Covered Entity Details

DSH330153AV Ellis Hospital (Terminated) - information as of 4/28/2025 1:52:10 AM

Main Details

Name

Ellis Hospital

Subdivision Name

Ellis - McClellan Division - Endocrinology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330153AV

Medicare Provider Number

330153

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/14/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/2/2016

Last Recertification Date

8/19/2021

Termination Date
Termination Reason

7/1/2022
Site closure

Contacts

Authorizing Official

Ellis
Marc Mesick, CFO & VP of Finance
(518) 243-4144

Primary Contact

Ellis Hospital
Monica Quinde, Pharmacy 340B Program Manager
(518) 243-1824

Addresses

Street Address

624 McClellan Street
Schenectady, NY 12304

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
CA	1487644993	1487644993
DE	1487644993,1558547034	1487644993
GA	000188273X	1487644993
MA	110027477B,110027477A	1487644993
MD	335715500	1487644993
ME	1487644993	1487644993
MI	1487644993	1487644993
MN	1487644993	1487644993
NM	1487644993	1487644993
OH	0487718	1487644993
CT	003045606	1487644993
MO	016343402	1487644993
VT	0330153	1487644993
NY	00347562,01207038,03177066	1487644993,1558547034,1760614317
NC		1487644993

Shipping Addresses

Shipping Address 1

Ellis Hospital
600 McClellan Street
Schenectady, NY 12304

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
DSH330153A	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Rheumatology OP	600 McClellan Street	Schenectady	NY	Terminated
DSH330153AA	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Ultrasound	2210 Troy Road	Niskayuna	NY	Terminated
DSH330153AB	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - Mammography	103 Sitterly Road	Clifton Park	NY	Terminated
DSH330153AC	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - CT Scan	103 Sitterly Road	Clifton Park	NY	Active
DSH330153AD	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - MRI	103 Sitterly Road	Clifton Park	NY	Active
DSH330153AE	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - Urgent Care Center	103 Sitterly Road	Clifton Park	NY	Active
DSH330153AF	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - Primary Care	103 Sitterly Road	Clifton Park	NY	Active
DSH330153AG	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park - ENT Clinic	103 Sitterly Road	Clifton Park	NY	Terminated
DSH330153AH	Child	DSH	Ellis Hospital	Ellis-Mclellan Division - ENT Clinic	624 McClellan Street	Schenectady	NY	Terminated
DSH330153AJ	Child	DSH	Ellis Hospital	Ellis-Mclellan Division - Family Health Center	624 Mclellan Street	Schenectady	NY	Active
DSH330153AK	Child	DSH	Ellis Hospital	Ellis - Adolescent Mental Health	1023 State Street	Schenectady	NY	Active
DSH330153AL	Child	DSH	Ellis Hospital	Ellis - Glenville Health Center	115 Saratoga Road, Suite 200	Glenville	NY	Active
DSH330153AM	Child	DSH	Ellis Hospital	Ellis - Ellis Family Practice Associates	1201 Nott Street, Medical Arts Building, Suite 204	Schenectady	NY	Active
DSH330153AN	Child	DSH	Ellis Hospital	Ellis - Bariatric Center	2125 River Road	Niskayuna	NY	Active
DSH330153AP	Child	DSH	Ellis Hospital	Ellis - Mental Health Clinic	1023 State Street	Schenectady	NY	Active
DSH330153AQ	Child	DSH	Ellis Hospital	Ellis / Cardiac Clinic	1201 Nott Street	Schenectady	NY	Active
DSH330153AR	Child	DSH	ELLIS HOSPITAL	Ellis - Medical Center of Clifton Park / Endocrinology Clinic	103 Sitterly Road	Clifton Park	NY	Terminated
DSH330153AS	Child	DSH	Ellis Hospital	Ellis - Medical Center of Clifton Park / Neuro Clinic	103 Sitterly Road	Clifton Park	NY	Terminated
DSH330153AT	Child	DSH	ELLIS HOSPITAL	Ellis / Malta Primary Care	2537 Route 9, Suite 203	Malta	NY	Terminated
DSH330153AU	Child	DSH	ELLIS HOSPITAL	Ellis / Ballston Spa Primary Care	990 State Route 67	Ballston Spa	NY	Terminated
DSH330153AV	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Endocrinology	624 McClellan Street	Schenectady	NY	Terminated
DSH330153AW	Child	DSH	Ellis Hospital	Ellis-McClellan Division - Internal Medicine	624 McClellan Street	Schenectady	NY	Terminated
DSH330153AX	Child	DSH	Ellis Hospital	ELLIS HOSPITAL - NISKAYUNA CAMPUS / Ellis - Bellevue Women's Division - Labor & Delivery	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153AY	Child	DSH	Ellis Hospital	ELLIS HOSPITAL MCCLELLAN STREET CAM - Primary Care Plus - McClellan	600 MCCLELLAN ST	SCHENECTADY	NY	Terminated
DSH330153AZ	Child	DSH	Ellis Hospital	Ellis Hospital - Mohawk Harbor Urgent Care - Urgent Care	200 Harborside Drive	Schenectady	NY	Active
