Covered Entity Details

PED093300-31 Children's National Medical Center (Active) - information as of 6/1/2025 3:57:59 AM

Main Details

Name

Children's National Medical Center

Subdivision Name

Montgomery County Regional Outpatient Center / Pain Medicine

Type

Children's Hospital

Rural

340B ID

PED093300-31

Medicare Provider Number

093300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/6/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/22/2017

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Childrens National Medical Center
Eric Manuel Balmir, VP Clinical Ancillary Svcs & Chief Pharmacy Officer
(202) 476-5553

Primary Contact

Children's National Medical Center
Michael Hagan, Pharmacy 340B Manager
(301) 572-6275

Addresses

Street Address

9850 Key West Avenue 3rd Floor
Rockville, MD 20850

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
DC	027980100	1912939703
WV	0174053000	1912939703
VA	1912939703	1912939703
MD	950025100	1912939703

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
PED093300-02	Child	PED	Children's National Medical Center	Children's National Columbia Heights	3336 14th Street NW	Washington	DC	Active
PED093300-03	Child	PED	Children's National Medical Center	Goldberg - Comp Clinic	2220 11th St NW	Washington	DC	Terminated
PED093300-04	Child	PED	Children's Hospital	Goldberg- Good Hope Road	2501 Good Hope Road SE	Washington	DC	Terminated
PED093300-05	Child	PED	Children's Hospital	Goldberg- MLK	3029 Martin Luther King, Jr. Avenue, SE	Washington	DC	Terminated
PED093300-06	Child	PED	Children's National Medical Center	Goldberg-Mobile Health	1901 Mississippi Avenue SE	Washington	DC	Active
PED093300-07	Child	PED	Children's National Medical Center	Goldberg- THEARC	1801 Mississippi Avenue SE	Washington	DC	Active
PED093300-08	Child	PED	Northern Virginia Heme-Onc Regional Outpatient Center	Northern Virginia Heme-Onc Regional Outpatient Center	6565 Arlington Boulevard	Falls Church	VA	Terminated
PED093300-09	Child	PED	Children's National Medical Center	Annapolis Regional Outpatient Center	1730 West St, 1st Floor	Annapolis	MD	Active
PED093300-10	Child	PED	Children's National Medical Center	Northern Virginia Regional Outpatient Center	3023 Hamaker Court	Fairfax	VA	Active
PED093300-11	Child	PED	Children's Hospital	ROC- Frederick	5910 Frederick Crossing Lane	Frederick	MD	Terminated
PED093300-12	Child	PED	Children's National Medical Center	Children's National Prince Georges	2900 North Campus Way	Lanham	MD	Active
PED093300-13	Child	PED	Children's National Medical Center	ROC- Montgomery County Neuropsych	15245 Shady Grove Rd	Rockville	MD	Active
PED093300-14	Child	PED	Children's National Medical Center	Montgomery County Regional	9850 Key West Avenue	Rockville	MD	Active
PED093300-15	Child	PED	Children's National Medical Center	Friendship Heights Outpatient Center	5028 Wisconsin Ave, NW	Washington	DC	Active
PED093300-16	Child	PED	Children's National Medical Center	Children's National Prince Georges	2900 North Campus Way	Lanham	MD	Active
PED093300-17	Child	PED	Children's National Medical Center	Children's NMC-Emergency Department at United Medical Center	1310 Southern Ave SE	Washington	DC	Active
PED093300-18	Child	PED	Children's National Medical Center	Montgomery County Regional / Dermatology	9850 Key West Avenue	Rockville	MD	Active
PED093300-19	Child	PED	Children's National Medical Center	Montgomery County Regional / Pulmonary	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-20	Child	PED	Children's National Medical Center	Montgomery County Regional / Allergy and Immunology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-21	Child	PED	Children's National Medical Center	Montgomery County Regional / Cardiology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-22	Child	PED	Children's National Medical Center	Montgomery County Regional / Endocrinology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-23	Child	PED	Children's National Medical Center	Montgomery County Regional / Genetics/Developmental Peds	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-24	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Hematology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-25	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Oncology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-26	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Rheumatology	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-27	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Neurosurgery	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-28	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / EEG	9850 Key West Avenue 4th Floor	Rockville	MD	Active
PED093300-29	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Neurology	9850 Key West Avenue 3rd Floor	Rockville	MD	Active
PED093300-30	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / General Surgery	9850 Key West Avenue	Rockville	MD	Active
PED093300-31	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Pain Medicine	9850 Key West Avenue 3rd Floor	Rockville	MD	Active
PED093300-32	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Urology	9850 Key West Avenue 3rd Floor	Rockville	MD	Active
PED093300-33	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Laser	9850 Key West Avenue 2nd Floor	Rockville	MD	Active
PED093300-34	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Occupational Therapy	9850 Key West Avenue	Rockville	MD	Active
PED093300-35	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Physical Therapy	9850 Key West Avenue	Rockville	MD	Active
PED093300-36	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Nutrition	9850 Key West Avenue	Rockville	MD	Active
PED093300-37	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Audiology	9850 Key West Avenue	Rockville	MD	Active
PED093300-38	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Speech	9850 Key West Avenue	Rockville	MD	Active
PED093300-39	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Plastic Surgery	9850 Key West Avenue 2nd Floor	Rockville	MD	Active
