| Contacts | Authorizing Official | Update | Change Request | McRoberts, Kevin Glen
CEO
Lake Regional Health System
5734808756 | Littleton, Paula
CFO
Lake Regional Health System
5733488388 | 10/2/2024 7:24 AM |
| Contacts | Primary Contact | Update | PC Change Request | Dow, Michael
Director of Ancillary Services
Lake Regional.com
5733488190 | Kauten, Tony
Pharmacy Manager
Lake Regional Health System
5733488763 | 8/27/2024 9:32 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2023 12:41:12 PM | 8/13/2024 3:06:55 PM | 8/13/2024 3:06 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Zeisel, Henry
Executive Vice President Finance/CFO
Lake Regional Health System
5733488388 | McRoberts, Kevin Glen
CEO
Lake Regional Health System
5734808756 | 10/17/2023 8:20 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2022 11:04:13 AM | 8/23/2023 12:41:12 PM | 8/23/2023 12:41 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2021 8:27:15 AM | 9/6/2022 11:04:13 AM | 9/6/2022 11:04 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2020 5:27:49 PM | 9/8/2021 8:27:15 AM | 9/8/2021 8:27 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1437440856 | 9/9/2020 5:27 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MO | 9/9/2020 5:27 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2019 3:10:44 PM | 9/9/2020 5:27:49 PM | 9/9/2020 5:27 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Halsell, David W.
CFO
Lake Regional Health System
5733488388 | Zeisel, Henry
Executive Vice President Finance/CFO
Lake Regional Health System
5733488388 | 9/8/2020 8:20 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Dow, Michael
Director of Pharmacy
Lake Regional.com
5733488190 | Dow, Michael
Director of Ancillary Services
Lake Regional.com
5733488190 | 10/2/2019 2:01 PM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2018 8:49:50 AM | 8/21/2019 3:10:44 PM | 8/21/2019 3:10 PM |
| Details | Last Recertification Date | Update | Recertification | 11/8/2017 8:23:23 AM | 8/15/2018 8:49:50 AM | 8/15/2018 8:49 AM |
| Details | Last Recertification Date | Update | Recertification | 10/25/2017 8:58:47 AM | 11/8/2017 8:23:23 AM | 11/8/2017 8:23 AM |
| Details | Entity Name | Update | Recertification | LAKE REGIONAL HEALTH SYSTEM | Lake Regional Health System | 10/25/2017 9:39 AM |
| Contacts | Primary Contact | Insert | Recertification | | Dow, Michael
Director of Pharmacy
Lake Regional.com
5733488190 | 10/25/2017 8:58 AM |
| Details | Last Recertification Date | Update | Recertification | | 10/25/2017 8:58:47 AM | 10/25/2017 8:58 AM |
| Contacts | Authorizing Official | Update | | Halsell, David W.
CFO
5733488388 | Halsell, David W.
CFO
Lake Regional Health System
5733488388 | 10/2/2017 10:56 AM |
| Contacts | Signed By | Update | | Halsell, David W.
CFO
5733488388 | Halsell, David W.
CFO
Lake Regional Health System
5733488388 | 10/2/2017 10:56 AM |
| Contacts | Authorizing Official | Insert | | | Halsell, David W.
CFO
5733488388 | 4/7/2017 11:09 AM |
| Contacts | Signed By | Insert | | | Halsell, David W.
CFO
5733488388 | 4/7/2017 11:09 AM |
| Addresses | Main Address | Insert | | |
1930-A N BUSINESS ROUTE 5
CAMDENTON WINDSOR ESTATES
CAMDENTON, MO 65020 | 4/7/2017 11:09 AM |
| Details | State | Update | | Terminated | Active | 12/15/2016 6:52 PM |
| Terminations | Termination Comments | Update | | Registration of entity as a new entity of SCH was approved. | | 12/15/2016 6:52 PM |
| Terminations | Termination Date | Update | | 1/1/2017 12:00:00 AM | | 12/15/2016 6:52 PM |
| Terminations | Termination Effective Date | Update | | 1/1/2017 12:00:00 AM | | 12/15/2016 6:52 PM |
| Terminations | Termination Reason | Update | | Change of covered entity type | | 12/15/2016 6:52 PM |
| Details | State | Update | | Active | Terminated | 12/15/2016 6:44 PM |
| Terminations | Termination Comments | Update | | | Registration of entity as a new entity of SCH was approved. | 12/15/2016 6:44 PM |
| Terminations | Termination Date | Update | | | 1/1/2017 12:00:00 AM | 12/15/2016 6:44 PM |
| Terminations | Termination Effective Date | Update | | | 1/1/2017 12:00:00 AM | 12/15/2016 6:44 PM |
| Terminations | Termination Reason | Update | | | Change of covered entity type | 12/15/2016 6:44 PM |
| Dates | Participating Approval Date | Update | | | 12/15/2016 12:00:00 AM | 12/15/2016 6:21 PM |
| Details | State | Update | | Pending | Active | 12/15/2016 6:21 PM |
| Dates | Start Date | Update | | | 1/1/2017 12:00:00 AM | 12/15/2016 6:21 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_72387 | SCH260186-06 | 11/4/2016 9:45 AM |
| Details | Entity Subname | Update | | LAKE REGIONAL HEALTH SYSTEM | Lake Regional Clinic-Camdenton | 11/4/2016 9:45 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_72387 | 10/4/2016 3:47 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/4/2016 3:47 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 010671600 | 10/4/2016 3:47 PM |
| Medicaid Billing | Medicaid: State | Insert | | | MO | 10/4/2016 3:47 PM |
| Details | Last Recertification Date | Insert | | | | 10/4/2016 3:47 PM |
| Details | Grant Number | Insert | | | | 10/4/2016 3:47 PM |
| Details | 340B ID | Insert | | | | 10/4/2016 3:47 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/4/2016 3:47 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/4/2016 3:47 PM |
| Details | Medicare Provider Number | Insert | | | 260186 | 10/4/2016 3:47 PM |
| Details | Entity Name | Insert | | | LAKE REGIONAL HEALTH SYSTEM | 10/4/2016 3:47 PM |
| Details | Program Code | Insert | | | SCH | 10/4/2016 3:47 PM |
| Details | Entity Subname | Insert | | | LAKE REGIONAL HEALTH SYSTEM | 10/4/2016 3:47 PM |
| Dates | Participating Approval Date | Insert | | | | 10/4/2016 3:47 PM |
| Details | State | Insert | | | Pending | 10/4/2016 3:47 PM |
| Dates | Registration Date | Insert | | | 10/4/2016 12:00:00 AM | 10/4/2016 3:47 PM |
| Dates | Signed By Date | Insert | | | 10/4/2016 12:00:00 AM | 10/4/2016 3:47 PM |
| Dates | Start Date | Insert | | | | 10/4/2016 3:47 PM |
| Terminations | Termination Comments | Insert | | | | 10/4/2016 3:47 PM |
| Terminations | Termination Date | Insert | | | | 10/4/2016 3:47 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/4/2016 3:47 PM |
| Terminations | Termination Reason | Insert | | | | 10/4/2016 3:47 PM |