Covered Entity Details

DSH360035AN MOUNT CARMEL HEALTH (Terminated) - information as of 4/29/2025 11:49:47 PM

Main Details

Name

MOUNT CARMEL HEALTH

Subdivision Name

East Emergency Department

Type

Disproportionate Share Hospital

Rural

340B ID

DSH360035AN

Medicare Provider Number

360035

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/11/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/13/2017

Last Recertification Date

8/25/2021

Termination Date
Termination Reason

10/1/2022
Outpatient facility moved within the 4 walls of the parent hospital

Contacts

Authorizing Official

Mount Carmel Health System
Nicholas Kreatsoulas, Executive Vice President & Chief Clinical Operations Officer
(614) 546-3266

Primary Contact

Mount Carmel Health System
Terrance John Slavin, Regional Director of Reimbursement
(734) 343-3320

Addresses

Street Address

6001 E Broad St
Columbus, OH 43213-1502

Billing Address

Mount Carmel Health System
6150 E Broad St
3rd Floor Finance
Columbus, OH 43213-1574

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
OH	6196165	1710067376,1982784534

Shipping Addresses

Shipping Address 1

Mount Carmel Health System
6150 E Broad St
3rd Floor Finance
Columbus, OH 43213-1574

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
DSH360035A	Child	DSH	MOUNT CARMEL HEALTH	GC GME Family Practice at St. Ann's Hospital	477 Cooper Rd	Westerville	OH	Active
DSH360035AA	Child	DSH	MOUNT CARMEL HEALTH	MOB 5 East Rehab Services	5965 E Broad St	Columbus	OH	Active
DSH360035AB	Child	DSH	MOUNT CARMEL HEALTH	Anticoagulation Clinic - Grove City	5350 N Meadows Dr	Grove City	OH	Terminated
DSH360035AC	Child	DSH	MOUNT CARMEL HEALTH	Anticoagulation Clinic	730 West Rich Street	Columbus	OH	Terminated
DSH360035AD	Child	DSH	MOUNT CARMEL HEALTH	MCEMO Outpatient Care Center	5965 East Broad Street	Columbus	OH	Active
DSH360035AE	Child	DSH	MOUNT CARMEL HEALTH	East Recovery Room	6001 E Broad St	Columbus	OH	Terminated
DSH360035AF	Child	DSH	MOUNT CARMEL HEALTH	East Anesthesia	6001 E Broad St	Columbus	OH	Terminated
DSH360035AG	Child	DSH	MOUNT CARMEL HEALTH	East Extracorporeal Services	6001 E Broad St	Columbus	OH	Terminated
DSH360035AH	Child	DSH	MOUNT CARMEL HEALTH	East Open Heart Surgery	6001 E Broad St	Columbus	OH	Terminated
DSH360035AJ	Child	DSH	MOUNT CARMEL HEALTH	East Same Day Admissions	6001 E Broad St	Columbus	OH	Terminated
DSH360035AK	Child	DSH	MOUNT CARMEL HEALTH	East Inpatient Surgery/OR	6001 E Broad St	Columbus	OH	Terminated
DSH360035AL	Child	DSH	MOUNT CARMEL HEALTH	East OB Triage Unit	6001 E Broad St	Columbus	OH	Terminated
DSH360035AM	Child	DSH	MOUNT CARMEL HEALTH	East Labor & Delivery	6001 E Broad St	Columbus	OH	Terminated
DSH360035AN	Child	DSH	MOUNT CARMEL HEALTH	East Emergency Department	6001 E Broad St	Columbus	OH	Terminated
DSH360035AP	Child	DSH	MOUNT CARMEL HEALTH	East Interventional Radiology	6001 E Broad St	Columbus	OH	Terminated
DSH360035AQ	Child	DSH	MOUNT CARMEL HEALTH	East MRI	6001 E Broad St	Columbus	OH	Terminated
DSH360035AR	Child	DSH	MOUNT CARMEL HEALTH	East Nuclear Medicine	6001 E Broad St	Columbus	OH	Terminated
