Covered Entity Details

DSH050441EF STANFORD HEALTH CARE (Active) - information as of 5/3/2025 11:31:28 PM

Main Details

Name

STANFORD HEALTH CARE

Subdivision Name

Head Neck Oncology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050441EF

Medicare Provider Number

050441

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/7/2016

Participating Start Date

10/1/2016

Participating Approval Date

8/24/2016

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Stanford Health Care
Linda Hoff, CFO
(650) 497-0391

Primary Contact

Stanford Health Care
Jannice Tan, Pharmacy Business Analyst, 340B
(510) 919-7483

Addresses

Street Address

900 Blake Wilbur Dr
3rd Floor
W3000
Palo Alto, CA 94304

Billing Address

Stanford Health Care
300 Pasteur Drive
H0301
Palo Alto, CA 94305

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
CA	HSC00441H	1053835595,1871543215

Shipping Addresses

Shipping Address 1

Stanford Health Care
300 Pasteur Drive
H0301
Palo Alto, CA 94305

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
DSH050441A	Child	DSH	STANFORD HEALTH CARE	MSPECIALTY PORTOLA VALLEY-TECH	3220 Alpine Road	Portola Valley	CA	Terminated
DSH050441AA	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-BL Wilbur Multi-specialty-Tech	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AB	Child	DSH	STANFORD HOSPITAL & CLINICS	Electroencephalography	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AC	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AD	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-OP CTR Dermatology	2433 Central Ave	Alameda	CA	Terminated
DSH050441AE	Child	DSH	STANFORD HEALTH CARE	Byers Surgery Clinic	2452 Watson Ct	Palo Alto	CA	Active
DSH050441AF	Child	DSH	STANFORD HEALTH CARE	Ophthalmology Clinic-Ophthalmology	2452 Watson Ct	Palo Alto	CA	Terminated
DSH050441AG	Child	DSH	STANFORD HEALTH CARE	Ophthalmology Clinic-Laser Excimer	2452 Watson Ct	Palo Alto	CA	Active
DSH050441AH	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-Dermatology-Hayward	27212 Caloroga Ave	Hayward	CA	Terminated
DSH050441AJ	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Gastroenterology-Portola Valley	3240 Alpine Rd	Portola Valley	CA	Terminated
DSH050441AK	Child	DSH	STANFORD HEALTH CARE	Clinic-Orthopaedics-Portola Valley	3260 Alpine Rd	Portola Valley	CA	Terminated
DSH050441AL	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	341 Galvez St	Stanford	CA	Terminated
DSH050441AM	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Orthopaedics-Plastic Surgery/Hand	450 Broadway St	Redwood City	CA	Active
DSH050441AN	Child	DSH	STANFORD HOSPITAL & CLINICS	Medical Specialties/Immunology-RWC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AP	Child	DSH	STANFORD HOSPITAL & CLINICS	Physical Therapy-Rehab-Ortho Sports Therapy	440 Broadway St	Redwood City	CA	Terminated
DSH050441AQ	Child	DSH	STANFORD HEALTH CARE	Ortho Clinic-Orthopaedics	450 Broadway St	Redwood City	CA	Active
DSH050441AR	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Immunology-Ortho OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AS	Child	DSH	STANFORD HOSPITAL & CLINICS	Surgery Clinic-Vascular Lab-RWC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AT	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Otolaryngology-OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AU	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic- OP CTR Outpatient Surgery Center	450 Broadway St	Redwood City	CA	Active
DSH050441AV	Child	DSH	STANFORD HOSPITAL & CLINICS	Physical Therapy-Rehab-Hand Therapy	450 Broadway St	Redwood City	CA	Terminated
DSH050441AW	Child	DSH	STANFORD HOSPITAL & CLINICS	MRI-Radiology-MRI OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AX	Child	DSH	STANFORD HOSPITAL & CLINICS	CT Scan-Radiology-CT Scan OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AY	Child	DSH	STANFORD HOSPITAL & CLINICS	Radioisotope-Radiology-Nuclear Med OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AZ	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic-OP CTR ULTRASOUND	440 Broadway St	Redwood City	CA	Terminated
