:53 AM
Dates	Signed By Date	Update	Reinstatement	5/11/2016 12:00:00 AM	4/10/2019 4:05:01 PM	5/1/2019 8:53 AM
Dates	Start Date	Update	Reinstatement		7/1/2019 12:00:00 AM	5/1/2019 8:53 AM
Details	Comments Public	Insert	Reinstatement		Participated starting 7/1/2016, terminated 2/28/2018. Reinstated 7/1/2019.	4/30/2019 3:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	4/10/2019 7:43 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		004041679	4/10/2019 7:43 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CT	4/10/2019 7:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	4/10/2019 7:43 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		004024972	4/10/2019 7:43 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CT	4/10/2019 7:43 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1073530879	4/10/2019 7:43 PM
Details	Last Recertification Date	Update	Reinstatement	11/15/2017 5:07:51 PM		4/10/2019 3:43 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	2/27/2018 12:00:00 AM		4/10/2019 3:43 PM
Dates	Participating Approval Date	Update	Reinstatement	5/12/2016 12:00:00 AM		4/10/2019 3:43 PM
Details	State	Update	Reinstatement	Terminated	Pending	4/10/2019 3:43 PM
Dates	Registration Date	Update	Reinstatement	5/11/2016 12:00:00 AM	4/10/2019 3:43:20 PM	4/10/2019 3:43 PM
Dates	Start Date	Update	Reinstatement	7/1/2016 12:00:00 AM		4/10/2019 3:43 PM
Terminations	Termination Date	Update	Reinstatement	2/28/2018 12:00:00 AM		4/10/2019 3:43 PM
Terminations	Termination Effective Date	Update	Reinstatement	2/27/2018 12:00:00 AM		4/10/2019 3:43 PM
Terminations	Termination Reason	Update	Reinstatement	Change of hospital entity type		4/10/2019 3:43 PM
Contacts	Signed By	Update		Morris, J. xbvx 2315698541	Morris, J. xbvx HRSA 2315698541	3/26/2018 10:45 AM
Terminations	Termination Date	Update	OPA Terminate	2/27/2018 12:00:00 AM	2/28/2018 12:00:00 AM	2/28/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Terminate		2/27/2018 12:00:00 AM	2/27/2018 8:46 AM
Details	State	Update	OPA Terminate	Active	Terminated	2/27/2018 8:46 AM
Terminations	Termination Date	Update	OPA Terminate		2/27/2018 12:00:00 AM	2/27/2018 8:46 AM
Terminations	Termination Effective Date	Update	OPA Terminate		2/27/2018 12:00:00 AM	2/27/2018 8:46 AM
Terminations	Termination Reason	Update	OPA Terminate		Change of hospital entity type	2/27/2018 8:46 AM
Contacts	Primary Contact	Insert	Recertification		Messina, Mary G Senior Manager, Regulatory Reimbursement Yale New Haven Health System 2036888543	11/15/2017 5:07 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/15/2017 5:07:51 PM	11/15/2017 5:07 PM
Contacts	Authorizing Official	Update		Van Essendelft, Seth CFO 8604420711-2211	Van Essendelft, Seth CFO Lawrence + Memorial Hospital 8604420711-2211	10/13/2017 3:00 PM
Contacts	Authorizing Official	Insert			Van Essendelft, Seth CFO 8604420711-2211	7/26/2017 5:56 PM
Contacts	Signed By	Insert			Morris, J. xbvx 2315698541	7/25/2017 12:21 PM
Addresses	Main Address	Insert			52 Hazelnut Hill Road Groton, CT 06340	8/16/2016 10:36 AM
Details	Last Recertification Date	Update			8/16/2016 12:00:00 AM	8/16/2016 10:36 AM
Dates	Participating Approval Date	Update			5/12/2016 12:00:00 AM	5/12/2016 11:02 AM
Details	State	Update		Pending	Active	5/12/2016 11:02 AM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/12/2016 11:02 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_60740	DSH070007D	5/11/2016 5:01 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_60740	5/11/2016 4:59 PM
Medicaid Billing	NPI: Number	Insert			1700092459	5/11/2016 4:59 PM
Details	Last Recertification Date	Insert				5/11/2016 4:59 PM
Details	Grant Number	Insert				5/11/2016 4:59 PM
Details	340B ID	Insert				5/11/2016 4:59 PM
Details	Is Authorizing Official EHB Data	Insert				5/11/2016 4:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert				5/11/2016 4:59 PM
Details	Medicare Provider Number	Insert			070007	5/11/2016 4:59 PM
Details	Entity Name	Insert			LAWRENCE & MEMORIAL HOSPITAL	5/11/2016 4:59 PM
Details	Program Code	Insert			DSH	5/11/2016 4:59 PM
Details	Entity Subname	Insert			PEQUOT EMERGENCY ROOM	5/11/2016 4:59 PM
Dates	Participating Approval Date	Insert				5/11/2016 4:59 PM
Details	State	Insert			Pending	5/11/2016 4:59 PM
Dates	Registration Date	Insert			5/11/2016 12:00:00 AM	5/11/2016 4:59 PM
Dates	Signed By Date	Insert			5/11/2016 12:00:00 AM	5/11/2016 4:59 PM
Dates	Start Date	Insert				5/11/2016 4:59 PM
Terminations	Termination Comments	Insert				5/11/2016 4:59 PM
Terminations	Termination Date	Insert				5/11/2016 4:59 PM
Terminations	Termination Effective Date	Insert				5/11/2016 4:59 PM
Terminations	Termination Reason	Insert				5/11/2016 4:59 PM