| Details | State | Update | | To Be Terminated | Terminated | 4/1/2025 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 4/1/2025 12:00:00 AM | 1/27/2025 9:23 AM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 1/27/2025 9:23 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 4/1/2025 12:00:00 AM | 1/27/2025 9:23 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 4/1/2025 12:00:00 AM | 1/27/2025 9:23 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 1/27/2025 9:23 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2023 8:50:24 AM | 8/20/2024 9:39:58 AM | 8/20/2024 9:39 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Cancel Termination Request | 4/1/2024 12:00:00 AM | | 3/8/2024 7:12 AM |
| Details | State | Update | OPA Cancel Termination Request | To Be Terminated | Active | 3/8/2024 7:12 AM |
| Terminations | Termination Date | Update | OPA Cancel Termination Request | 4/1/2024 12:00:00 AM | | 3/8/2024 7:12 AM |
| Terminations | Termination Effective Date | Update | OPA Cancel Termination Request | 4/1/2024 12:00:00 AM | | 3/8/2024 7:12 AM |
| Terminations | Termination Reason | Update | OPA Cancel Termination Request | Change of covered entity type | | 3/8/2024 7:12 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 4/1/2024 12:00:00 AM | 2/27/2024 7:40 AM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 2/27/2024 7:40 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 4/1/2024 12:00:00 AM | 2/27/2024 7:40 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 4/1/2024 12:00:00 AM | 2/27/2024 7:40 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 2/27/2024 7:40 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2022 2:41:06 PM | 8/25/2023 8:50:24 AM | 8/25/2023 8:50 AM |
| Addresses | Billing Address | Insert | Change Request | | St. Elizabeth Healthcare
1 Medical Village Dr.
Edgewood, KY 41017 | 9/2/2022 12:06 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 10:53:39 AM | 8/24/2022 2:41:06 PM | 8/24/2022 2:41 PM |
| Addresses | Main Address | Update | Recertification |
900 Medical Village Drive
Edgewood, KY 41017 |
711 Medical Village Drive
110
Edgewood, KY 41017 | 8/30/2021 10:53 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2020 10:23:24 AM | 8/30/2021 10:53:39 AM | 8/30/2021 10:53 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1467492421 | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | KY | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1467492421 | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IN | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1467492421 | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | OH | 9/9/2020 10:23 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1467492421 ( ) | | 9/9/2020 10:23 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2019 1:57:49 PM | 9/9/2020 10:23:24 AM | 9/9/2020 10:23 AM |
| Medicaid Billing | Medicaid: Number | Update | Recertification | 100034230A | 300024657 | 8/30/2019 1:57 PM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2018 9:00:33 AM | 8/30/2019 1:57:49 PM | 8/30/2019 1:57 PM |
| Details | Last Recertification Date | Update | Recertification | 11/9/2017 10:20:54 AM | 8/20/2018 9:00:33 AM | 8/20/2018 9:00 AM |
| Details | Last Recertification Date | Update | Recertification | | 11/9/2017 10:20:54 AM | 11/9/2017 10:20 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/23/2017 4:25 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 100034230A | 10/23/2017 4:25 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | IN | 10/23/2017 4:25 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/10/2017 7:54 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 7645114 | 10/10/2017 7:54 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OH | 10/10/2017 7:54 AM |
| Contacts | Authorizing Official | Update | | Ritchey-Baldwin, Lori
CFO
8596551642 | Ritchey-Baldwin, Lori
CFO
St. Elizabeth Healthcare
8596551642 | 10/2/2017 12:55 PM |
| Contacts | Signed By | Update | | Ritchey-Baldwin, Lori
CFO
8596551642 | Ritchey-Baldwin, Lori
CFO
St. Elizabeth Healthcare
8596551642 | 10/2/2017 12:55 PM |
| Contacts | Primary Contact | Update | | Thamann, Joe
Director of Reimbursement
8596551889 | Thamann, Joe
Director of Reimbursement
St. Elizabeth Healthcare
8596551889 | 9/26/2017 3:44 PM |
| Addresses | Main Address | Insert | | |
900 Medical Village Drive
Edgewood, KY 41017 | 7/12/2017 4:02 PM |
| Contacts | Primary Contact | Insert | | | Thamann, Joe
Director of Reimbursement
8596551889 | 7/12/2017 4:02 PM |
| Contacts | Authorizing Official | Insert | | | Ritchey-Baldwin, Lori
CFO
8596551642 | 7/12/2017 4:02 PM |
| Contacts | Signed By | Insert | | | Ritchey-Baldwin, Lori
CFO
8596551642 | 7/12/2017 4:02 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/24/2016 12:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 01013671 | 8/24/2016 12:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | KY | 8/24/2016 12:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1467492421 | 8/24/2016 12:15 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 7/1/2016 12:00:00 AM | | 8/24/2016 12:15 PM |
| Dates | Participating Approval Date | Update | | 5/12/2016 12:00:00 AM | 8/24/2016 12:00:00 AM | 8/24/2016 12:15 PM |