DSH360035AS	Child	DSH	MOUNT CARMEL HEALTH	East Ultrasound	6001 E Broad St	Columbus	OH	Terminated
DSH360035AT	Child	DSH	MOUNT CARMEL HEALTH	East CT	6001 E Broad St	Columbus	OH	Terminated
DSH360035AU	Child	DSH	MOUNT CARMEL HEALTH	East Diagnostic Radiology	6001 E Broad St	Columbus	OH	Terminated
DSH360035AV	Child	DSH	MOUNT CARMEL HEALTH	East Electrophysiology	6001 E Broad St	Columbus	OH	Terminated
DSH360035AW	Child	DSH	MOUNT CARMEL HEALTH	East Cardiac Cath Lab	6001 E Broad St	Columbus	OH	Terminated
DSH360035AX	Child	DSH	MOUNT CARMEL HEALTH	East Clinical Neurophysiology	6001 E Broad St	Columbus	OH	Terminated
DSH360035AY	Child	DSH	MOUNT CARMEL HEALTH	East Respiratory Care	6001 E Broad St	Columbus	OH	Terminated
DSH360035AZ	Child	DSH	MOUNT CARMEL HEALTH	East Enterostomal Therapy	6001 E Broad St	Columbus	OH	Terminated
DSH360035B	Child	DSH	MOUNT CARMEL HEALTH	East Endoscopy/Gastroenterology	6001 E Broad St	Columbus	OH	Terminated
DSH360035BA	Child	DSH	MOUNT CARMEL HEALTH	East Maternal Fetal Medicine	6001 E Broad St	Columbus	OH	Terminated
DSH360035BB	Child	DSH	MOUNT CARMEL HEALTH	West Outpatient Clinic	793 W State St	Columbus	OH	Terminated
DSH360035BC	Child	DSH	MOUNT CARMEL HEALTH	East Outpatient Clinic	5965 E Broad St	Columbus	OH	Terminated
DSH360035BD	Child	DSH	MOUNT CARMEL HEALTH	East Imaging Center	5969 E Broad St	Columbus	OH	Active
DSH360035BE	Child	DSH	MOUNT CARMEL HEALTH	East Cardiovascular Imaging Lab	6001 E Broad St	Columbus	OH	Terminated
DSH360035BF	Child	DSH	MOUNT CARMEL HEALTH	East Images for Women	5965 E Broad St	Columbus	OH	Terminated
DSH360035BG	Child	DSH	MOUNT CARMEL HEALTH	Cardiac Nuclear Medicine Grove City	5350 N Meadows Drive	Grove City	OH	Terminated
DSH360035BH	Child	DSH	MOUNT CARMEL HEALTH	Cardiac Nuclear Medicine McNaughten	85 McNaughten Road	Columbus	OH	Active
DSH360035BJ	Child	DSH	MOUNT CARMEL HEALTH	Cardiac Nuclear Medicine Diley Ridge	7901 Diley Road	Canal Winchester	OH	Active
DSH360035BK	Child	DSH	MOUNT CARMEL HEALTH	Emergency Department Franklinton	120 SOUTH GREEN STREET	COLUMBUS	OH	Active
DSH360035BL	Child	DSH	MOUNT CARMEL HEALTH	ANTICOAGULATION CENTER - Anticoagulation Center	4674 BRITTON PKWY	HILLIARD	OH	Terminated
DSH360035BM	Child	DSH	MOUNT CARMEL HEALTH	Hilliard Imaging Center	4674 BRITTON PKWY	HILLIARD	OH	Active
DSH360035BN	Child	DSH	MOUNT CARMEL HEALTH	Hilliard Heart & Vascular Imaging Center	4674 BRITTON PKWY	HILLIARD	OH	Active
DSH360035BP	Child	DSH	MOUNT CARMEL HEALTH	Cardiovascular Imaging Services - Nuclear Medicine	4674 BRITTON PKWY	HILLIARD	OH	Active
DSH360035BQ	Child	DSH	MOUNT CARMEL HEALTH	Grove City Respiratory Care - Respiratory Therapy	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035BR	Child	DSH	MOUNT CARMEL HEALTH	Mount Carmel Imaging Center - Hilliard CT - CT Scan	4674 Britton Parkway	Hilliard	OH	Active
DSH360035BS	Child	DSH	MOUNT CARMEL HEALTH	Grove City Emergency Department - Emergency Services	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035BT	Child	DSH	MOUNT CARMEL HEALTH	East Heart & Vascular Imaging Center - Cardiology	85 McNaughten Rd.	Columbus	OH	Active
DSH360035BU	Child	DSH	MOUNT CARMEL HEALTH	Franklinton CT Scan - CT Scan	120 S Green St.	Columbus	OH	Active
