Covered Entity Details

SCH330136-73 MARY IMOGENE BASSETT HOSPITAL (Terminated) - information as of 4/25/2025 9:20:25 PM

Main Details

Name

MARY IMOGENE BASSETT HOSPITAL

Subdivision Name

STAMFORD CLINIC

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH330136-73

Medicare Provider Number

330136

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/4/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/26/2017

Last Recertification Date

8/16/2021

Termination Date
Termination Reason

1/1/2022
Change of covered entity type

Contacts

Authorizing Official

Bassett Healthcare Network
Paul Swinko, CFO
(607) 547-3096

Primary Contact

Bassett Healthcare Network
Russell McCall, 340B Coordinator
(607) 547-3347

Addresses

Street Address

STAMFORD CLINIC
28650 STATE HIGHWAY 23
STAMFORD, NY 12167

Billing Address

MARY IMOGENE BASSETT HOSPITAL
ONE ATWELL ROAD
COOPERSTOWN, NY 13326

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?
No

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
SCH330136-01	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER / Hemotology/Oncology	321E ALBANY ST	HERKIMER	NY	Active
SCH330136-02	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE AT FOX CARE / Hematology/Oncology	1 FOXCARE DR	ONEONTA	NY	Active
SCH330136-03	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Mary Imogene Bassett Hospital Cancer Treatment Center / Hematology/Oncology	60 River Street	Cooperstown	NY	Terminated
SCH330136-04	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER / Ambulatory Surgery	321E ALBANY ST	HERKIMER	NY	Active
SCH330136-05	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS / Ambulatory Surgery	1 ASSOCIATE DR	ONEONTA	NY	Active
SCH330136-06	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE LITTLE FALLS / Renal Dialysis	140 BURWELL ST	LITTLE FALLS	NY	Active
SCH330136-07	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS / Renal Dialysis	1 ASSOCIATE DR	ONEONTA	NY	Active
SCH330136-08	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Surgical Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-09	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Ophthalmology Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-10	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Otolaryngology Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-100	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER - Herkimer Specialty Services	321 E ALBANY ST	HERKIMER	NY	Active
SCH330136-101	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Oneonta Specialty - Eye Clinic - Oneonta Specialty Services - Eye Clinic	1 Associate Drive	Oneonta	NY	Active
SCH330136-102	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Radiology at FoxCare - FoxCare Radiology-Ortho	1 Foxcare Drive	Oneonta	NY	Active
SCH330136-103	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE LITTLE FALLS - Peritoneal Dialysis	140 BURWELL ST	LITTLE FALLS	NY	Active
SCH330136-104	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Richfield Springs Central SBHC - Richfield Springs Central School Based Health Clinic	93 Main Street	Richfield Springs	NY	Active
SCH330136-105	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Little Falls Cardiology Clinic - Little Falls Cardiology Clinic	140 Burwell Street	Little Falls	NY	Active
SCH330136-106	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Anticoagulation Management Services - Anticoagulation Clinic at FoxCare	1 FoxCare Drive	Oneonta	NY	Active
SCH330136-107	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Oneonta Specialty Services - Radiology - Diagnostic Radiology at OSS	1 Associate Drive	Oneonta	NY	Active
SCH330136-108	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Peritoneal Dialysis	1 ASSOCIATE DR	ONEONTA	NY	Active
SCH330136-109	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Home Hemodialysis	1 ASSOCIATE DR	ONEONTA	NY	Active
SCH330136-11	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Prime Care Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-12	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	RCP - Radiation Therapy	60 River Street	Cooperstown	NY	Terminated
SCH330136-13	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Radiology, Diagnostic	60 River Street	Cooperstown	NY	Terminated
SCH330136-14	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Gastroenterology Laboratory	60 River Street	Cooperstown	NY	Terminated
