Covered Entity Details

DSH220077AG BAYSTATE MEDICAL CENTER (Active) - information as of 5/9/2025 12:07:23 AM

Main Details

Name

BAYSTATE MEDICAL CENTER

Subdivision Name

Baystate Neurology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH220077AG

Medicare Provider Number

220077

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/6/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/11/2017

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Baystate Health
Raymond P McCarthy, SVP, Chief Financial Officer & Treasurer
(413) 794-3290

Primary Contact

Baystate Health
Nancy Cruz, Pharmacy Compliance Manager
(413) 794-8282

Addresses

Street Address

3300 Main street
Suites 3C, 3D
Springfield, MA 01107

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
MA	110020829H	1487655064

Shipping Addresses

Same as Street Address

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
DSH220077A	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE HIGH STREET HEALTH CENTER	140 HIGH STREET	SPRINGFIELD	MA	Active
DSH220077AA	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Gynecology Oncology	3300 Main Street	Springfield	MA	Active
DSH220077AB	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Behavioral Health and Child Psychiatry	3300 Main Street	Springfield	MA	Active
DSH220077AC	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Child Partial Hospitalization Program	150 Lower Westfield Road	Holyoke	MA	Active
DSH220077AD	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Breast and Wellness Center	100 Wason Avenue	Springfield	MA	Active
DSH220077AE	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Endocrinology	3300 Main Street	Springfield	MA	Active
DSH220077AF	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Gastroenterology	3300 Main Street	Springfield	MA	Active
DSH220077AG	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Neurology	3300 Main street	Springfield	MA	Active
DSH220077AH	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Infectious Disease	3300 Main Street	springfield	MA	Active
DSH220077AJ	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Neuropsychology Services	3300 Main St	Springfield	MA	Active
DSH220077AK	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Pulmonary & Critical Care Medicine Springfield - Pulmonary	3300 Main Street	Springfield	MA	Active
DSH220077AL	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Cardiology Springfield - Cardiology	3300 Main Street	Springfield	MA	Active
DSH220077AM	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Mason Square Neighborhood Health Center - TB Clinic	11 Wilbraham Road	Springfield	MA	Active
DSH220077AN	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Medical Center Infusion Suite - Infusion	2 Medical Center Drive	Springfield	MA	Active
DSH220077AP	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Pulmonology	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AQ	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Gastroenterology	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AR	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Infectious Disease	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AS	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Cardiology	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AT	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Endocrinology	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AU	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Pediatric Neurology	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AV	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE CHILDREN'S SPECIALTY CENTE - Adolescent Medicine	50 WASON AVE	SPRINGFIELD	MA	Active
DSH220077AW	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE INFUSION CENTER - PALMER - Infusion - Wing Satellite	40 WRIGHT ST	PALMER	MA	Approved
DSH220077AX	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE INFUSION CENTER NOBLE HOSP - Baystate Infusion - Noble Sat	115 W SILVER ST	WESTFIELD	MA	Approved
DSH220077B	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE BRIGHTWOOD HEALTH CENTER CENTRO DE SALUD	380 PLAINFIELD STREET	SPRINGFIELD	MA	Active
DSH220077D	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE ACUTE CARE	759 CHESTNUT STREET	SPRINGFIELD	MA	Terminated
DSH220077E	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE REGIONAL CANCER CENTER D'AMOUR CENTER FOR CANCER CARE	3350 MAIN STREET	SPRINGFIELD	MA	Active
DSH220077F	Child	DSH	BAYSTATE MEDICAL CENTER	CHESTNUT SURGICAL CENTER	759 CHESTNUT STREET	SPRINGFIELD	MA	Terminated
DSH220077G	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Orthopedic Surgery Center	50 Wason Avenue	SPRINGFIELD	MA	Terminated
DSH220077H	Child	DSH	BAYSTATE MEDICAL CENTER	BAYSTATE PAIN MANAGEMENT CENTER	3400 MAIN STREET	SPRINGFIELD	MA	Active
DSH220077L	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Mason Square Neighborhood Health Center	11 Wilbraham Rd	Springfield	MA	Active
DSH220077M	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Behavioral Health	3300 Main St.	Springfield	MA	Active
DSH220077N	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate General Pediatrics	140 High Street	Springfield	MA	Active
DSH220077P	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Midwifery & Women's Health	3300 Main St.	Springfield	MA	Active
DSH220077Q	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Vascular Services	3500 Main St.	Springfield	MA	Active
DSH220077R	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Regional Cancer Program at Baystate Mary Lane	85 South St.	Ware	MA	Terminated
DSH220077S	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Medical Center Transplant Services	100 Wason Ave.	Springfield	MA	Active
DSH220077T	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Children's Specialty Center / Baystate Medical Genetics	50 Wason Avenue	Springfield	MA	Active
DSH220077U	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Children's Specialty Center / Baystate Developmental and Behavioral Pediatrics	50 Wason Avenue	Springfield	MA	Active
DSH220077V	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Adult Partial Hospitalization	140 High St	Springfield	MA	Active
DSH220077W	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Cardiac Rehabilitation and Wellness	3300 Main Street	Springfield	MA	Active
DSH220077X	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Pulmonary Function Lab	3300 Main Street	Springfield	MA	Active
DSH220077Y	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Pulmonary Rehabilitation	3300 Main Street	Springfield	MA	Active