DSH050441B	Child	DSH	STANFORD HEALTH CARE	PRIMARY CARE - PORTOLA VALLEY	3250 Alpine Road	Portola Valley	CA	Active
DSH050441BA	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic-OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441BB	Child	DSH	STANFORD HEALTH CARE	MRI-Radiology-MRI Sherman	451 Sherman Ave	Palo Alto	CA	Terminated
DSH050441BC	Child	DSH	STANFORD HEALTH CARE	CT Scan-Radiology-CT Scan-Sherman	451 Sherman Ave	Palo Alto	CA	Terminated
DSH050441BD	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-Dermatology Medicine-Vaden	866 Campus Dr	Stanford	CA	Terminated
DSH050441BE	Child	DSH	STANFORD HOSPITAL & CLINICS	Ophthalmology Clinic-Vaden	866 Campus Dr	Stanford	CA	Terminated
DSH050441BF	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Lymphoma Clinic	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BG	Child	DSH	STANFORD HEALTH CARE	Breast Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BH	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Cutaneous Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441BJ	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Neuro Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BK	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Hematology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BL	Child	DSH	STANFORD HEALTH CARE	GYN Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BM	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Apheresis	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BN	Child	DSH	STANFORD HEALTH CARE	BMT Clinic-Infusion Treatment Area	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BP	Child	DSH	STANFORD HEALTH CARE	Clinic-Infusion Center-Redwood City	440 Broadway St	Redwood City	CA	Active
DSH050441BQ	Child	DSH	STANFORD HEALTH CARE	Radiology-Therapeutic-Radiation Therapy CC	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BR	Child	DSH	STANFORD HEALTH CARE	Radiology-Therapeutic-Radiation Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BS	Child	DSH	STANFORD HEALTH CARE	Radiology-Diagnostic-Mammography CC	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BT	Child	DSH	STANFORD HEALTH CARE	Gastro Intestinal-Gastroenterology	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441BU	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Apheresis	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BV	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Sarcoma	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BW	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Lymphoma	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BX	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Breast Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BY	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-GI Oncology-BW	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BZ	Child	DSH	STANFORD HEALTH CARE	Cutaneous Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441C	Child	DSH	STANFORD HOSPITAL & CLINICS	STANFORD POSITIVE CARE CLINIC	351 El Camino Real	Atherton	CA	Terminated
DSH050441CA	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Neuro Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CB	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Hematology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CC	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Gyn Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CD	Child	DSH	STANFORD HOSPITAL & CLINICS	BMT Clinic-Infusion Treatment Area	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CE	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Plastic Surgery-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CF	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Infectious Disease	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441CG	