| Details | State | Update | | Terminated | Active | 8/24/2016 12:15 PM |
| Dates | Registration Date | Update | | 4/4/2016 12:00:00 AM | 7/14/2016 12:00:00 AM | 8/24/2016 12:15 PM |
| Dates | Signed By Date | Update | | 4/4/2016 12:00:00 AM | 7/14/2016 12:00:00 AM | 8/24/2016 12:15 PM |
| Dates | Start Date | Update | | 7/1/2016 12:00:00 AM | 10/1/2016 12:00:00 AM | 8/24/2016 12:15 PM |
| Terminations | Termination Comments | Update | | Terminating due to awaiting full implementation of our split billing vendor. | | 8/24/2016 12:15 PM |
| Terminations | Termination Date | Update | | 7/1/2016 12:00:00 AM | | 8/24/2016 12:15 PM |
| Terminations | Termination Effective Date | Update | | 7/1/2016 12:00:00 AM | | 8/24/2016 12:15 PM |
| Terminations | Termination Reason | Update | | Site closure | | 8/24/2016 12:15 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 7/1/2016 12:00:00 AM | 7/14/2016 9:57 AM |
| Details | State | Update | | Active | Terminated | 7/14/2016 9:57 AM |
| Terminations | Termination Comments | Update | | | Terminating due to awaiting full implementation of our split billing vendor. | 7/14/2016 9:57 AM |
| Terminations | Termination Date | Update | | | 7/1/2016 12:00:00 AM | 7/14/2016 9:57 AM |
| Terminations | Termination Effective Date | Update | | | 7/1/2016 12:00:00 AM | 7/14/2016 9:57 AM |
| Terminations | Termination Reason | Update | | | Site closure | 7/14/2016 9:57 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 10/1/2015 12:00:00 AM | | 5/12/2016 5:09 PM |
| Dates | Participating Approval Date | Update | | 8/12/2015 12:00:00 AM | 5/12/2016 12:00:00 AM | 5/12/2016 5:09 PM |
| Details | State | Update | | Terminated | Active | 5/12/2016 5:09 PM |
| Dates | Registration Date | Update | | 7/13/2015 12:00:00 AM | 4/4/2016 12:00:00 AM | 5/12/2016 5:09 PM |
| Dates | Signed By Date | Update | | 7/13/2015 12:00:00 AM | 4/4/2016 12:00:00 AM | 5/12/2016 5:09 PM |
| Dates | Start Date | Update | | 10/1/2015 12:00:00 AM | 7/1/2016 12:00:00 AM | 5/12/2016 5:09 PM |
| Terminations | Termination Comments | Update | | St. Elizabeth Healthcare is not ready to fully implement the Program and we intend to re-enroll in the future. | | 5/12/2016 5:09 PM |
| Terminations | Termination Date | Update | | 1/1/2016 12:00:00 AM | | 5/12/2016 5:09 PM |
| Terminations | Termination Effective Date | Update | | 10/1/2015 12:00:00 AM | | 5/12/2016 5:09 PM |
| Terminations | Termination Reason | Update | | Site closure | | 5/12/2016 5:09 PM |
| Details | Comments Public | Insert | | | 5/12/16 Participated 10/1/15 until terminated 1/1/16, reinstated effective 7/1/16 | 5/12/2016 5:09 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 10/1/2015 12:00:00 AM | 12/3/2015 11:51 AM |
| Details | State | Update | | Active | Terminated | 12/3/2015 11:51 AM |
| Terminations | Termination Comments | Update | | | St. Elizabeth Healthcare is not ready to fully implement the Program and we intend to re-enroll in the future. | 12/3/2015 11:51 AM |
| Terminations | Termination Date | Update | | | 1/1/2016 12:00:00 AM | 12/3/2015 11:51 AM |
| Terminations | Termination Effective Date | Update | | | 10/1/2015 12:00:00 AM | 12/3/2015 11:51 AM |
| Terminations | Termination Reason | Update | | | Site closure | 12/3/2015 11:51 AM |
| Dates | Participating Approval Date | Update | | | 8/12/2015 12:00:00 AM | 8/12/2015 5:27 PM |
| Details | State | Update | | Pending | Active | 8/12/2015 5:27 PM |
| Dates | Start Date | Update | | | 10/1/2015 12:00:00 AM | 8/12/2015 5:27 PM |
| Details | Entity Subname | Update | | St. Elizabeth Healthcare Cardiac Diagnostics - Medical Village | Cardiac Diagnostics - Medical Village | 8/4/2015 11:25 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_53440 | DSH180035B | 8/4/2015 9:45 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_53440 | 7/13/2015 4:39 PM |
| Details | Last Recertification Date | Insert | | | | 7/13/2015 4:39 PM |
| Details | Grant Number | Insert | | | | 7/13/2015 4:39 PM |
| Details | 340B ID | Insert | | | | 7/13/2015 4:39 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/13/2015 4:39 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/13/2015 4:39 PM |
| Details | Medicare Provider Number | Insert | | | 180035 | 7/13/2015 4:39 PM |
| Details | Entity Name | Insert | | | ST ELIZABETH HEALTHCARE | 7/13/2015 4:39 PM |
| Details | Program Code | Insert | | | DSH | 7/13/2015 4:39 PM |
| Details | Entity Subname | Insert | | | St. Elizabeth Healthcare Cardiac Diagnostics - Medical Village | 7/13/2015 4:39 PM |
| Dates | Participating Approval Date | Insert | | | | 7/13/2015 4:39 PM |
| Details | State | Insert | | | Pending | 7/13/2015 4:39 PM |
| Dates | Registration Date | Insert | | | 7/13/2015 12:00:00 AM | 7/13/2015 4:39 PM |
| Dates | Signed By Date | Insert | | | 7/13/2015 12:00:00 AM | 7/13/2015 4:39 PM |
| Dates | Start Date | Insert | | | | 7/13/2015 4:39 PM |
| Terminations | Termination Comments | Insert | | | | 7/13/2015 4:39 PM |
| Terminations | Termination Date | Insert | | | | 7/13/2015 4:39 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/13/2015 4:39 PM |
| Terminations | Termination Reason | Insert | | | | 7/13/2015 4:39 PM |