DSH220077Z	Child	DSH	BAYSTATE MEDICAL CENTER	Baystate Urogynecology	3300 Main Street	Springfield	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 5:19:49 PM	8/12/2024 1:11:10 PM	8/12/2024 1:11 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 2:42:44 PM	8/15/2023 5:19:49 PM	8/15/2023 5:19 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000152467 (CO)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300035931 (IN)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2549123P0001 (MD)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1487655064 (ME)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200897230 (OK)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	A (OK)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003024015 (CT)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3086886 (NH)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00511266 (NY)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220077 (VT)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	BAY0077N (AL)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	094418100 (FL)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000104123A (GA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	042790311001 (IL)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0720409 (IA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0140015900 (KY)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	XHSP41780 (CA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	404708480 (MI)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	15034507 (MO)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1288426 (NV)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4122402 (NJ)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0391599 (OH)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0013011700001 (PA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	OP20077 (RI)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	341958 (SC)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220077 (TN)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	042790311 (VI)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	002200775 (VA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3010006 (WA)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	80608900 (WI)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	794504 (AZ)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1487655064 (NC)		4/12/2023 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1487655064 (PR)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (GA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (PA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (VA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (CT)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (NY)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (KY)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (VT)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (TN)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (OH)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (VI)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (IL)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (IA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (FL)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (NV)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (NC)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (PR)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (ME)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (MO)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (IN)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (WA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (NH)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (SC)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (MI)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (NJ)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (AZ)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (WI)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (MD)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (AL)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (RI)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (CA)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (CO)		4/12/2023 8:11 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1487655064 (OK)		4/12/2023 8:11 AM
Contacts	Primary Contact	Update	Change Request	kerr, gary j. chief pharmacy officer baystate health 4137943178	Cruz, Nancy Pharmacy Compliance Manager Baystate Health 4137948282	10/27/2022 10:22 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 8:27:17 AM	8/31/2022 2:42:44 PM	8/31/2022 2:42 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 3:24:02 PM	8/16/2021 8:27:17 AM	8/16/2021 8:27 AM
Contacts	Authorizing Official	Update	Profile Change Request	McCarthy, Raymond P Interim CFO Baystate Health 4137947944	McCarthy, Raymond P SVP, Chief Financial Officer & Treasurer Baystate Health 4137943290	8/3/2021 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000152467	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300035931	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2549123P0001	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1487655064	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200897230	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		A	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	149670000 (ME)		1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200812540A (IN)		1/26/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9733558P0001 (MD)		1/26/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1487655064	1/26/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	1/26/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1487655064	1/26/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	1/26/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		VI	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		PR	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1487655064	9/10/2020 3:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2020 3:24 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1487655064 ( )		9/10/2020 3:24 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 9:39:00 AM	9/10/2020 3:24:02 PM	9/10/2020 3:24 PM
Contacts	Authorizing Official	Update	AO Change Request	Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer Baystate Health 4137943290	McCarthy, Raymond P Interim CFO Baystate Health 4137947944	2/25/2020 9:06 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 2:35:33 PM	8/28/2019 9:39:00 AM	8/28/2019 9:39 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 10:20:13 AM	8/23/2018 2:35:33 PM	8/23/2018 2:35 PM
