Covered Entity Details

DSH390174BE THOMAS JEFFERSON UNIVERSITY HOSPITAL (Active) - information as of 4/25/2025 12:01:35 AM

Main Details

Name

THOMAS JEFFERSON UNIVERSITY HOSPITAL

Subdivision Name

HB Clinic / Multiple Sclerosis

Type

Disproportionate Share Hospital

Rural

340B ID

DSH390174BE

Medicare Provider Number

390174

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/4/2016

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Jefferson Health
Walter Wyatt, VP-Finance
(215) 254-3254

Primary Contact

Jefferson Health
Dustin Ottemiller, VP, Finance
(215) 503-5219

Addresses

Street Address

1101 Chestnut Street
10th Floor
Philadelphia, PA 19107-5509

Billing Address
Same as Street Address

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
NJ	4196805	1215916002
DE	0000066505	1215916002
PA	1007508540018	1215916002

Shipping Addresses

Shipping Address 1

HB Clinic / Multiple Sclerosis
1101 Chestnut Street
10th Floor
Philadelphia, PA 19107

Shipping Address 2

Thomas Jefferson University Hospital Pharmacy
111 South 11th St
Suite 2290
Philadelphia, PA 19107

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
DSH390174A	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	METHODIST HOSPITAL DIVISION, TJUH	2301 SOUTH BROAD STREET	PHILADELPHIA	PA	Terminated
DSH390174AA	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Mammography	2301 South Broad Street	Philadelphia	PA	Active
DSH390174AB	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Radiology - Special Studies	2301 South Broad Street	Philadelphia	PA	Active
DSH390174AC	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Anesthesia	2301 South Broad Street	Philadelphia	PA	Active
DSH390174AD	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Recovery Room	2301 South Broad Street	Philadelphia	PA	Active
DSH390174AE	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Operating Room	2301 South Broad Street	Philadelphia	PA	Active
DSH390174AF	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Urodynamics	2301 South Broad Street	Philadelphia	PA	Terminated
DSH390174AG	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Emergency Room	900 Walnut Street	Philadelphia	PA	Active
DSH390174AH	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Radiology - MRI	900 Walnut Street	Philadelphia	PA	Active
DSH390174AJ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Radiology - CT	900 Walnut Street	Philadelphia	PA	Active
DSH390174AK	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Brain Tumor Center	900 Walnut Street	Philadelphia	PA	Active
DSH390174AL	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Gamma Knife Suite	900 Walnut Street	Philadelphia	PA	Active
DSH390174AM	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Interventional Radiology	900 Walnut Street	Philadelphia	PA	Active
DSH390174AN	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Radiology	900 Walnut Street	Philadelphia	PA	Active
DSH390174AP	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Anesthesia	900 Walnut Street	Philadelphia	PA	Active
DSH390174AQ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Recovery Room	900 Walnut Street	Philadelphia	PA	Active
DSH390174AR	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Operating Room	900 Walnut Street	Philadelphia	PA	Active
DSH390174AS	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	THOMAS JEFFERSON UNIVERSITY HOSPITALS O/P Ultrasound	909 WALNUT STREET	PHILADELPHIA	PA	Active
DSH390174AT	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Pulmonary Function Lab	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174AU	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Mammography- Breast Imaging / Mammography	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174AV	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	CLINICAL OFFICE BUILDING / ALS Clinic	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174AW	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Medical Oncology MHD	1300 Wolf Street	Philadelphia	PA	Active
DSH390174AX	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / GI/Hepatology MHD	1300 Wolf Street	Philadelphia	PA	Active
DSH390174AY	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Internal Med. JIMA	33 South 9th Street	Philadelphia	PA	Active
DSH390174AZ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Endocrinology	211 South 9th Street	Philadelphia	PA	Active
DSH390174B	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Hospital Ambulatory Practice	33 South 9th Street	Philadelphia	PA	Active
DSH390174BA	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Rheumatology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BB	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Neuroscience	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BC	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Neurology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BD	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Headache	900 Walnut St	Philadelphia	PA	Active
DSH390174BE	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Multiple Sclerosis	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BF	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Family Medicine	33 South 9th Street	Philadelphia	PA	Active
DSH390174BG	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic / Medical Oncology CC	1101 Chestnut St	Philadelphia	PA	Active
DSH390174BH	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jeff Fit Rehab	2144 Cecil B. Moore Ave	Philadelphia	PA	Active