SCH330136-15	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Obstetrics & Gynecology Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-16	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Pediatric Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-17	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Medical Clinic	60 River Street	Cooperstown	NY	Terminated
SCH330136-18	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Oneonta Cardiology	1 Fox Care Drive	Oneonta	NY	Active
SCH330136-19	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE ANTI-COAGULATION CLINIC	BASSETT HEALTHCARE ANTI-COAGULATION CLINIC	COOPERSTOWN	NY	Terminated
SCH330136-20	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SCHOHARIE	BASSETT HEALTHCARE SCHOHARIE	SCHOHARIE	NY	Active
SCH330136-21	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHARON SPG CLINIC	BASSETT HEALTHCARE SHARON SPG CLINIC	SHARON SPRINGS	NY	Active
SCH330136-22	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE SHERBURNE CLINIC	BASSETT HEALTHCARE SHERBURNE CLINIC	SHERBURNE	NY	Active
SCH330136-23	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HAMILTON CLINIC	BASSETT HEALTHCARE HAMILTON CLINIC	HAMILTON	NY	Terminated
SCH330136-24	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE RICHFIELD CLINIC	BASSETT HEALTHCARE RICHFIELD CLINIC	RICHFIELD	NY	Terminated
SCH330136-25	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HAMILTON DENTAL CLINIC	BASSETT HEALTHCARE HAMILTON DENTAL CLINIC	HAMILTON	NY	Active
SCH330136-26	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE MORRIS HEALTH CENTER	BASSETT HEALTHCARE MORRIS HEALTH CENTER	MORRIS	NY	Terminated
SCH330136-27	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE EDMESTON CLINIC	BASSETT HEALTHCARE EDMESTON CLINIC	EDMESTON	NY	Terminated
SCH330136-28	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE CANAJOHARIE	BASSETT HEALTHCARE CANAJOHARIE	CANAJOHARIE	NY	Active
SCH330136-29	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE COBLESKILL CLINC	BASSETT HEALTHCARE COBLESKILL CLINC	COBLESKILL	NY	Active
SCH330136-30	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NORWICH	BASSETT HEALTHCARE NORWICH	NORWICH	NY	Active
SCH330136-31	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ONEONTA CLINIC	ONEONTA CLINIC	ONEONTA	NY	Terminated
SCH330136-32	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ONEONTA SURGEONS & SPECIALISTS	ONEONTA SURGEONS & SPECIALISTS	ONEONTA	NY	Terminated
SCH330136-33	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HARTWICK SEMINARY SPEC SVCS	HARTWICK SEMINARY SPEC SVCS	MILFORD	NY	Active
SCH330136-34	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HAMILTON SPECIALTY CENTER	HAMILTON SPECIALTY CENTER	HAMILTON	NY	Active
SCH330136-35	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HERKIMER PROCEDURES	HERKIMER PROCEDURES	HERKIMER	NY	Terminated
SCH330136-36	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HERKIMER RADIOLOGY	321 EAST ALBANY STREET	HERKIMER	NY	Active
SCH330136-37	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	NORTH REGIONAL LAB	NORTH REGIONAL LAB	HERKIMER	NY	Terminated
SCH330136-38	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ONEONTA PEDIATRICS	ONEONTA PEDIATRICS	ONEONTA	NY	Active
SCH330136-39	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	OSS RADIOLOGY	7 ASSOCIATE DRIVE	ONEONTA	NY	Terminated
SCH330136-40	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HERKIMER HEALTH PEDIATRICS	HERKIMER HEALTH PEDIATRICS	HERKIMER	NY	Active
SCH330136-41	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	FAMILY MEDICINE ONEONTA	FAMILY MEDICINE ONEONTA	ONEONTA	NY	Terminated
SCH330136-42	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ONEONTA WOMENS HEALTH SVC	ONEONTA WOMENS HEALTH SVC	ONEONAT	NY	Terminated
SCH330136-43	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	CLINTON HEALTH CENTER	CLINTON HEALTH CENTER	CLINTON	NY	Active
SCH330136-44	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ONEONTA SURGICAL ASSOCIATES	ONEONTA SURGICAL ASSOCIATES	ONEONTA	NY	Terminated
SCH330136-45	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	CENTER FOR WOUND HEALING	CENTER FOR WOUND HEALING	MILFORD	NY	Terminated
SCH330136-46	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	INTERVENTIONAL PAIN MANAGEMENT	INTERVENTIONAL PAIN MANAGEMENT	MILFORD	NY	Terminated
SCH330136-47	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	RICH SPA CENTRAL SCHOOL	RICH SPA CENTRAL SCHOOL	RICHFIELD SPRINGS	NY	Terminated
SCH330136-48	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	UNADILLA VALLEY CENTRAL SCHOOL	UNADILLA VALLEY CENTRAL SCHOOL	NEW BERLIN	NY	Active