DSH360035BV	Child	DSH	MOUNT CARMEL HEALTH	Cardiac Nuclear Medicine Grove City - Nuclear Medicine	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035BW	Child	DSH	MOUNT CARMEL HEALTH	Grove City Pain Management Clinic - Pain Management	5500 N Meadows Dr.	Grove City	OH	Active
DSH360035BX	Child	DSH	MOUNT CARMEL HEALTH	East Rehab Services - Physical Therapy	5965 E Broad St	Columbus	OH	Active
DSH360035BY	Child	DSH	MOUNT CARMEL HEALTH	MOUNT CARMEL WOMENS HEALTH CENTER F - Women's Health	775 W BROAD ST	COLUMBUS	OH	Terminated
DSH360035BZ	Child	DSH	MOUNT CARMEL HEALTH	Grove City Heart & Vascular Imaging at DRMC - Cardiology	7901 Diley Rd.	Canal Winchester	OH	Active
DSH360035C	Child	DSH	MOUNT CARMEL HEALTH	Grove City Women's Health Center	5300 N Meadows Dr	Grove City	OH	Terminated
DSH360035CA	Child	DSH	MOUNT CARMEL HEALTH	Grove City OP Surgery - Surgery	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CB	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services - Speech Pathology	3000 Meadow Pond Ct.	Grove City	OH	Active
DSH360035CC	Child	DSH	MOUNT CARMEL HEALTH	Grove City Heart & Vascular Imaging Center - Cardiology	5300 N. Meadows Drive	Grove City	OH	Active
DSH360035CD	Child	DSH	MOUNT CARMEL HEALTH	East Outpatient Clinics - Clinics	5965 E. Broad St.	Columbus	OH	Active
DSH360035CE	Child	DSH	MOUNT CARMEL HEALTH	Grove City Diabetes Education - Diabetes Education	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CF	Child	DSH	MOUNT CARMEL HEALTH	Grove City Heart Failure Clinic - Heart Failure	5300 N Meadows Dr.	Grove City	OH	Terminated
DSH360035CG	Child	DSH	MOUNT CARMEL HEALTH	West Imaging Center - Radiology	120 S Green Street	Columbus	OH	Active
DSH360035CH	Child	DSH	MOUNT CARMEL HEALTH	WOUND CARE CENTER - Wound Care	5500 N MEADOWS DR	GROVE CITY	OH	Active
DSH360035CJ	Child	DSH	MOUNT CARMEL HEALTH	Grove City Cardiac Rehab - Cardiac Rehab	5300 N. Meadows Dr.	Grove City	OH	Active
DSH360035CK	Child	DSH	MOUNT CARMEL HEALTH	McNaughten Cardiology - Cardiology	85 McNaughten Rd.	Columbus	OH	Active
DSH360035CL	Child	DSH	MOUNT CARMEL HEALTH	Grove City Imaging Center - Radiology	5300 N. Meadows Dr.	Grove City	OH	Active
DSH360035CM	Child	DSH	MOUNT CARMEL HEALTH	MCFRC Respiratory Care - Respiratory Therapy	120 S Green St.	Columbus	OH	Active
DSH360035CN	Child	DSH	MOUNT CARMEL HEALTH	MCGC Pharmacy Outpatient Care Center - Anticoagulation	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CP	Child	DSH	MOUNT CARMEL HEALTH	Mount Carmel Reynoldsburg Emergency Department - Emergency Services	2300 Baltimore-Reynoldsburg Rd	Reynoldsburg	OH	Active
DSH360035CQ	Child	DSH	MOUNT CARMEL HEALTH	Grove City Diagnostic Radiology - Radiology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CR	Child	DSH	MOUNT CARMEL HEALTH	Grove City Outpatient Clinics - Enterostomal Therapy	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CS	Child	DSH	MOUNT CARMEL HEALTH	Grove City CT - CT Scan	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CT	Child	DSH	MOUNT CARMEL HEALTH	East Cardiology - Cardiology	5965 E Broad St.	Columbus	OH	Active
DSH360035CU	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services - Rehab	3000 Meadow Pond Ct.	Grove City	OH	Active