DSH390174BJ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jeff Comprehensive Concussion Center	4050 South 26th Street	philadelphia	PA	Active
DSH390174BK	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic- Cardiology CC - Cardiology	925 Chestnut Street	Philadelphia	PA	Active
DSH390174BL	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic- Urology CC - Urology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BM	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic- Nephrology CC - Nephrology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BN	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic- Pulmonary CC - Pulmonary	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BP	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic- OBGYN CC - OBGYN	833 Chestnut Street	Philadelphia	PA	Active
DSH390174BQ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic-Internal Med Brd - Internal Medicine	2301 S Broad St, Suite 205	Philadelphia	PA	Active
DSH390174BR	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Cardio Pulmonary - MHD Cardio Pulmonary	2301 South Broad Street	Philadelphia	PA	Active
DSH390174BS	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	TJUH Echocardiography - Echocardiology Walnut Towers	900 Walnut Street	Philadelphia	PA	Active
DSH390174BT	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Radiology - JHN Neuro Non-Invasive Lab	900 Walnut Street	Philadelphia	PA	Active
DSH390174BU	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Ultrasound - MHD Ultrasound	2301 South Broad Street	Philadelphia	PA	Active
DSH390174BV	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Hemodialysis - MHD Hemodialysis	2301 South Broad Street	Philadelphia	PA	Active
DSH390174BW	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Hematology - Hematology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BX	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Otolaryngology - Otolaryngology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174BY	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - MHD Endo - Endocrinology	2301 S. Broad Street	Philadelphia	PA	Active
DSH390174BZ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Dermatology - Dermatology	33 South 9th Street	Philadelphia	PA	Active
DSH390174C	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Neurology Infusion Center	900 Walnut Street	Philadelphia	PA	Active
DSH390174CA	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-Pain Management - Pain Management	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CB	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-Internal Med - Internal Medicine	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CC	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-Family Med - Family Medicine	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CD	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-Neurosurgery - Neurosurgery	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CE	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-OB/GYN - OB/GYN	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CF	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-Neurology - Neurology	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CG	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Navy Yard-PM&R - PM&R	3 Crescent Drive	Philadelphia	PA	Active
DSH390174CH	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB - Neurology Meadowbrook - Neurology	3501 Masons Mill Road	Huntingdon Valley	PA	Active
DSH390174CJ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Infusion Center Meadowbrook - Neurology	3501 Masons Mill Rd, Suite 504	Huntingdon Valley	PA	Active
DSH390174CK	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	THOMAS JEFFERSON UNIVERSITY HOSPITA - ACP Physical Therapy	3941 Commerce Avenue	Willow Grove	PA	Active
DSH390174CL	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	TJUH Infusion Center - ACP Cancer Care	3941 Commerce Ave	Willow Grove	PA	Active
DSH390174CM	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	TJUH Asplundh - Interventional Radiology ACP	3941 Commerce Ave	Willow Grove	PA	Active
DSH390174CN	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	TJUH Asplundh - ACP Rehab-Speech Therapy	3941 Commerce Ave	Willow Grove	PA	Active
DSH390174CP	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	THOMAS JEFFERSON UNIVERSITY HOSPITA - Asplundh Oncology Clinic	3941 Commerce Avenue	Willow Grove	PA	Active
DSH390174CQ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Cardio - Cardiology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174CR	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic-Alg 211 - Asthma and Allergy	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174CS	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic-Pul CC - Pulmonary	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174CT	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN SPU - Short Procedure Unit	900 Walnut	Philadelphia	PA	Active
DSH390174CU	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD OP Rehab - PT/OT/Speech	2301 South Broad Street	Philadelphia	PA	Active
DSH390174CV	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Dialysis - Nephrology - Acute Dialysis	900 Walnut	Philadelphia	PA	Active
DSH390174CW	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN Neurodiagnostics - Electrodiagnostic - Emg	900 Walnut	Philadelphia	PA	Active