PED093300-40	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Physical Medicine	9850 Key West Avenue	Rockville	MD	Active
PED093300-41	Child	PED	Children's National Medical Center	Montgomery County Regional / Orthopedics	9850 Key West Avenue	Rockville	MD	Active
PED093300-42	Child	PED	Children's National Medical Center	Montgomery County Regional / Gastroenterology	9850 Key West Avenue	Rockville	MD	Active
PED093300-43	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Otolaryngology	9850 KEY WEST AVE	ROCKVILLE	MD	Active
PED093300-44	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Nephrology	9850 Key West Avenue	Rockville	MD	Active
PED093300-45	Child	PED	Children's National Medical Center	Childrens National Imaging	9850 Key West Ave	Rockville	MD	Active
PED093300-46	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Surgical Gynecology	9850 Key West Ave	Rockville	MD	Active
PED093300-47	Child	PED	Children's National Medical Center	Montgomery County Regional Outpatient Center / Ophthalmology	9850 KEY WEST AVE	ROCKVILLE	MD	Active
PED093300-48	Child	PED	Children's National Medical Center	Goldberg-Anacostia - Anacostia	2101 Martin Luther King, Jr. Ave SE	Washington	DC	Active
PED093300-49	Child	PED	Children's National Medical Center	Howard County Outpatient Center - Howard County Outpatient Center	7625 Maple Lawn Blvd, Suite 230	Fulton	MD	Active
PED093300-50	Child	PED	Children's National Medical Center	Children's National Shepherd Park - Genetics	7125 13th Place NW	Washington	DC	Active
PED093300-51	Child	PED	Children's National Medical Center	Children's National Shepherd Park - Primary Care and Rare Disease Institute	7125 13th Place NW	Washington	DC	Active
PED093300-52	Child	PED	Children's National Medical Center	CHILDREN'S HOSPITAL - Pulmonary Medicine Rockville	9711 MEDICAL CENTER DR	ROCKVILLE	MD	Active
PED093300-53	Child	PED	Children's National Medical Center	CHILDREN'S HOSPITAL - Fight For Children Sports Medicine Center	1 INVENTA PL	SILVER SPRING	MD	Active
PED093300-54	Child	PED	Children's National Medical Center	CHILDRENS HOSPITAL - Montgomery County Ambulatory Surgery Center	9850 KEY WEST AVE	ROCKVILLE	MD	Active
PED093300-55	Child	PED	Children's National Medical Center	Shaw Metro - Primary Care	641 S Street NW	Washington	DC	Active
PED093300-56	Child	PED	Children's National Medical Center	CHILDREN'S HOSPITAL - Takoma Theatre	6833 4TH ST NW	WASHINGTON	DC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		027980100	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0174053000	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912939703	9/4/2024 10:55 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/4/2024 10:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/4/2024 10:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/4/2024 10:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/4/2024 10:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/4/2024 10:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/4/2024 10:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2024 10:55 AM
Details	Last Recertification Date	Update	Recertification	9/8/2023 10:12:52 AM	9/4/2024 10:55:50 AM	9/4/2024 10:55 AM
Contacts	Primary Contact	Update	PC Change Request	Balmir, Eric Manuel VP Clinical Ancillary Svcs & Chief Pharmacy Officer Childrens National Medical Center 2024765553	Hagan, Michael Pharmacy 340B Manager Children's National Medical Center 3015726275	10/17/2023 7:47 AM
Contacts	Authorizing Official	Update	Change Request	Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer Children's National Medical Center 2024762939	Balmir, Eric Manuel VP Clinical Ancillary Svcs & Chief Pharmacy Officer Childrens National Medical Center 2024765553	10/12/2023 10:15 AM
Contacts	Primary Contact	Update	Profile Change Request	Balmir, Eric Manuel Vice President & Chief Pharmacy Officer Childrens National Medical Center 2024765553	Balmir, Eric Manuel VP Clinical Ancillary Svcs & Chief Pharmacy Officer Childrens National Medical Center 2024765553	10/10/2023 9:04 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 2:30:27 PM	9/8/2023 10:12:52 AM	9/8/2023 10:12 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 3:22:16 PM	9/13/2022 2:30:27 PM	9/13/2022 2:30 PM
Contacts	Primary Contact	Update	Profile Change Request	Balmir, Eric Manuel Chief of Pharmacy Childrens National Medical Center 2024765553	Balmir, Eric Manuel Vice President & Chief Pharmacy Officer Childrens National Medical Center 2024765553	1/18/2022 1:17 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000900168 (VA)		9/9/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0174053000 (WV)		9/9/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	027980100 (DC)		9/9/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912939703 (DC)		9/9/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912939703 (VA)		9/9/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912939703 (WV)		9/9/2021 3:22 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 4:23:08 PM	9/9/2021 3:22:16 PM	9/9/2021 3:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000900168	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0174053000	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000900168 (DC)		9/10/2020 4:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/10/2020 4:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/10/2020 4:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/10/2020 4:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/10/2020 4:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/10/2020 4:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/10/2020 4:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912939703	9/10/2020 4:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/10/2020 4:23 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912939703 ( )		9/10/2020 4:23 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 11:21:11 AM	9/10/2020 4:23:08 PM	9/10/2020 