SCH330136-49	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	MILFORD CENTRAL SCHOOL	MILFORD CENTRAL SCHOOL	MILFORD	NY	Active
SCH330136-50	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SIDNEY	SIDNEY	SIDNEY	NY	Terminated
SCH330136-51	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	OSS CONVENIENT CARE	OSS CONVENIENT CARE	ONEONTA	NY	Active
SCH330136-52	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	STAMFORD CENTRAL SCHOOL	STAMFORD CENTRAL SCHOOL	STAMFORD	NY	Active
SCH330136-54	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SIDNEY M-H SCHOOL	SIDNEY M-H SCHOOL	SIDNEY	NY	Terminated
SCH330136-55	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SIDNEY ELEM SCHOOL	SIDNEY ELEM SCHOOL	SIDNEY	NY	Terminated
SCH330136-56	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	COOPERSTOWN SCHOOL HEALTH CNT	COOPERSTOWN SCHOOL HEALTH CNT	COOPERSTOWN	NY	Active
SCH330136-57	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	WORCESTER SCHOOL HEALTH CNT	WORCESTER SCHOOL HEALTH CNT	WORCESTER	NY	Active
SCH330136-58	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	MIDDLEBURGH SCHOOL HEALTH CNT	MIDDLEBURGH SCHOOL HEALTH CNT	MIDDLEBURGH	NY	Active
SCH330136-59	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	MIDDLEBURGH HEALTH CENTER	MIDDLEBURGH HEALTH CENTER	MIDDLEBURGH	NY	Active
SCH330136-60	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HERKIMER SPECIALTY CLINIC	HERKIMER SPECIALTY CLINIC	HERKIMER	NY	Terminated
SCH330136-61	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	UNIDILLA HEALTH CENTER	UNIDILLA HEALTH CENTER	UNADILLA	NY	Terminated
SCH330136-62	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	WEST WINFIELD HEALTH CENTER	WEST WINFIELD HEALTH CENTER	WEST WINFIELD	NY	Terminated
SCH330136-63	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	ST JOHNSVILLE HEALTH CENTER	ST JOHNSVILLE HEALTH CENTER	ST JOHNSVILLE	NY	Terminated
SCH330136-65	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	LITTLE FALLS SPECIALTY CLINIC	LITTLE FALLS	LITTLE FALLS	NY	Active
SCH330136-66	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SHERBURNE SCHOOL HEALTH CTR	SHERBURNE SCHOOL HEALTH CTR	SHERBURNE	NY	Active
SCH330136-67	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SOUTH KORTRIGHT CLINIC	SOUTH KORTRIGHT	SOUTH KORTRIGHT	NY	Terminated
SCH330136-68	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HERKIMER CONVENIENT CARE	HERKIMER CONVENIENT CARE	HERKIMER	NY	Active
SCH330136-69	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	DELHI SCHOOL HEALTH PROGRAM	DELHI SCHOOL HEALTH PROGRAM	DELHI	NY	Terminated
SCH330136-70	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HEALTHZONE LAURENS	HEALTHZONE LAURENS	MORRIS	NY	Terminated
SCH330136-71	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HEALTHZONE EDMESTON	HEALTHZONE EDMESTON	EDMESTON	NY	Active
SCH330136-72	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HEALTHZONE MORRIS	HEATLHZONE MORRIS	MORRIS	NY	Active
SCH330136-73	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	STAMFORD CLINIC	STAMFORD CLINIC	STAMFORD	NY	Terminated
SCH330136-74	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	DELHI FAMILY PRACTICE	DELHI FAMILY PRACTICE	DELHI	NY	Terminated
SCH330136-75	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	DELHI DENTAL OFFICE	DELHI DENTAL OFFICE	DELHI	NY	Active
SCH330136-76	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	LITTLE FALLS HEALTH CENTER	LITTLE FALLS HEALTH CENTER	LITTLE FALLS	NY	Terminated
SCH330136-77	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	SCHENEVUS CENTRAL SCHOOL	SCHENEVUS CENTRAL SCHOOL	SCHENEVUS	NY	Active
SCH330136-78	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE PSYCHIATRIC CLINIC	BASSETT HEALTHCARE PSYCHIATRIC CLINIC	COOPERSTOWN	NY	Terminated
SCH330136-79	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE HERKIMER CLINIC Cancer TMNT	BASSETT HEALTHCARE HERKIMER CLINIC	HERKIMER	NY	Terminated
SCH330136-80	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Herkimer Health Center	Herkimer Health Center	Herkimer	NY	Active
SCH330136-81	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE DELHI II - Delhi Healthcare Center	460 ANDES RD	DELHI	NY	Active
SCH330136-82	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare at Springbrook SBHC - Springbrook School Based Health Clinic	105 Campus Road	Oneonta	NY	Active
SCH330136-83	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Healthzone at Laurens - Healthzone at Laurens Central School	55 Main Street	Laurens	NY	Active