DSH390174CX	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic - Endo CC - Endocrinology	33 S 9th St	Philadelphia	PA	Active
DSH390174CY	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Honickman Radiology - - X-Ray	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174CZ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Honickman Radiology - - Ultrasound	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174D	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Oncology Infusion Center	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174DA	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Rehab CC - - PT/OT/Speech	25 S 9th St	Philadelphia	PA	Active
DSH390174DB	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Honickman - - General Surgery	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174DC	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Colorectal Surgery	225 E City Ave	Philadelphia	PA	Active
DSH390174DD	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Endocrinology	225 E City Ave	Philadelphia	PA	Active
DSH390174DE	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Weight Management	225 E City Ave	Philadelphia	PA	Active
DSH390174DF	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Cardiology	225 E City Ave	Philadelphia	PA	Active
DSH390174DG	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Rheumatology	225 E City Ave	Philadelphia	PA	Active
DSH390174DH	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Gastroenterology	225 E City Ave	Philadelphia	PA	Active
DSH390174DJ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Internal Medicine	225 E City Ave	Philadelphia	PA	Active
DSH390174DK	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Pulmonary	225 E City Ave	Philadelphia	PA	Active
DSH390174DL	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Bala - - Nephrology	225 E City Ave	Philadelphia	PA	Active
DSH390174DM	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Honickman - Neurodiagnostics - Electrodiagnostic - Emg	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174DN	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Honickman Vas Ctr - - Vascular and Cardiac Surg	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174DP	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic GI/Hep CC - - GI/Hepatology	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174DQ	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	HB Clinic Inf - - Infectious Disease	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174E	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Infusion Center at Methodist	1300 Wolf Street	Philadelphia	PA	Active
DSH390174F	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	JHN EKG	900 Walnut Street	Philadelphia	PA	Active
DSH390174G	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Rheumatology Infusion Center	211 South 9th Street	Philadelphia	PA	Active
DSH390174H	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Vascular Center at Methodist	1300 Wolf Street	Philadelphia	PA	Active
DSH390174J	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	O/P MRI Facility	909 Walnut Street	Philadelphia	PA	Active
DSH390174K	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Radiation Oncology - Riddle Memorial	1078 West Baltimore Pike	Media	PA	Active
DSH390174L	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Jefferson Surgery Center	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174M	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Cardiac Imaging Center	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174N	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Urologic Diagnostic Center	1101 Chestnut Street	Philadelphia	PA	Active
DSH390174P	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	Sickle Cell OBV Unit	833 Chestnut Street	Philadelphia	PA	Terminated
DSH390174Q	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Observation Unit	2301 South Broad Street	Philadelphia	PA	Active
DSH390174R	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Emegency Room	2301 South Broad Street	Philadelphia	PA	Active
DSH390174S	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Short Procedure Unit	2301 South Broad Street	Philadelphia	PA	Active
DSH390174T	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD EEG	2301 South Broad Street	Philadelphia	PA	Active
DSH390174U	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Gastroenterology	2301 South Broad Street	Philadelphia	PA	Active
DSH390174V	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Radiology - MRI	2301 South Broad Street	Philadelphia	PA	Active
DSH390174W	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Radiology - CT	2301 South Broad Street	Philadelphia	PA	Active
DSH390174X	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Nuclear Medicine	2301 South Broad Street	Philadelphia	PA	Active
DSH390174Y	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Radiation Oncology	2301 South Broad Street	Philadelphia	PA	Terminated
DSH390174Z	Child	DSH	THOMAS JEFFERSON UNIVERSITY HOSPITAL	MHD Radiology	2301 South Broad Street	Philadelphia	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Wyatt, Walter VP-Finance Albert Einstein Medical Center 2152543254	Wyatt, Walter VP-Finance Jefferson Health 2152543254	1/30/2025 1:33 PM
Contacts	Authorizing Official	Update	Change Request	Nathans, Andrew Vice president Finance, TJUH Inc. TJUH Inc 2159556599	Wyatt, Walter VP-Finance Albert Einstein Medical Center 2152543254	1/30/2025 11:11 AM