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Infusion Center-Redwood City	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CH	Child	DSH	STANFORD HEALTH CARE	Concierge Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CJ	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Stanford Executive Medicine	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CK	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Immunology-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CL	Child	DSH	STANFORD HEALTH CARE	OB/GYN Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441CM	Child	DSH	STANFORD HOSPITAL & CLINICS	CV Surgery Clinic-Cardiothoracic Surgery-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CN	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-ECG-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CP	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-ECHO-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CQ	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-Cardiovascular Medicine	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CR	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-OP CTR Dermatology	960 N San Antonio Rd	Los Altos	CA	Terminated
DSH050441CS	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Surgery	440 Broadway St	Redwood City	CA	Terminated
DSH050441CT	Child	DSH	STANFORD HEALTH CARE	Pain Management	450 Broadway St	Redwood City	CA	Active
DSH050441CU	Child	DSH	STANFORD HEALTH CARE	Dermatology Medicine	440 Broadway St	Redwood City	CA	Active
DSH050441CV	Child	DSH	STANFORD HOSPITAL & CLINICS	Infectious Disease-OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441CW	Child	DSH	STANFORD HEALTH CARE	Neuro at Hoover	211 Quarry Rd	Palo Alto	CA	Active
DSH050441CX	Child	DSH	STANFORD HEALTH CARE	SNHC Infusion Treatment Center	213 Quarry Road	Palo Alto	CA	Active
DSH050441CY	Child	DSH	STANFORD HEALTH CARE	SNHC Neurology	213 Quarry Road	Palo Alto	CA	Active
DSH050441CZ	Child	DSH	STANFORD HEALTH CARE	Cath Angio Pre-Proced & Recov	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441D	Child	DSH	STANFORD HOSPITAL & CLINICS	ARRILLAGA SPORTS CENTER / Sports Medicine	341 Galvez St	Stanford	CA	Terminated
DSH050441DA	Child	DSH	STANFORD HEALTH CARE	SNHC Neurosurgery	213 Quarry Road	Palo Alto	CA	Active
DSH050441DB	Child	DSH	STANFORD HEALTH CARE	Uro Oncology Facility 3001014	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DC	Child	DSH	STANFORD HEALTH CARE	8002501 - South Bay Cancer Ctr Infusion	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DE	Child	DSH	STANFORD HEALTH CARE	Lane Surgery Center 7101000	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DF	Child	DSH	STANFORD HEALTH CARE	General Radiology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DG	Child	DSH	STANFORD HEALTH CARE	OP CTR Foot and Ankle	420 Broadway St	Redwood City	CA	Active
DSH050441DH	Child	DSH	STANFORD HEALTH CARE	OP CTR Spine	420 Broadway St	Redwood City	CA	Active
DSH050441DJ	Child	DSH	STANFORD HEALTH CARE	OP CTR Hand/Upper and Shoulder/Elbow	450 Broadway St	Redwood City	CA	Active
DSH050441DK	Child	DSH	STANFORD HEALTH CARE	OP CTR Boswell Joint Replacement	450 Broadway St	Redwood City	CA	Active
DSH050441DL	Child	DSH	STANFORD HEALTH CARE	OP CTR Shultz Orthopedics	420 Broadway St	Redwood City	CA	Active
DSH050441DM	Child	DSH	STANFORD HEALTH CARE	OP CTR Sleep	440 Broadway St	Redwood City	CA	Terminated
DSH050441DN	Child	DSH	STANFORD HEALTH CARE	OP CTR Wound Care	440 Broadway St	Redwood City	CA	Active