Details	Last Recertification Date	Update	Recertification		11/6/2017 10:20:13 AM	11/6/2017 10:20 AM
Contacts	Authorizing Official	Update		Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer 4137943290	Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer Baystate Health 4137943290	10/13/2017 10:42 AM
Contacts	Signed By	Update		Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer 4137943290	Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer Baystate Health 4137943290	10/13/2017 10:42 AM
Contacts	Primary Contact	Update		kerr, gary j. chief pharmacy officer 4137943178	kerr, gary j. chief pharmacy officer baystate health 4137943178	10/11/2017 2:50 PM
Contacts	Primary Contact	Insert			kerr, gary j. chief pharmacy officer 4137943178	8/10/2017 3:37 PM
Contacts	Authorizing Official	Insert			Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer 4137943290	8/10/2017 3:37 PM
Contacts	Signed By	Insert			Chalke, Dennis Sr. VP Finance & Community Hospitals/CFO & Treasurer 4137943290	8/10/2017 3:37 PM
Addresses	Main Address	Insert			3300 Main street Suites 3C, 3D Springfield, MA 01107	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Number	Insert			794504	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: State	Insert			AZ	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Number	Insert			1487655064	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: State	Insert			NC	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: Number	Insert			1487655064	8/10/2017 3:28 PM
Medicaid Billing	Medicaid: State	Insert			PR	8/10/2017 3:28 PM
Dates	Participating Approval Date	Update			3/11/2017 12:00:00 AM	3/11/2017 11:08 AM
Details	State	Update		Pending	Active	3/11/2017 11:08 AM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/11/2017 11:08 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74119	DSH220077AG	2/10/2017 1:59 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74119	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			110020829H	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			MA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			003024015	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			CT	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			149670000	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			ME	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			3086886	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			NH	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			00511266	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			NY	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0220077	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			VT	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			BAY0077N	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			AL	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			094418100	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			FL	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			000104123A	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			042790311001	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			200812540A	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			IN	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0720409	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			IA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0140015900	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			KY	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			9733558P0001	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			MD	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			XHSP41780	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			CA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			404708480	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			MI	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			15034507	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			MO	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			1288426	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			NV	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			4122402	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			NJ	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0391599	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			OH	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0013011700001	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			PA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			OP20077	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			RI	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			341958	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			SC	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			0220077	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			TN	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			042790311	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			VI	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			002200775	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			VA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			3010006	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			WA	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: Number	Insert			80608900	1/6/2017 2:34 PM
Medicaid Billing	Medicaid: State	Insert			WI	1/6/2017 2:34 PM
Medicaid Billing	NPI: Number	Insert			1487655064	1/6/2017 2:34 PM
Details	Last Recertification Date	Insert				1/6/2017 2:34 PM
Details	Grant Number	Insert				1/6/2017 2:34 PM
Details	340B ID	Insert				1/6/2017 2:34 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2017 2:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2017 2:34 PM
Details	Medicare Provider Number	Insert			220077	1/6/2017 2:34 PM
Details	Entity Name	Insert			BAYSTATE MEDICAL CENTER	1/6/2017 2:34 PM
Details	Program Code	Insert			DSH	1/6/2017 2:34 PM
Details	Entity Subname	Insert			Baystate Neurology	1/6/2017 2:34 PM
Dates	Participating Approval Date	Insert				1/6/2017 2:34 PM
Details	State	Insert			Pending	1/6/2017 2:34 PM
Dates	Registration Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 2:34 PM
Dates	Signed By Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 2:34 PM
Dates	Start Date	Insert				1/6/2017 2:34 PM
Terminations	Termination Comments	Insert				1/6/2017 2:34 PM
Terminations	Termination Date	Insert				1/6/2017 2:34 PM
Terminations	Termination Effective Date	Insert				1/6/2017 2:34 PM
Terminations	Termination Reason	Insert				1/6/2017 2:34 PM