Covered Entity Details

DSH040114P BAPTIST HEALTH MEDICAL CENTER - LR (Active) - information as of 5/25/2025 1:09:55 AM

Main Details

Name

BAPTIST HEALTH MEDICAL CENTER - LR

Subdivision Name

BAPTIST HEALTH / Outpatient Imaging Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH040114P

Medicare Provider Number

040114

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/7/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/4/2016

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Baptist Health
Brent Beaulieu, CFO
(501) 202-2017

Primary Contact

Baptist Health
Stefanie Jaeger, Sr. Reimbursement Specialist
(501) 202-1813

Addresses

Street Address

9101 KANIS RD
Suite 100
LITTLE ROCK, AR 72205-6454

Billing Address

Baptist Health Medical Center - Little Rock
9601 Baptist Health Drive
Little Rock, AR 72205

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
AR	104304105	1043240682

Shipping Addresses

Shipping Address 1

Baptist Health Medical Center - Little Rock
9601 Baptist Health Drive
Little Rock, AR 72205

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
DSH040114A	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Sleep Disorder Center	9500 Kanis Road	Little Rock	AR	Active
DSH040114B	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Breast Center	9500 Kanis Road	Little Rock	AR	Active
DSH040114C	Child	DSH	Baptist Health Medical Center - Little Rock	Kidney Transplant	9500 Kanis Road	Little Rock	AR	Terminated
DSH040114D	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Heart Transplant	9500 Kanis Road	Little Rock	AR	Active
DSH040114E	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Eye Center	9800 Baptist Health Drive	Little Rock	AR	Active
DSH040114G	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Arkansas Cardiology Clinic	9501 Baptist Health Drive Suite 600	Little Rock	AR	Active
DSH040114J	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Infusion Therapy	9600 Baptist Health Drive Suite 330	Little Rock	AR	Terminated
DSH040114K	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	MRI	9500 Kanis Road	Little Rock	AR	Active
DSH040114L	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Vein Center	9501 Baptist Health Drive Suite 830	Little Rock	AR	Terminated
DSH040114M	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Pediatric Afterhour Clinic	9601 Baptist Health Drive	Little Rock	AR	Terminated
DSH040114N	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	VAD	9500 Kanis Road	Little Rock	AR	Active
DSH040114P	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BAPTIST HEALTH / Outpatient Imaging Center	9101 KANIS RD	LITTLE ROCK	AR	Active
DSH040114Q	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Heart Inst-Valve Clinic	9500 Kanis Road	Little Rock	AR	Terminated
DSH040114R	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Employee Clinic	9600 Baptist Health Drive	Little Rock	AR	Active
DSH040114S	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Gastroenterology Center - BH Gastroenterology Center	9501 Baptist Health Drive	Little Rock	AR	Active
DSH040114T	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Heart Failure Clinic - Heart Failure Clinic	9500 Kanis Road	Little Rock	AR	Active
DSH040114U	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	LR INFUSION THERAPY - LR INFUSION THERAPY	9500 Kanis Road	Little Rock	AR	Active
DSH040114V	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Oncology Clinic - Oncology Clinic	9500 Kanis Road	Little Rock	AR	Active
DSH040114W	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Neurology Clinic - Neurology Clinic	9600 Baptist Health Drive	Little Rock	AR	Active
DSH040114X	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Gastroenterology Clinic - Gastroenterology Clinic	9501 Baptist Health Drive	Little Rock	AR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Recertification	9101 KANIS RD 100 BAPTIST HEALTH IMAGING CENTER - LR LITTLE ROCK, AR 72205-6454	9101 KANIS RD Suite 100 LITTLE ROCK, AR 72205-6454	9/3/2024 7:07 PM
Details	Last Recertification Date	Update	Recertification	9/13/2023 11:26:15 AM	9/3/2024 7:07:13 PM	9/3/2024 7:07 PM