DSH360035CV	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services - Occupational Therapy	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CW	Child	DSH	MOUNT CARMEL HEALTH	WOMENS HEALTH CENTER - Women's Health	4674 BRITTON PKWY	HILLIARD	OH	Active
DSH360035CX	Child	DSH	MOUNT CARMEL HEALTH	Grove City Radiation Oncology - Radiation Oncology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035CY	Child	DSH	MOUNT CARMEL HEALTH	Reynoldsburg CT - CT Scan	2300 Baltimore-Reynoldsburg Rd.	Reynoldsburg	OH	Active
DSH360035CZ	Child	DSH	MOUNT CARMEL HEALTH	Grove City Endo/Gastro - Endoscopy & Gastroenterology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035D	Child	DSH	MOUNT CARMEL HEALTH	East Women's Health Center	5965 E Broad St	Columbus	OH	Active
DSH360035DA	Child	DSH	MOUNT CARMEL HEALTH	Grove City Interventional Radiology - Interventional Radiology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DB	Child	DSH	MOUNT CARMEL HEALTH	Grove City OP Heart Surgery - Heart Surgery	5300 N Meadows Dr.	Grove City	OH	Terminated
DSH360035DC	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services - Speech Pathology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DD	Child	DSH	MOUNT CARMEL HEALTH	Reynoldsburg Ultrasound - Ultrasound	2300 Baltimore-Reynoldsburg Rd.	Reynoldsburg	OH	Active
DSH360035DE	Child	DSH	MOUNT CARMEL HEALTH	Hilliard Rehab Services - Rehab	4674 Britton Parkway	Hilliard	OH	Active
DSH360035DF	Child	DSH	MOUNT CARMEL HEALTH	GROVE CITY WOMENS HEALTH - Women's Health	5300 N MEADOWS DR	GROVE CITY	OH	Active
DSH360035DG	Child	DSH	MOUNT CARMEL HEALTH	Grove City Heart & Vascular Imaging Center - Radiology	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DH	Child	DSH	MOUNT CARMEL HEALTH	Grove City Neurophysiology - Neurophysiology	5300 N Meadows Dr., 2nd Floor	Grove City	OH	Active
DSH360035DJ	Child	DSH	MOUNT CARMEL HEALTH	Reynoldsburg Imaging - Radiology	2300 Baltimore-Reynoldsburg Rd	Reynoldsburg	OH	Active
DSH360035DK	Child	DSH	MOUNT CARMEL HEALTH	Grove City Infusion - Infusion	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DL	Child	DSH	MOUNT CARMEL HEALTH	Mount Carmel East Diabetes Education - Diabetes Education	5975 E Broad St.	Columbus	OH	Active
DSH360035DM	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services - Occupational Therapy	3000 Meadow Pond Ct.	Grove City	OH	Active
DSH360035DN	Child	DSH	MOUNT CARMEL HEALTH	Grove City Pain Management Procedural Area - Pain Management	5300 N. Meadows Drive	Grove City	OH	Active
DSH360035DP	Child	DSH	MOUNT CARMEL HEALTH	MCGC Main Lab - Lab & Blood Bank	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DQ	Child	DSH	MOUNT CARMEL HEALTH	MCGC MRI - MRI	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DR	Child	DSH	MOUNT CARMEL HEALTH	MCGC Labor & Delivery - Labor & Delivery	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DS	Child	DSH	MOUNT CARMEL HEALTH	MCEMB Pain - Pain Management	5969 E Broad St.	Columbus	OH	Active