4:23 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0008397330001 (PA)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00095446 (MS)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0093300 (TN)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	01570543 (NY)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0174053000 (WV)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0315279 (OH)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	093742800 (FL)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	107866901 (TX)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1764043 (LA)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912939703 (WA)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912939703 (WI)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912939703 (DE)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912939703 (IA)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	213122 (SC)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	530196580001 (IL)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSA15OP (AK)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	99003300 (NC)		9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110027607A (MA)		9/13/2019 11:21 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 3:06:05 PM	9/13/2019 11:21:11 AM	9/13/2019 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0008397330001	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00095446	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0093300	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01570543	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0174053000	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0315279	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		093742800	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		107866901	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1764043	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912939703	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912939703	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912939703	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912939703	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		213122	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		530196580001	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSA15OP	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		99003300	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027607A	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	27980100	027980100	9/10/2018 3:06 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	09-0016-8	000900168	9/10/2018 3:06 PM
Details	Last Recertification Date	Update	Recertification	11/30/2017 11:25:01 AM	9/10/2018 3:06:05 PM	9/10/2018 3:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Balmir, Eric Manuel Chief of Pharmacy Childrens National Medical Center 2024762697	Balmir, Eric Manuel Chief of Pharmacy Childrens National Medical Center 2024765553	9/6/2018 5:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		27980100	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		950025100	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		09-0016-8	11/30/2017 11:25 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	11/30/2017 11:25 AM
Contacts	Primary Contact	Insert	Recertification		Balmir, Eric Manuel Chief of Pharmacy Childrens National Medical Center 2024762697	11/30/2017 11:25 AM
Details	Last Recertification Date	Update	Recertification		11/30/2017 11:25:01 AM	11/30/2017 11:25 AM
Details	Entity Name	Update	Recertification	CHILDRENS HOSPITAL	Children's National Medical Center	11/30/2017 10:00 AM
Contacts	Authorizing Official	Update		Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer 2024762939	Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer Children's National Medical Center 2024762939	11/30/2017 9:39 AM
Contacts	Signed By	Update		Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer 2024762939	Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer Children's National Medical Center 2024762939	11/30/2017 9:39 AM
Contacts	Authorizing Official	Insert			Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer 2024762939	8/10/2017 11:03 PM
Contacts	Signed By	Insert			Gorman, Kathleen EVP, Patient Care services & Chief Operating Officer 2024762939	8/10/2017 11:03 PM
Addresses	Main Address	Insert			9850 Key West Avenue 3rd Floor Rockville, MD 20850	2/22/2017 6:27 PM
Dates	Participating Approval Date	Update			2/22/2017 12:00:00 AM	2/22/2017 6:18 PM
Details	State	Update		Pending	Active	2/22/2017 6:18 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/22/2017 6:18 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74154	PED093300-31	2/14/2017 10:03 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74154	1/6/2017 5:29 PM
Medicaid Billing	NPI: Number	Insert			1912939703	1/6/2017 5:29 PM
Details	Last Recertification Date	Insert				1/6/2017 5:29 PM
Details	Grant Number	Insert				1/6/2017 5:29 PM
Details	340B ID	Insert				1/6/2017 5:29 PM
Details	Is Authorizing Official EHB Data	Insert				1/6/2017 5:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2017 5:29 PM
Details	Medicare Provider Number	Insert			093300	1/6/2017 5:29 PM
Details	Entity Name	Insert			CHILDRENS HOSPITAL	1/6/2017 5:29 PM
Details	Program Code	Insert			PED	1/6/2017 5:29 PM
Details	Entity Subname	Insert			Montgomery County Regional Outpatient Center / Pain Medicine	1/6/2017 5:29 PM
Dates	Participating Approval Date	Insert				1/6/2017 5:29 PM
Details	State	Insert			Pending	1/6/2017 5:29 PM
Dates	Registration Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 5:29 PM
Dates	Signed By Date	Insert			1/6/2017 12:00:00 AM	1/6/2017 5:29 PM
Dates	Start Date	Insert				1/6/2017 5:29 PM
Terminations	Termination Comments	Insert				1/6/2017 5:29 PM
Terminations	Termination Date	Insert				1/6/2017 5:29 PM
Terminations	Termination Effective Date	Insert				1/6/2017 5:29 PM
Terminations	Termination Reason	Insert				1/6/2017 5:29 PM