DSH050441DP	Child	DSH	STANFORD HEALTH CARE	South Bay MRI	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DQ	Child	DSH	STANFORD HEALTH CARE	South Bay CT	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DR	Child	DSH	STANFORD HEALTH CARE	South Bay Ultrasound	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DS	Child	DSH	STANFORD HEALTH CARE	South Bay Radiation Therapy	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DT	Child	DSH	STANFORD HEALTH CARE	South Bay Mammography, Radiology	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DU	Child	DSH	STANFORD HEALTH CARE	South Bay Cancer Center - Clinic 3	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DV	Child	DSH	STANFORD HEALTH CARE	South Bay Cancer Center - Clinic 4	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DW	Child	DSH	STANFORD HEALTH CARE	South Bay Oncology Surgery	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DX	Child	DSH	STANFORD HEALTH CARE	Ultrasound	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DY	Child	DSH	STANFORD HEALTH CARE	Mammography	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DZ	Child	DSH	STANFORD HEALTH CARE	CT	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441E	Child	DSH	STANFORD HOSPITAL & CLINICS	Ophthalmology Clinic	2453 Watson Court	Palo Alto	CA	Terminated
DSH050441EA	Child	DSH	STANFORD HEALTH CARE	MRI	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EB	Child	DSH	STANFORD HEALTH CARE	OP CTR-LIVER CLINIC	420 Broadway St	Redwood City	CA	Active
DSH050441EC	Child	DSH	STANFORD HEALTH CARE	Sleep Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441ED	Child	DSH	STANFORD HEALTH CARE	General Surgery	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EE	Child	DSH	STANFORD HEALTH CARE	BW Anti-Coag	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441EF	Child	DSH	STANFORD HEALTH CARE	Head Neck Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EG	Child	DSH	STANFORD HEALTH CARE	BW Cyberknife	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EH	Child	DSH	STANFORD HEALTH CARE	CCSB Nuclear Medicine	2589 Samaritan Drive	San Jose	CA	Active
DSH050441EJ	Child	DSH	STANFORD HEALTH CARE	CCSB Pain Management	2589 Samaritan Drive	San Jose	CA	Active
DSH050441EK	Child	DSH	STANFORD HEALTH CARE	SNHC Cyberknife	213 Quarry Rd.	Palo Alto	CA	Terminated
DSH050441EL	Child	DSH	STANFORD HEALTH CARE	Radiation Oncology WCC	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EM	Child	DSH	STANFORD HEALTH CARE	SNHC General Radiology	213 Quarry Road	Palo Alto	CA	Active
DSH050441EN	Child	DSH	STANFORD HEALTH CARE	Thoracic Oncology - Thoracic Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EP	Child	DSH	STANFORD HEALTH CARE	EHC - Urology - Urology Clinic	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EQ	Child	DSH	STANFORD HEALTH CARE	EHC - PACU - Surgery Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ER	Child	DSH	STANFORD HEALTH CARE	EHC - CT - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ES	Child	DSH	STANFORD HEALTH CARE	EHC-MULTISPCIALTY CLIN II TECH - Emeryville Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ET	Child	DSH	STANFORD HEALTH CARE	EHC - PULMONARY FUNCTN TESTING - PULMONARY FUNCTION TESTING	5800 Hollis St.	Emeryville	CA	Active
DSH050441EU	Child	DSH	STANFORD HEALTH CARE	EHC - PULMONARY FUNCTION TESTING ( Lab) - PULMONARY FUNCTION TESTING	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EV	Child	DSH	STANFORD HEALTH CARE	EHC-MULTISPECIALTY CLIN I TECH - Emeryville Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441EW	Child	DSH	STANFORD HEALTH CARE	EHC - PRE ANESTHESIA CLINIC - Anesthesiology	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EX	Child	DSH	STANFORD HEALTH CARE	EHC - OR - Surgery Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441EY	Child	DSH	STANFORD HEALTH CARE	EHC - MRI	5800 Hollis St.	Emeryville	CA	Active
DSH050441EZ	Child	DSH	STANFORD HEALTH CARE	EHC - CARDIOVASCULAR TESTING - Catheterization	5800 Hollis St.	Emeryville	CA	Active
DSH050441F	Child	DSH	STANFORD HEALTH CARE	STANFORD PRIMARY CARE-PORTOLA VALLEY	3240 Alpine Road	Portola Valley	CA	Terminated
DSH050441FA	Child	DSH	STANFORD HEALTH CARE	EHC - MAMMOGRAPHY - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FB	Child	DSH	STANFORD HEALTH CARE	OP CTR DIAGNOSTIC RADIOLOGY PR - Radiology-Diagnostic	440 Broadway St	Redwood City	CA	Active