DSH360035DT	Child	DSH	MOUNT CARMEL HEALTH	MCGC Cardiovascular Imaging - Cardiovascular Imaging	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DU	Child	DSH	MOUNT CARMEL HEALTH	MCGC Maternal Fetal Medicine - Maternal Fetal Medicine	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DV	Child	DSH	MOUNT CARMEL HEALTH	MCGC Dialysis - Dialysis	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DW	Child	DSH	MOUNT CARMEL HEALTH	MCGC Cardiac Cath Lab - Cardiac Cath	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DX	Child	DSH	MOUNT CARMEL HEALTH	MCGC Pet Scan - Pet Scan	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DY	Child	DSH	MOUNT CARMEL HEALTH	MCGC Preop & PACU - Preop & PACU	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035DZ	Child	DSH	MOUNT CARMEL HEALTH	MCGC Ultrasound - Ultrasound	5300 N Meadows Dr.	Grove City	OH	Active
DSH360035E	Child	DSH	MOUNT CARMEL HEALTH	East Siegel Center Infusion	5975 E Broad St	Columbus	OH	Active
DSH360035EA	Child	DSH	MOUNT CARMEL HEALTH	Mount Carmel Grove City Medical Oncology Clinic - Medical Oncology	5300 N Meadows Dr	Grove City	OH	Active
DSH360035F	Child	DSH	MOUNT CARMEL HEALTH	West Heart Failure & Structural Heart	730 West Rich St	Columbus	OH	Terminated
DSH360035G	Child	DSH	MOUNT CARMEL HEALTH	East Heart Failure Clinic	5965 E Broad St	Columbus	OH	Terminated
DSH360035H	Child	DSH	MOUNT CARMEL HEALTH	Grove City Emergency Department	5300 N Meadows Dr	Grove City	OH	Terminated
DSH360035J	Child	DSH	MOUNT CARMEL HEALTH	East Radiation Oncology	5969 East Broad St.	Columbus	OH	Active
DSH360035K	Child	DSH	MOUNT CARMEL HEALTH	Grove City CT	5300 N Meadows Dr	Grove City	OH	Terminated
DSH360035L	Child	DSH	MOUNT CARMEL HEALTH	Grove City Diagnostic Radiology	5300 N Meadows Dr	Grove City	OH	Terminated
DSH360035M	Child	DSH	MOUNT CARMEL HEALTH	West Mill Run Imaging	3779 Truman Ct	Hilliard	OH	Terminated
DSH360035N	Child	DSH	MOUNT CARMEL HEALTH	Grove City Cardiovascular Imaging	5350 N Meadows Dr	Grove City	OH	Terminated
DSH360035P	Child	DSH	MOUNT CARMEL HEALTH	West Other Cardiology Dublin	6670 Perimeter Dr	Dublin	OH	Terminated
DSH360035Q	Child	DSH	MOUNT CARMEL HEALTH	East Other Cardiology McNaughten	85 McNaughten Rd	Columbus	OH	Terminated
DSH360035R	Child	DSH	MOUNT CARMEL HEALTH	West Cardiac Imaging at DRMC	7901 Diley Rd	Canal Winchester	OH	Terminated
DSH360035S	Child	DSH	MOUNT CARMEL HEALTH	Grove City Cardiac Rehab	5350 N Meadows Dr	Grove City	OH	Terminated
DSH360035T	Child	DSH	MOUNT CARMEL HEALTH	East Cardiac Rehab	150 Taylor Station Rd	Columbus	OH	Active
DSH360035U	Child	DSH	MOUNT CARMEL HEALTH	Grove City Respiratory Care	5300 N Meadows Dr	Grove City	OH	Terminated
DSH360035V	Child	DSH	MOUNT CARMEL HEALTH	East Enterostomal Therapy Wound Care Clinic	5965 E Broad St	Columbus	OH	Active
DSH360035W	Child	DSH	MOUNT CARMEL HEALTH	East Occupational Therapy	5965 E Broad St	Columbus	OH	Active
DSH360035X	Child	DSH	MOUNT CARMEL HEALTH	Grove City Rehab Services	5350 N Meadows Dr	Grove City	OH	Terminated
DSH360035Y	Child	DSH	MOUNT CARMEL HEALTH	East Speech Therapy	5965 E Broad St	Columbus	OH	Active
