| Contacts | Authorizing Official | Update | Profile Change Request | Riley, Kevin
CFO
Firelands Regional Medical Center
4195577792 | Riley, Kevin
CFO
Firelands Regional Medical Center
4195577797 | 9/9/2024 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2023 11:09:11 AM | 8/27/2024 3:46:43 PM | 8/27/2024 3:46 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Horsfall II, Joseph T.
Pharmacy Director
Firelands Regional Medical Center
4195576942 | Posendek, Keith
Pharmacy Director
Firelands Regional Medical Center
4195576942 | 6/13/2024 2:18 PM |
| Contacts | Primary Contact | Update | PC Change Request | Turner, Scott
340B Compliance Analyst
Firelands Regional Medical Center
4195575038 | Horsfall II, Joseph T.
Pharmacy Director
Firelands Regional Medical Center
4195576942 | 2/20/2024 7:39 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2022 10:35:26 AM | 8/25/2023 11:09:11 AM | 8/25/2023 11:09 AM |
| Contacts | Authorizing Official | Update | Change Request | moore, Robert M
vice president
Firelands Regional Medical Center
4195575510 | Riley, Kevin
CFO
Firelands Regional Medical Center
4195577792 | 12/29/2022 12:21 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2021 11:09:22 AM | 9/1/2022 10:35:26 AM | 9/1/2022 10:35 AM |
| Contacts | Primary Contact | Update | PC Change Request | Waller, David
Director, Pharmacy Services
Firelands Regional Medical Center
4195576942 | Turner, Scott
340B Compliance Analyst
Firelands Regional Medical Center
4195575038 | 6/28/2022 11:00 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Moncher, Daniel J.
Executive Vice President & CFO
Firelands Regional Medical Center
4195577793 | moore, Robert M
vice president
Firelands Regional Medical Center
4195575510 | 2/22/2022 9:18 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2020 9:54:20 AM | 9/7/2021 11:09:22 AM | 9/7/2021 11:09 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2019 9:56:07 AM | 8/18/2020 9:54:20 AM | 8/18/2020 9:54 AM |
| Medicaid Billing | NPI: State | Update | Change Request | | OH | 8/16/2020 7:33 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/19/2020 1:59 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 3016828 | 7/19/2020 1:59 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OH | 7/19/2020 1:59 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 10:49:56 AM | 8/20/2019 9:56:07 AM | 8/20/2019 9:56 AM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 10:18:27 AM | 8/16/2018 10:49:56 AM | 8/16/2018 10:49 AM |
| Contacts | Primary Contact | Insert | Recertification | | Waller, David
Director, Pharmacy Services
Firelands Regional Medical Center
4195576942 | 11/3/2017 10:18 AM |
| Details | Last Recertification Date | Update | Recertification | | 11/3/2017 10:18:27 AM | 11/3/2017 10:18 AM |
| Contacts | Authorizing Official | Update | | Moncher, Daniel J.
Executive Vice President & CFO
4195577793 | Moncher, Daniel J.
Executive Vice President & CFO
Firelands Regional Medical Center
4195577793 | 9/19/2017 10:30 AM |
| Contacts | Signed By | Update | | Moncher, Daniel J.
Executive Vice President & CFO
4195577793 | Moncher, Daniel J.
Executive Vice President & CFO
Firelands Regional Medical Center
4195577793 | 9/19/2017 10:30 AM |
| Contacts | Authorizing Official | Insert | | | Moncher, Daniel J.
Executive Vice President & CFO
4195577793 | 3/23/2017 7:53 AM |
| Contacts | Signed By | Insert | | | Moncher, Daniel J.
Executive Vice President & CFO
4195577793 | 3/23/2017 7:53 AM |
| Addresses | Main Address | Insert | | |
290 Progress Drive
Suite A
Bellevue, OH 44811 | 11/1/2016 11:01 AM |
| Dates | Participating Approval Date | Update | | | 11/1/2016 12:00:00 AM | 11/1/2016 10:58 AM |
| Details | State | Update | | Pending | Active | 11/1/2016 10:58 AM |
| Dates | Start Date | Update | | | 1/1/2017 12:00:00 AM | 11/1/2016 10:58 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_72628 | DSH360025G | 10/18/2016 1:07 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_72628 | 10/7/2016 10:42 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/7/2016 10:42 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 3293725 | 10/7/2016 10:42 AM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 10/7/2016 10:42 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1376780379 | 10/7/2016 10:42 AM |
| Details | Last Recertification Date | Insert | | | | 10/7/2016 10:42 AM |
| Details | Grant Number | Insert | | | | 10/7/2016 10:42 AM |
| Details | 340B ID | Insert | | | | 10/7/2016 10:42 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/7/2016 10:42 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/7/2016 10:42 AM |
| Details | Medicare Provider Number | Insert | | | 360025 | 10/7/2016 10:42 AM |
| Details | Entity Name | Insert | | | FIRELANDS REGIONAL MEDICAL CENTER | 10/7/2016 10:42 AM |
| Details | Program Code | Insert | | | DSH | 10/7/2016 10:42 AM |
| Details | Entity Subname | Insert | | | Bellevue Dialysis - outpatient | 10/7/2016 10:42 AM |
| Dates | Participating Approval Date | Insert | | | | 10/7/2016 10:42 AM |
| Details | State | Insert | | | Pending | 10/7/2016 10:42 AM |
| Dates | Registration Date | Insert | | | 10/7/2016 12:00:00 AM | 10/7/2016 10:42 AM |
| Dates | Signed By Date | Insert | | | 10/7/2016 12:00:00 AM | 10/7/2016 10:42 AM |
| Dates | Start Date | Insert | | | | 10/7/2016 10:42 AM |
| Terminations | Termination Comments | Insert | | | | 10/7/2016 10:42 AM |
| Terminations | Termination Date | Insert | | | | 10/7/2016 10:42 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/7/2016 10:42 AM |
| Terminations | Termination Reason | Insert | | | | 10/7/2016 10:42 AM |