| Medicaid Billing | Medicaid: Number | Delete | Change Request | 05-0761 (CA) | | 2/17/2025 3:18 PM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2023 5:02:31 PM | 8/16/2024 6:03:55 PM | 8/16/2024 6:03 PM |
| Details | Entity Name | Update | Recertification | PROVIDENCE CEDARS SINAI TARZANA MEDICAL CENTER | TARZANA MEDICAL CENTER LLC DBA PROVIDENCE CEDARS SINAI TARZANA MEDICAL CENTER | 8/31/2023 8:07 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 2:41:02 PM | 8/28/2023 5:02:31 PM | 8/28/2023 5:02 PM |
| Contacts | Primary Contact | Update | Change Request | Boghossian, Goorgen
Director of Pharmacy
Providence Cedars-Sinai Tarzana Medical Center
8187085413 | Boghossian, Goorgen
Director of Pharmacy
Providence Cedars Sinai Tarzana Medical Center
8187085413 | 1/13/2023 11:12 AM |
| Addresses | Main Address | Update | Change Request |
18411 CLARK ST 301
TARZANA, CA 91356-3547 |
5411 Etiwanda Ave., Suite 100
TARZANA, CA 91356-3547 | 1/11/2023 6:49 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Hanly, Jessica Marie
Chief Financial Officer
Providence Cedars Tarzana Medical Center
8184014195 | Trimble, Jessica Marie
Chief Financial Officer
Providence Cedars Tarzana Medical Center
8184014195 | 1/11/2023 6:44 AM |
| Contacts | Authorizing Official | Update | Change Request | Lymberopoulos, Nick
Chief Operating Officer
Providence Tarzana Medical Center
8187085151 | Hanly, Jessica Marie
Chief Financial Officer
Providence Cedars Tarzana Medical Center
8184014195 | 12/14/2022 11:56 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2021 5:43:33 PM | 8/30/2022 2:41:02 PM | 8/30/2022 2:41 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2020 6:27:35 PM | 9/1/2021 5:43:33 PM | 9/1/2021 5:43 PM |
| Contacts | Primary Contact | Update | Change Request | Boghossian, Goorgen
Director of Pharmacy
Providence Tarzana Medical Center
8187085413 | Boghossian, Goorgen
Director of Pharmacy
Providence Cedars-Sinai Tarzana Medical Center
8187085413 | 4/29/2021 6:52 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/24/2020 6:27 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2019 9:36:28 AM | 8/24/2020 6:27:35 PM | 8/24/2020 6:27 PM |
| Details | Entity Name | Update | Change Request | PROVIDENCE TARZANA MEDICAL CENTER | PROVIDENCE CEDARS SINAI TARZANA MEDICAL CENTER | 3/26/2020 1:20 PM |
| Addresses | Billing Address | Insert | Recertification | | Providence Tarzana Medical Center
PO BOX 696430
San Antonio, TX 78269 | 9/8/2019 9:36 AM |
| Addresses | Shipping Address | Insert | Recertification | | Providence Tarzana Medical Center
18321 Clark Street
Tarzana, CA 91356 | 9/8/2019 9:36 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2018 4:50:03 PM | 9/8/2019 9:36:28 AM | 9/8/2019 9:36 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Lymberopoulos, Nick
Chief Operating Officer
Providence Tarzana Medical Center
8187085452 | Lymberopoulos, Nick
Chief Operating Officer
Providence Tarzana Medical Center
8187085151 | 9/5/2019 5:26 PM |
| Contacts | Authorizing Official | Update | Change Request | Surowitz, Dale
CEO
Providence Tarzana Medical Center
8187085143 | Lymberopoulos, Nick
Chief Operating Officer
Providence Tarzana Medical Center
8187085452 | 1/15/2019 3:15 PM |
| Details | Last Recertification Date | Update | Recertification | 11/17/2017 2:09:02 PM | 9/5/2018 4:50:03 PM | 9/5/2018 4:50 PM |
| Details | Last Recertification Date | Update | Recertification | | 11/17/2017 2:09:02 PM | 11/17/2017 2:09 PM |
| Contacts | Primary Contact | Update | Recertification | Boghossian, Goorgen
Director of Pharmacy
8187085413 | Boghossian, Goorgen
Director of Pharmacy
Providence Tarzana Medical Center
8187085413 | 11/17/2017 2:07 PM |
| Contacts | Authorizing Official | Update | | Surowitz, Dale
CEO
8187085143 | Surowitz, Dale
CEO
Providence Tarzana Medical Center
8187085143 | 11/17/2017 1:59 PM |
| Contacts | Signed By | Update | | Wang, Ted
CFO
3103036114 | Wang, Ted
CFO
LCM Torrance and San Pedro
3103036114 | 10/9/2017 5:15 PM |
| Contacts | Signed By | Insert | | | Wang, Ted
CFO
3103036114 | 8/11/2017 5:12 PM |
| Contacts | Primary Contact | Insert | | | Boghossian, Goorgen
Director of Pharmacy
8187085413 | 6/15/2017 10:53 AM |
| Contacts | Authorizing Official | Insert | | | Surowitz, Dale
CEO
8187085143 | 6/15/2017 10:53 AM |
| Addresses | Main Address | Insert | | |
18411 CLARK ST 301
TARZANA, CA 91356-3547 | 6/15/2017 10:52 AM |
| Dates | Participating Approval Date | Update | | | 11/7/2016 12:00:00 AM | 11/7/2016 1:02 PM |
| Details | State | Update | | Pending | Active | 11/7/2016 1:02 PM |
| Dates | Start Date | Update | | | 1/1/2017 12:00:00 AM | 11/7/2016 1:02 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_73139 | DSH050761A | 11/4/2016 2:40 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_73139 | 10/13/2016 6:07 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/13/2016 6:07 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 05-0761 | 10/13/2016 6:07 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 10/13/2016 6:07 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1821250762 | 10/13/2016 6:07 PM |
| Details | Last Recertification Date | Insert | | | | 10/13/2016 6:07 PM |
| Details | Grant Number | Insert | | | | 10/13/2016 6:07 PM |
| Details | 340B ID | Insert | | | | 10/13/2016 6:07 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/13/2016 6:07 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/13/2016 6:07 PM |
| Details | Medicare Provider Number | Insert | | | 050761 | 10/13/2016 6:07 PM |
| Details | Entity Name | Insert | | | PROVIDENCE TARZANA MEDICAL CENTER | 10/13/2016 6:07 PM |
| Details | Program Code | Insert | | | DSH | 10/13/2016 6:07 PM |
| Details | Entity Subname | Insert | | | PROVIDENCE TARZANA WOUND CENTER | 10/13/2016 6:07 PM |
| Dates | Participating Approval Date | Insert | | | | 10/13/2016 6:07 PM |
| Details | State | Insert | | | Pending | 10/13/2016 6:07 PM |
| Dates | Registration Date | Insert | | | 10/13/2016 12:00:00 AM | 10/13/2016 6:07 PM |
| Dates | Signed By Date | Insert | | | 10/13/2016 12:00:00 AM | 10/13/2016 6:07 PM |
| Dates | Start Date | Insert | | | | 10/13/2016 6:07 PM |
| Terminations | Termination Comments | Insert | | | | 10/13/2016 6:07 PM |
| Terminations | Termination Date | Insert | | | | 10/13/2016 6:07 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/13/2016 6:07 PM |
| Terminations | Termination Reason | Insert | | | | 10/13/2016 6:07 PM |