DSH050441FC	Child	DSH	STANFORD HEALTH CARE	OP Pelvic health Center - Clinic	420 Broadway St	Redwood City	CA	Active
DSH050441FD	Child	DSH	STANFORD HEALTH CARE	EHC - NUCLEAR MEDICINE - Radioisotope	5800 Hollis St.	Emeryville	CA	Active
DSH050441FE	Child	DSH	STANFORD HEALTH CARE	EHC - NEURODIAGNOSTIC LAB - Electroencephalography	5800 Hollis St.	Emeryville	CA	Active
DSH050441FF	Child	DSH	STANFORD HEALTH CARE	EHC - ULTRASOUND - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FG	Child	DSH	STANFORD HEALTH CARE	BL WILBUR MULTISPECIALTY CLIN CCSB LIV - Clinic	2589 Samaritan Drive	San Jose	CA	Active
DSH050441FH	Child	DSH	STANFORD HEALTH CARE	IMMUNOLOGY DERM - OC - Clinic	440 Broadway St	Redwood City	CA	Active
DSH050441FJ	Child	DSH	STANFORD HEALTH CARE	Immunology Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441FK	Child	DSH	STANFORD HEALTH CARE	IMMUNOLOGY ORTHO - OC - Clinic	450 Broadway St	Redwood City	CA	Active
DSH050441FL	Child	DSH	STANFORD HEALTH CARE	Infectious Diseases Hoover	211 Quarry Rd	Palo Alto	CA	Active
DSH050441FM	Child	DSH	STANFORD HEALTH CARE	Endocrinology Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441FN	Child	DSH	STANFORD HEALTH CARE	BW DIGESTIVE HEALTH CENTER CCSB DHC - SURG - Surgery Clinic	2589 Samaritan Drive	San Jose	CA	Active
DSH050441FP	Child	DSH	STANFORD HEALTH CARE	MSPECIALTY PORTOLA VALLEY - TECH - Clinic	3240 Alpine Road	Portola Valley	CA	Terminated
DSH050441FQ	Child	DSH	STANFORD HEALTH CARE	Gynecology Clinic OPC - Gynecology	420 Broadway St	Redwood City	CA	Active
DSH050441FR	Child	DSH	STANFORD HEALTH CARE	ORTHOPAEDIC TRAUMA - ORTHOPEDICS	450 Broadway St	Redwood City	CA	Active
DSH050441FS	Child	DSH	STANFORD HEALTH CARE	Endocrine Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441FT	Child	DSH	STANFORD HEALTH CARE	DHC /GEN SURGERY TECH BILLING -DIGESTIVE HEALTH RWC - Surgery Clinic	420 Broadway St	Redwood City	CA	Active
DSH050441FU	Child	DSH	STANFORD HEALTH CARE	Blood and Marrow Transplant	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441FV	Child	DSH	STANFORD HEALTH CARE	EMERGENCY SERVICES - EMERGENCY	500 Pasteur Drive	Stanford	CA	Terminated
DSH050441FW	Child	DSH	STANFORD HEALTH CARE	SNHC CT Scan	213 Quarry Road	Palo Alto	CA	Active
DSH050441FX	Child	DSH	STANFORD HEALTH CARE	EHC CANCER CLINIC - Cancer Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FY	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR CT PAV D	420 Broadway St	Redwood City	CA	Active
DSH050441FZ	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR CT PAV B	440 Broadway St	Redwood City	CA	Active
DSH050441G	Child	DSH	STANFORD HOSPITAL & CLINICS	STANFORD MEDICINE OUTPATIENT CENTER / Dermatology Clinic	440 Broadway Street	Redwood City	CA	Terminated
DSH050441GA	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR PRE ANESTHESIA PAV D	420 Broadway St	Redwood City	CA	Active
DSH050441GB	Child	DSH	STANFORD HEALTH CARE	SNHC Ortho	213 Quarry Road	Palo Alto	CA	Active
DSH050441GC	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR ENDOSCOPY OR	420 Broadway St	Redwood City	CA	Active
DSH050441GD	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR ORTHO PMR AND SPORTS MEDICINE	450 Broadway St	Redwood City	CA	Active
DSH050441GE	Child	DSH	STANFORD HEALTH CARE	SNHC MRI	213 Quarry Road	Palo Alto	CA	Active
DSH050441GG	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR MRI PAV B	440 Broadway St	Redwood City	CA	Active
DSH050441GH	Child	DSH	STANFORD HEALTH CARE	Lane Surgery Pre/Post Care - Surgery Clinic	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441GJ	Child	DSH	STANFORD HEALTH CARE	BW MRI - MRI	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441GK	Child	DSH	STANFORD HEALTH CARE	BYERS PRE ANESTHESIA CLINIC - Anesthesiology	2452 Watson Court	Palo Alto	CA	Active
DSH050441GL	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Neurosurgery - Neurosurgery	875 Blake Wibur Dr	Palo Alto	CA	Active