Addresses	Shipping Address	Insert	Change Request		HB Clinic / Multiple Sclerosis 1101 Chestnut Street 10th Floor Philadelphia, PA 19107	1/16/2025 8:19 AM
Addresses	Shipping Address	Insert	Change Request		Thomas Jefferson University Hospital Pharmacy 111 South 11th St Suite 2290 Philadelphia, PA 19107	1/16/2025 8:19 AM
Addresses	Main Address	Update	Change Request	900 Walnut St 2nd Floor Philadelphia, PA 19107-5509	1101 Chestnut Street 10th Floor Philadelphia, PA 19107-5509	1/16/2025 8:19 AM
Contacts	Primary Contact	Update	Recertification	Swift, Brian G. Chief Pharmacy Officer Thomas Jefferson University Hospital 2159556736	Ottemiller, Dustin VP, Finance Jefferson Health 2155035219	9/6/2024 6:56 AM
Details	Last Recertification Date	Update	Recertification	9/10/2023 8:10:15 PM	9/6/2024 6:56:26 AM	9/6/2024 6:56 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 2:44:09 PM	9/10/2023 8:10:15 PM	9/10/2023 8:10 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 10:26:56 AM	9/7/2022 2:44:09 PM	9/7/2022 2:44 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 10:14:20 AM	8/23/2021 10:26:56 AM	8/23/2021 10:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1215916002	8/24/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/24/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1215916002	8/24/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/24/2020 10:14 AM
Medicaid Billing	NPI: State	Update	Recertification		PA	8/24/2020 10:14 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 2:45:07 PM	8/24/2020 10:14:20 AM	8/24/2020 10:14 AM
Contacts	Authorizing Official	Update	AO Change Request	LUBARSKY, NEIL G. SR VP FOR FINANCE Thomas Jefferson Univ Hospital 2159559993	Nathans, Andrew Vice president Finance, TJUH Inc. TJUH Inc 2159556599	3/27/2020 11:17 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 12:38:12 PM	8/26/2019 2:45:07 PM	8/26/2019 2:45 PM
Addresses	Main Address	Update	Change Request	900 WALNUT ST PHILADELPHIA, PA 19107-5509	900 WALNUT ST 2nd Floor PHILADELPHIA, PA 19107-5509	5/22/2019 4:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2018 12:38 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4196805	9/6/2018 12:38 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/6/2018 12:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2018 12:38 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0000066505	9/6/2018 12:38 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/6/2018 12:38 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 1:43:29 PM	9/6/2018 12:38:12 PM	9/6/2018 12:38 PM
Details	Last Recertification Date	Update	Recertification		11/29/2017 1:43:29 PM	11/29/2017 1:43 PM
Contacts	Primary Contact	Insert	Change Request		Swift, Brian G. Chief Pharmacy Officer Thomas Jefferson University Hospital 2159556736	10/23/2017 8:59 PM
Contacts	Authorizing Official	Update		LUBARSKY, NEIL G. SR VP FOR FINANCE 2159559993	LUBARSKY, NEIL G. SR VP FOR FINANCE Thomas Jefferson Univ Hospital 2159559993	10/6/2017 12:27 PM
Contacts	Signed By	Update		LUBARSKY, NEIL G. SR VP FOR FINANCE 2159559993	LUBARSKY, NEIL G. SR VP FOR FINANCE Thomas Jefferson Univ Hospital 2159559993	10/6/2017 12:27 PM
Contacts	Authorizing Official	Insert			LUBARSKY, NEIL G. SR VP FOR FINANCE 2159559993	8/9/2017 1:10 PM
Contacts	Signed By	Insert			LUBARSKY, NEIL G. SR VP FOR FINANCE 2159559993	8/9/2017 1:10 PM
Addresses	Main Address	Insert			900 WALNUT ST PHILADELPHIA, PA 19107-5509	5/11/2017 5:31 PM
Dates	Participating Approval Date	Update			11/4/2016 12:00:00 AM	11/4/2016 6:57 PM
Details	State	Update		Pending	Active	11/4/2016 6:57 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/4/2016 6:57 PM
Details	Entity Subname	Update		/ HB Clinic - Multiple Sclerosis	HB Clinic / Multiple Sclerosis	11/4/2016 6:03 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73224	DSH390174BE	11/1/2016 3:33 PM
Details	Entity Subname	Update		THOMAS JEFFERSON UNIVERSITY HOSPITA / HB Clinic - Multiple Sclerosis	/ HB Clinic - Multiple Sclerosis	11/1/2016 3:33 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73224	10/14/2016 12:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2016 12:19 PM
Medicaid Billing	Medicaid: Number	Insert			1007508540018	10/14/2016 12:19 PM
Medicaid Billing	Medicaid: State	Insert			PA	10/14/2016 12:19 PM
Medicaid Billing	NPI: Number	Insert			1215916002	10/14/2016 12:19 PM
Details	Last Recertification Date	Insert				10/14/2016 12:19 PM
Details	Grant Number	Insert				10/14/2016 12:19 PM
Details	340B ID	Insert				10/14/2016 12:19 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2016 12:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2016 12:19 PM
Details	Medicare Provider Number	Insert			390174	10/14/2016 12:19 PM
Details	Entity Name	Insert			THOMAS JEFFERSON UNIVERSITY HOSPITAL	10/14/2016 12:19 PM
Details	Program Code	Insert			DSH	10/14/2016 12:19 PM
Details	Entity Subname	Insert			THOMAS JEFFERSON UNIVERSITY HOSPITA / HB Clinic - Multiple Sclerosis	10/14/2016 12:19 PM
Dates	Participating Approval Date	Insert				10/14/2016 12:19 PM
Details	State	Insert			Pending	10/14/2016 12:19 PM
Dates	Registration Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 12:19 PM
Dates	Signed By Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 12:19 PM
Dates	Start Date	Insert				10/14/2016 12:19 PM
Terminations	Termination Comments	Insert				10/14/2016 12:19 PM
Terminations	Termination Date	Insert				10/14/2016 12:19 PM
Terminations	Termination Effective Date	Insert				10/14/2016 12:19 PM
Terminations	Termination Reason	Insert				10/14/2016 12:19 PM