Details	Last Recertification Date	Update	Recertification	9/12/2022 12:29:17 PM	9/13/2023 11:26:15 AM	9/13/2023 11:26 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 4:42:26 PM	9/12/2022 12:29:17 PM	9/12/2022 12:29 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 4:18:26 PM	9/3/2021 4:42:26 PM	9/3/2021 4:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		104304105	9/14/2020 4:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AR	9/14/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	104304105 (AR)		9/14/2020 4:18 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043240682 ( )		9/14/2020 4:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043240682	9/14/2020 4:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/14/2020 4:18 PM
Details	Last Recertification Date	Update	Recertification	9/16/2019 11:57:53 AM	9/14/2020 4:18:26 PM	9/14/2020 4:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1043240682	9/16/2019 11:57 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 9:40:20 AM	9/16/2019 11:57:53 AM	9/16/2019 11:57 AM
Contacts	Authorizing Official	Update	Profile Change Request	Beaulieu, Brent VP of Finance Baptist Health 5012022017	Beaulieu, Brent CFO Baptist Health 5012022017	4/5/2019 3:34 PM
Contacts	Signed By	Update	Profile Change Request	Beaulieu, Brent VP of Finance Baptist Health 5012022017	Beaulieu, Brent CFO Baptist Health 5012022017	4/5/2019 3:34 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 4:23:19 PM	8/31/2018 9:40:20 AM	8/31/2018 9:40 AM
Details	Last Recertification Date	Update	Recertification		11/29/2017 4:23:19 PM	11/29/2017 4:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/27/2017 4:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		104304105	9/27/2017 4:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	9/27/2017 4:35 PM
Contacts	Primary Contact	Update	Change Request	Cobb, David Pharmacy Director 5012022126	Jaeger, Stefanie Sr. Reimbursement Specialist Baptist Health 5012021813	9/26/2017 6:33 PM
Contacts	Authorizing Official	Update		Beaulieu, Brent VP of Finance 5012022017	Beaulieu, Brent VP of Finance Baptist Health 5012022017	9/26/2017 5:56 PM
Contacts	Signed By	Update		Beaulieu, Brent VP of Finance 5012022017	Beaulieu, Brent VP of Finance Baptist Health 5012022017	9/26/2017 5:56 PM
Contacts	Authorizing Official	Insert			Beaulieu, Brent VP of Finance 5012022017	7/26/2017 12:26 PM
Contacts	Signed By	Insert			Beaulieu, Brent VP of Finance 5012022017	7/26/2017 12:26 PM
Addresses	Main Address	Insert			9101 KANIS RD 100 BAPTIST HEALTH IMAGING CENTER - LR LITTLE ROCK, AR 72205-6454	7/13/2017 1:38 PM
Addresses	Billing Address	Insert			Baptist Health Medical Center - Little Rock 9601 Baptist Health Drive Little Rock, AR 72205	7/13/2017 1:38 PM
Addresses	Shipping Address	Insert			Baptist Health Medical Center - Little Rock 9601 Baptist Health Drive Little Rock, AR 72205	7/13/2017 1:38 PM
Contacts	Primary Contact	Insert			Cobb, David Pharmacy Director 5012022126	7/13/2017 1:38 PM
Dates	Participating Approval Date	Update			11/4/2016 12:00:00 AM	11/4/2016 1:15 PM
Details	State	Update		Pending	Active	11/4/2016 1:15 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/4/2016 1:15 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_72705	DSH040114P	11/4/2016 11:11 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_72705	10/7/2016 5:13 PM
Details	Last Recertification Date	Insert				10/7/2016 5:13 PM
Details	Grant Number	Insert				10/7/2016 5:13 PM
Details	340B ID	Insert				10/7/2016 5:13 PM
Details	Is Authorizing Official EHB Data	Insert				10/7/2016 5:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/7/2016 5:13 PM
Details	Medicare Provider Number	Insert			040114	10/7/2016 5:13 PM
Details	Entity Name	Insert			BAPTIST HEALTH MEDICAL CENTER - LR	10/7/2016 5:13 PM
Details	Program Code	Insert			DSH	10/7/2016 5:13 PM
Details	Entity Subname	Insert			BAPTIST HEALTH / Outpatient Imaging Center	10/7/2016 5:13 PM
Dates	Participating Approval Date	Insert				10/7/2016 5:13 PM
Details	State	Insert			Pending	10/7/2016 5:13 PM
Dates	Registration Date	Insert			10/7/2016 12:00:00 AM	10/7/2016 5:13 PM
Dates	Signed By Date	Insert			10/7/2016 12:00:00 AM	10/7/2016 5:13 PM
Dates	Start Date	Insert				10/7/2016 5:13 PM
Terminations	Termination Comments	Insert				10/7/2016 5:13 PM
Terminations	Termination Date	Insert				10/7/2016 5:13 PM
Terminations	Termination Effective Date	Insert				10/7/2016 5:13 PM
Terminations	Termination Reason	Insert				10/7/2016 5:13 PM