DSH050441GM	Child	DSH	STANFORD HEALTH CARE	EHC - Infusion Treatment Center	5800 Hollis St.	Emeryville	CA	Active
DSH050441GN	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - CCSB Palliative Medicine	2589 SAMARITAN DR	SAN JOSE	CA	Active
DSH050441GP	Child	DSH	STANFORD HEALTH CARE	CANCER CLINIC REDWOOD CITY - CANCER CLINIC	440 Broadway Street	Redwood City	CA	Active
DSH050441GQ	Child	DSH	STANFORD HEALTH CARE	BLOOD AND MARROW TRANSPLANT CLINIC - HEMATOLOGY	875 Blake Wilbur Drive	Palo Alto	CA	Active
DSH050441GR	Child	DSH	STANFORD HEALTH CARE	WALK-IN CLINIC - EMERGENCY	211 Quarry Rd	Palo Alto	CA	Active
DSH050441GS	Child	DSH	STANFORD HEALTH CARE	OTOLARYNGOLOGY SNHC - OTOLARYNGOLOGY SNHC	213 Quarry Road	Palo Alto	CA	Active
DSH050441H	Child	DSH	STANFORD HEALTH CARE	ENT Clinic / ENT/Surgery	801 Welch Rd	Palo Alto	CA	Active
DSH050441J	Child	DSH	STANFORD HEALTH CARE	EYE INSTITUTE AT STANFORD	2452 Watson Ct	Palo Alto	CA	Active
DSH050441K	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic - Plastics	1000 Welch Rd	Palo Alto	CA	Active
DSH050441L	Child	DSH	STANFORD HEALTH CARE	Sarcoma	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441M	Child	DSH	STANFORD HEALTH CARE	OP CTR Multispeciality Dermatology-Phototherapy	440 Broadway St	Redwood City	CA	Active
DSH050441N	Child	DSH	STANFORD HEALTH CARE	Urology Clinic	1000 Welch Rd	Palo Alto	CA	Active
DSH050441P	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic	100A San Pablo Towne Center	San Pablo	CA	Terminated
DSH050441Q	Child	DSH	STANFORD HOSPITAL & CLINICS	Pain Services	100A San Pablo Towne Center	San Pablo	CA	Terminated
DSH050441R	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic	1555 Soquel Dr	Santa Cruz	CA	Terminated
DSH050441S	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	16400 Lark Ave	Los Gatos	CA	Terminated
DSH050441T	Child	DSH	STANFORD HOSPITAL & CLINICS	LOS GATOS NEUROSURGERY	16400 LARK AVE	LOS GATOS	CA	Terminated
DSH050441U	Child	DSH	STANFORD HEALTH CARE	Dermatology Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441V	Child	DSH	STANFORD HEALTH CARE	Senior Care	211 Quarry Rd	Palo Alto	CA	Active
DSH050441W	Child	DSH	STANFORD HEALTH CARE	Internal Medicine	211 Quarry Rd	Palo Alto	CA	Active
DSH050441X	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Stanford Coordinated Care	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441Y	Child	DSH	STANFORD HEALTH CARE	Express Care Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441Z	Child	DSH	STANFORD HEALTH CARE	Family Medicine	211 Quarry Rd	Palo Alto	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 12:46:37 PM	8/22/2024 3:30:38 PM	8/22/2024 3:30 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 6:42:53 PM	8/29/2023 12:46:37 PM	8/29/2023 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 12:46:55 PM	9/9/2022 6:42:53 PM	9/9/2022 6:42 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 2:42:32 PM	8/24/2021 12:46:55 PM	8/24/2021 12:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053835595	9/10/2020 2:42 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2020 2:42 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/10/2020 2:42 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1871543215 ( )		9/10/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1053835595 ( )		9/10/2020 2:42 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 12:20:09 PM	9/10/2020 2:42:32 PM	9/10/2020 2:42 PM
Details	Entity Subname	Update	Recertification	BW HEAD/NECK ONCOLOGY	Head Neck Oncology	9/10/2020 2:42 PM
Addresses	Main Address	Update	Recertification	900 Blake Wilbur Drive 3rd Floor W3000 Palo Alto, CA 94304	900 Blake Wilbur Dr 3rd Floor W3000 Palo Alto, CA 94304	9/11/2019 12:20 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 3:05:21 PM	9/11/2019 12:20:09 PM	9/11/2019 12:20 PM
Contacts	Primary Contact	Update	Change Request	Chellamy, Caroline Assistant Director of Pharmacy Services Stanford Health Care 6507247812	Tan, Jannice Pharmacy Business Analyst, 340B Stanford Health Care 5109197483	4/4/2019 10:52 AM