DSH360035Z	Child	DSH	MOUNT CARMEL HEALTH	Mill run Physical Therapy	3775 Truman Ct	Hilliard	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	Wilber, Scott T Chief Medical Officer Mount Carmel Health 6142346765	Kreatsoulas, Nicholas Executive Vice President & Chief Clinical Operations Officer Mount Carmel Health System 6145463266	9/23/2022 1:02 PM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/22/2022 12:00:00 AM	9/6/2022 3:42 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/6/2022 3:42 PM
Terminations	Termination Date	Update	Recertification		10/1/2022 12:00:00 AM	9/6/2022 3:42 PM
Terminations	Termination Effective Date	Update	Recertification		6/23/2022 12:00:00 AM	9/6/2022 3:42 PM
Terminations	Termination Reason	Update	Recertification		Outpatient facility moved within the 4 walls of the parent hospital	9/6/2022 3:42 PM
Contacts	Authorizing Official	Update	AO Change Request	Kreatsoulas, Nicholas Executive Vice President & Chief Clinical Operations Officer Mount Carmel Health System 6145463266	Wilber, Scott T Chief Medical Officer Mount Carmel Health 6142346765	8/25/2022 1:27 PM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	1/26/2022 12:00:00 AM		3/25/2022 2:02 PM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	3/25/2022 2:02 PM
Terminations	Termination Date	Update	OPA Cancel Termination Request	4/1/2022 12:00:00 AM		3/25/2022 2:02 PM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	1/27/2022 12:00:00 AM		3/25/2022 2:02 PM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	DSH percentage below statutory minimum		3/25/2022 2:02 PM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/26/2022 12:00:00 AM	2/1/2022 4:28 PM
Details	State	Update	Termination Request	Active	To Be Terminated	2/1/2022 4:28 PM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	2/1/2022 4:28 PM
Terminations	Termination Effective Date	Update	Termination Request		1/27/2022 12:00:00 AM	2/1/2022 4:28 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	2/1/2022 4:28 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 1:56:40 PM	8/25/2021 1:26:23 PM	8/25/2021 1:26 PM
Contacts	Primary Contact	Update	Group Change Request	Ware, Steve Reimbursement Manager St. Ann's Hospital 6145463290	Slavin, Terrance John Regional Director of Reimbursement Mount Carmel Health System 7343433320	7/28/2021 11:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1710067376 ( )		8/18/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1710067376	8/18/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/18/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1982784534	8/18/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/18/2020 1:56 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1982784534 ( )		8/18/2020 1:56 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 7:43:47 PM	8/18/2020 1:56:40 PM	8/18/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710067376	6/12/2020 2:12 PM
Contacts	Authorizing Official	Update	Change Request	Morris, Paul CFO & Executive V.P. St. Ann's Hospital 6145464620	Kreatsoulas, Nicholas Executive Vice President & Chief Clinical Operations Officer Mount Carmel Health System 6145463266	1/3/2020 10:34 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 7:56:26 AM	8/20/2019 7:43:47 PM	8/20/2019 7:43 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 10:16:12 AM	8/22/2018 7:56:26 AM	8/22/2018 7:56 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1982784534	7/2/2018 9:41 AM