DSH330153B	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Pediatric Clinic	624 McClellan Street	Schenectady	NY	Active
DSH330153BA	Child	DSH	Ellis Hospital	Ellis Hospital - Ellis Dermatology - Dermatology	1201 Nott Street	Schenectady	NY	Terminated
DSH330153BB	Child	DSH	Ellis Hospital	Ellis Hospital - Mohawk Harbor Primary Care - Primary Care	200 Harborside Drive	Schenectady	NY	Active
DSH330153BC	Child	DSH	Ellis Hospital	ELLIS HOSPITAL - NISKAYUNA CAMPUS - Ellis - Bellevue Women's Division - GYN Surgery	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153BD	Child	DSH	Ellis Hospital	Bellevue Women's Division - PACU/Recovery Room	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153BE	Child	DSH	Ellis Hospital	Bellevue Women's Division - Maternal Fetal Medicine	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153BF	Child	DSH	Ellis Hospital	ELLIS HOSPITAL - - Cardiovascular Associates	1201 Nott Street	Schenectady	NY	Active
DSH330153BG	Child	DSH	Ellis Hospital	ELLIS HOSPITAL - - UROLOGY	1201 Nott Street	Schenectady	NY	Active
DSH330153C	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Emergency Department	600 McClellan Street	Schenectady	NY	Terminated
DSH330153D	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Operating Room	600 McClellan Street	Schenectady	NY	Terminated
DSH330153E	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Ambulatory Surgery	600 McClellan Street	Schenectady	NY	Terminated
DSH330153F	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Recovery Room	600 McClellan Street	Schenectady	NY	Terminated
DSH330153G	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Radiology	600 McClellan Street	Schenectady	NY	Terminated
DSH330153H	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Mammo	600 McClellan Street	Schenectady	NY	Terminated
DSH330153J	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Radiation Therapy	600 McClellan Street	Schenectady	NY	Terminated
DSH330153K	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Nuclear Medicine	600 McClellan Street	Schenectady	NY	Terminated
DSH330153L	Child	DSH	Ellis Hospital	Ellis - McClellan Division - CT Scan	600 McClellan Street	Schenectady	NY	Terminated
DSH330153M	Child	DSH	Ellis Hospital	Ellis - McClellan Division - MRI	600 McClellan Street	Schenectady	NY	Terminated
DSH330153N	Child	DSH	Ellis Hospital	Ellis - McClellan Division - IV Therapy	600 McClellan Street	Schenectady	NY	Terminated
DSH330153P	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Physical Therapy	650 McClellan Street	Schenectady	NY	Terminated
DSH330153Q	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Neurology	600 McClellan Street	Schenectady	NY	Terminated
DSH330153R	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Ultrasound	600 McClellan Street	Schenectady	NY	Terminated
DSH330153S	Child	DSH	Ellis Hospital	Ellis - McClellan Division - Diabetic Education	600 McClellan Street	Schenectady	NY	Active
DSH330153T	Child	DSH	Ellis Hospital	Ellis Bellevue Women's Division - Urology Clinic	2210 Troy Road	Niskayuna	NY	Terminated
DSH330153U	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Operating Room	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153V	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Ambulatory Surgery	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153W	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Radiology	2210 Troy Schenectady Road	Niskayuna	NY	Terminated
DSH330153X	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Mammo	2210 Troy Schenectady Road	Niskayuna	NY	Active
DSH330153Y	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Imaging Breast Center	2210 Troy Road	Niskayuna	NY	Terminated
DSH330153Z	Child	DSH	Ellis Hospital	Ellis - Bellevue Women's Division - Imaging Mammo Van	2210 Troy Road	Niskayuna	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/10/2021 12:00:00 AM	4/27/2022 6:41 AM
Details	State	Update	Termination Request	Active	To Be Terminated	4/27/2022 6:41 AM
Terminations	Termination Date	Update	Termination Request		7/1/2022 12:00:00 AM	4/27/2022 6:41 AM
Terminations	Termination Effective Date	Update	Termination Request		11/30/2021 12:00:00 AM	4/27/2022 6:41 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	4/27/2022 6:41 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 12:29:58 PM	8/19/2021 9:31:09 AM	8/19/2021 9:31 AM