Addresses	Main Address	Update	Recertification	900 Blake Wilbur Drive, 3rd Floor, Suite W3000 Palo Alto, CA 94304	900 Blake Wilbur Drive 3rd Floor W3000 Palo Alto, CA 94304	9/10/2018 3:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:05 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	9/10/2018 3:05 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/10/2018 3:05 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053835595	9/10/2018 3:05 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 5:38:44 PM	9/10/2018 3:05:21 PM	9/10/2018 3:05 PM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care 300 Pasteur Drive H0301 Palo Alto, CA 94305	12/4/2017 5:38 PM
Addresses	Billing Address	Update	Recertification	Stanford Healthcare 300 Pasteur Drive Palo Alto, CA 94304	Stanford Health Care 300 Pasteur Drive H0301 Palo Alto, CA 94305	12/4/2017 5:38 PM
Details	Last Recertification Date	Update	Recertification		12/4/2017 5:38:44 PM	12/4/2017 5:38 PM
Contacts	Authorizing Official	Update		Hoff, Linda CFO 6504970391	Hoff, Linda CFO Stanford Health Care 6504970391	9/29/2017 12:38 PM
Contacts	Primary Contact	Update		Chellamy, Caroline Assistant Director of Pharmacy Services 6507247812	Chellamy, Caroline Assistant Director of Pharmacy Services Stanford Health Care 6507247812	9/18/2017 4:52 PM
Contacts	Authorizing Official	Insert			Hoff, Linda CFO 6504970391	8/3/2017 7:24 AM
Contacts	Primary Contact	Update		Sisodiya, Deepak Director of Pharmacy Services 6507255801	Chellamy, Caroline Assistant Director of Pharmacy Services 6507247812	8/3/2017 7:24 AM
Contacts	Signed By	Insert			Connor, David CFO 6507251074	8/3/2017 7:22 AM
Addresses	Shipping Address	Delete		Stanford Healthcare 300 Pasteur Drive Palo Alto, CA 94304		8/3/2017 7:21 AM
Addresses	Main Address	Insert			900 Blake Wilbur Drive, 3rd Floor, Suite W3000 Palo Alto, CA 94304	8/3/2017 7:21 AM
Addresses	Billing Address	Insert			Stanford Healthcare 300 Pasteur Drive Palo Alto, CA 94304	8/3/2017 7:21 AM
Addresses	Shipping Address	Insert			Stanford Healthcare 300 Pasteur Drive Palo Alto, CA 94304	8/3/2017 7:21 AM
Details	Entity Name	Update		STANFORD HOSPITAL & CLINICS	STANFORD HEALTH CARE	8/3/2017 7:21 AM
Contacts	Primary Contact	Insert			Sisodiya, Deepak Director of Pharmacy Services 6507255801	12/7/2016 7:50 AM
Dates	Participating Approval Date	Update			8/24/2016 12:00:00 AM	8/24/2016 1:00 PM
Details	State	Update		Pending	Active	8/24/2016 1:00 PM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	8/24/2016 1:00 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_71165	DSH050441EF	7/14/2016 2:26 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_71165	7/7/2016 8:26 PM
Medicaid Billing	NPI: Number	Insert			1871543215	7/7/2016 8:26 PM
Details	Last Recertification Date	Insert				7/7/2016 8:26 PM
Details	Grant Number	Insert				7/7/2016 8:26 PM
Details	340B ID	Insert				7/7/2016 8:26 PM
Details	Is Authorizing Official EHB Data	Insert				7/7/2016 8:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/7/2016 8:26 PM
Details	Medicare Provider Number	Insert			050441	7/7/2016 8:26 PM
Details	Entity Name	Insert			STANFORD HOSPITAL & CLINICS	7/7/2016 8:26 PM
Details	Program Code	Insert			DSH	7/7/2016 8:26 PM
Details	Entity Subname	Insert			BW HEAD/NECK ONCOLOGY	7/7/2016 8:26 PM
Dates	Participating Approval Date	Insert				7/7/2016 8:26 PM
Details	State	Insert			Pending	7/7/2016 8:26 PM
Dates	Registration Date	Insert			7/7/2016 12:00:00 AM	7/7/2016 8:26 PM
Dates	Signed By Date	Insert			7/7/2016 12:00:00 AM	7/7/2016 8:26 PM
Dates	Start Date	Insert				7/7/2016 8:26 PM
Terminations	Termination Comments	Insert				7/7/2016 8:26 PM
Terminations	Termination Date	Insert				7/7/2016 8:26 PM
Terminations	Termination Effective Date	Insert				7/7/2016 8:26 PM
Terminations	Termination Reason	Insert				7/7/2016 8:26 PM