Details	Last Recertification Date	Update	Recertification		11/7/2017 10:16:12 AM	11/7/2017 10:16 AM
Contacts	Authorizing Official	Insert	Change Request		Morris, Paul CFO & Executive V.P. St. Ann's Hospital 6145464620	10/2/2017 7:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Ware, Steve Reimbursement Manager Mount Carmel Health 6145463290	Ware, Steve Reimbursement Manager St. Ann's Hospital 6145463290	9/27/2017 9:26 AM
Contacts	Primary Contact	Update	Profile Change Request	Ware, Steve Reimbursement Manager st.ann's hospital 6145463290	Ware, Steve Reimbursement Manager Mount Carmel Health 6145463290	9/27/2017 9:22 AM
Contacts	Primary Contact	Update		Ware, Steve Reimbursement Manager 6145463290	Ware, Steve Reimbursement Manager st.ann's hospital 6145463290	9/25/2017 9:29 AM
Contacts	Primary Contact	Insert			Ware, Steve Reimbursement Manager 6145463290	7/13/2017 10:48 AM
Contacts	Signed By	Insert			Powell, Dan CFO, SVP Finance 6145464619	7/13/2017 10:48 AM
Addresses	Main Address	Insert			6001 E Broad St Columbus, OH 43213-1502	7/13/2017 10:48 AM
Addresses	Billing Address	Insert			Mount Carmel Health System 6150 E Broad St 3rd Floor Finance Columbus, OH 43213-1574	7/13/2017 10:48 AM
Addresses	Shipping Address	Insert			Mount Carmel Health System 6150 E Broad St 3rd Floor Finance Columbus, OH 43213-1574	7/13/2017 10:48 AM
Dates	Participating Approval Date	Update			3/13/2017 12:00:00 AM	3/13/2017 3:21 PM
Details	State	Update		Pending	Active	3/13/2017 3:21 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/13/2017 3:21 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74520	DSH360035AN	1/13/2017 12:42 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74520	1/11/2017 1:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2017 1:00 PM
Medicaid Billing	Medicaid: Number	Insert			6196165	1/11/2017 1:00 PM
Medicaid Billing	Medicaid: State	Insert			OH	1/11/2017 1:00 PM
Details	Last Recertification Date	Insert				1/11/2017 1:00 PM
Details	Grant Number	Insert				1/11/2017 1:00 PM
Details	340B ID	Insert				1/11/2017 1:00 PM
Details	Is Authorizing Official EHB Data	Insert				1/11/2017 1:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/11/2017 1:00 PM
Details	Medicare Provider Number	Insert			360035	1/11/2017 1:00 PM
Details	Entity Name	Insert			MOUNT CARMEL HEALTH	1/11/2017 1:00 PM
Details	Program Code	Insert			DSH	1/11/2017 1:00 PM
Details	Entity Subname	Insert			East Emergency Department	1/11/2017 1:00 PM
Dates	Participating Approval Date	Insert				1/11/2017 1:00 PM
Details	State	Insert			Pending	1/11/2017 1:00 PM
Dates	Registration Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 1:00 PM
Dates	Signed By Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 1:00 PM
Dates	Start Date	Insert				1/11/2017 1:00 PM
Terminations	Termination Comments	Insert				1/11/2017 1:00 PM
Terminations	Termination Date	Insert				1/11/2017 1:00 PM
Terminations	Termination Effective Date	Insert				1/11/2017 1:00 PM
Terminations	Termination Reason	Insert				1/11/2017 1:00 PM