Contacts	Primary Contact	Update	Group Change Request	Leach, Ross Director of Reimbursement Ellis Hospital 5186128672	Quinde, Monica Pharmacy 340B Program Manager Ellis Hospital 5182431824	8/4/2021 9:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1558547034	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000188273X	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027477B	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027477A	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		335715500	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0487718	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003045606	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		016343402	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0330153	9/4/2020 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/4/2020 12:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487644993	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 12:29 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 12:29 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 9:22:40 AM	9/4/2020 12:29:58 PM	9/4/2020 12:29 PM
Details	Last Recertification Date	Update	Recertification	8/20/2018 9:41:08 AM	8/20/2019 9:22:40 AM	8/20/2019 9:22 AM
Details	Last Recertification Date	Update	Recertification	12/4/2017 4:23:07 PM	8/20/2018 9:41:08 AM	8/20/2018 9:41 AM
Details	Last Recertification Date	Update	Recertification		12/4/2017 4:23:07 PM	12/4/2017 4:23 PM
Contacts	Authorizing Official	Update		Mesick, Marc CFO & VP of Finance 5182434144	Mesick, Marc CFO & VP of Finance Ellis 5182434144	10/13/2017 5:39 PM
Contacts	Signed By	Update		Mesick, Marc CFO & VP of Finance 5182434144	Mesick, Marc CFO & VP of Finance Ellis 5182434144	10/13/2017 5:39 PM
Contacts	Primary Contact	Update		Leach, Ross Director of Reimbursement 5186128672	Leach, Ross Director of Reimbursement Ellis Hospital 5186128672	9/29/2017 8:27 AM
Addresses	Main Address	Insert			624 McClellan Street Schenectady, NY 12304	7/25/2017 11:21 AM
Addresses	Shipping Address	Insert			Ellis Hospital 600 McClellan Street Schenectady, NY 12304	7/25/2017 11:21 AM
Contacts	Primary Contact	Insert			Leach, Ross Director of Reimbursement 5186128672	7/25/2017 11:21 AM
Contacts	Authorizing Official	Insert			Mesick, Marc CFO & VP of Finance 5182434144	7/25/2017 11:21 AM
Contacts	Signed By	Insert			Mesick, Marc CFO & VP of Finance 5182434144	7/25/2017 11:21 AM
Dates	Participating Approval Date	Update			11/2/2016 12:00:00 AM	11/2/2016 8:08 PM
Details	State	Update		Pending	Active	11/2/2016 8:08 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/2/2016 8:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73281	DSH330153AV	11/2/2016 3:27 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73281	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Number	Insert			00347562	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: State	Insert			NY	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Number	Insert			01207038	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: State	Insert			NY	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: Number	Insert			03177066	10/14/2016 2:23 PM
Medicaid Billing	Medicaid: State	Insert			NY	10/14/2016 2:23 PM
Medicaid Billing	NPI: Number	Insert			1487644993	10/14/2016 2:23 PM
Medicaid Billing	NPI: Number	Insert			1558547034	10/14/2016 2:23 PM
Medicaid Billing	NPI: Number	Insert			1760614317	10/14/2016 2:23 PM
Details	Last Recertification Date	Insert				10/14/2016 2:23 PM
Details	Grant Number	Insert				10/14/2016 2:23 PM
Details	340B ID	Insert				10/14/2016 2:23 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2016 2:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2016 2:23 PM
Details	Medicare Provider Number	Insert			330153	10/14/2016 2:23 PM
Details	Entity Name	Insert			Ellis Hospital	10/14/2016 2:23 PM
Details	Program Code	Insert			DSH	10/14/2016 2:23 PM
Details	Entity Subname	Insert			Ellis - McClellan Division - Endocrinology	10/14/2016 2:23 PM
Dates	Participating Approval Date	Insert				10/14/2016 2:23 PM
Details	State	Insert			Pending	10/14/2016 2:23 PM
Dates	Registration Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 2:23 PM
Dates	Signed By Date	Insert			10/14/2016 12:00:00 AM	10/14/2016 2:23 PM
Dates	Start Date	Insert				10/14/2016 2:23 PM
Terminations	Termination Comments	Insert				10/14/2016 2:23 PM
Terminations	Termination Date	Insert				10/14/2016 2:23 PM
Terminations	Termination Effective Date	Insert				10/14/2016 2:23 PM
Terminations	Termination Reason	Insert				10/14/2016 2:23 PM