SCH330136-84	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Hamilton Radiology - Hamilton-Madison SS Radiology - Ultrasound	1055 Madison Marketplace	Hamilton	NY	Active
SCH330136-86	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Center - Delaware Academy - Delhi School Based Health Clinic (SBHC)	2 Sheldon Drive	Delhi	NY	Active
SCH330136-87	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare at South Kortright SBHC - BH Central School School Based Health Clinic (SBHC)	58200 State Highway 10	South Kortright	NY	Active
SCH330136-88	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare at Oneonta Specialty Center - Oneonta Specialty Eyewear Center	1 Associate Drive	Oneonta	NY	Active
SCH330136-89	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE NETWORK HAMILTON - Hamilton-Madison Health Center	1055 MADISON MARKETPLACE	HAMILTON	NY	Active
SCH330136-90	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE ONEONTA - Oneonta Healthcare Center	125 MAIN ST	ONEONTA	NY	Active
SCH330136-91	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Cooperstown Central -Middle/High SBHC - Cooperstown Middle/High School Based Health Clinic	39 Linden Ave.	Cooperstown	NY	Active
SCH330136-92	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Oneonta Womens Health - Oneonta Womens Health	7 Associate Drive	Oneonta	NY	Active
SCH330136-93	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HEALTHCARE EDMESTON - Edmeston Healthcare Center	15 TURNER LANE	EDMESTON	NY	Active
SCH330136-94	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare at Gilbertsville-Mount Upton Central School - Gilbertsville-Mount Upton Central School Based Clinic	693 State Highway 51	Gilbertsville	NY	Active
SCH330136-95	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	BASSETT HC ONEONTA SPECIALTY SVCS - Oneonta Specialty Services	1 ASSOCIATE DR	ONEONTA	NY	Active
SCH330136-96	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Orthopedics at FoxCare - FoxCare Orthopedics Clinic	1 Foxcare Drive	Oneonta	NY	Active
SCH330136-97	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare Oneonta Specialty Procedures Clinic - Oneonta Specialty Procedures Clinic	1 Associate Drive	Oneonta	NY	Active
SCH330136-98	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	HARTWICK SEMINARY SPECIALTY SERVICE - Wound Care Center	4580 STATE HIGHWAY 28	MILFORD	NY	Active
SCH330136-99	Child	SCH	MARY IMOGENE BASSETT HOSPITAL	Bassett Healthcare at Middleburgh Elementary SBHC - Middleburgh Elementary School Based Health Clinic	245-1 Main Street	Middleburgh	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	10/8/2021 8:27 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	10/8/2021 8:27 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	10/8/2021 8:27 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	10/8/2021 8:27 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	10/8/2021 8:27 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 12:25:26 PM	8/16/2021 12:52:08 PM	8/16/2021 12:52 PM
Contacts	Primary Contact	Update	Change Request	Sweet, Michael A. Director Finance Operations Mary Imogene Bassett Hospital 6075476775	McCall, Russell 340B Coordinator Bassett Healthcare Network 6075473347	2/28/2021 10:16 PM
Contacts	Authorizing Official	Update	Change Request	LeCates, MD, William President CEO BMC Bassett Medical Center 6075477600	Swinko, Paul CFO Bassett Healthcare Network 6075473096	12/23/2020 1:52 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 8:48:49 AM	9/2/2020 12:25:26 PM	9/2/2020 12:25 PM
Details	Last Recertification Date	Update	Recertification	8/29/2018 1:19:37 PM	8/27/2019 8:48:49 AM	8/27/2019 8:48 AM
Contacts	Primary Contact	Update	Change Request	Partenza, Anthony D. Senior Director, Finance-Hospital & Physician Services Mary Imogene Bassett Hospital 6075473736	Sweet, Michael A. Director Finance Operations Mary Imogene Bassett Hospital 6075476775	1/3/2019 5:15 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 9:41:43 AM	8/29/2018 1:19:37 PM	8/29/2018 1:19 PM
Contacts	Authorizing Official	Update	Change Request	Tengeres, Michael J. Corporate Vice President - CFO Mary Imogene Bassett Hospital 6075473635	LeCates, MD, William President CEO BMC Bassett Medical Center 6075477600	7/18/2018 7:20 AM
Details	Last Recertification Date	Update	Recertification	10/26/2017 9:30:46 AM	11/7/2017 9:41:43 AM	11/7/2017 9:41 AM
Contacts	Primary Contact	Insert	Recertification		Partenza, Anthony D. Senior Director, Finance-Hospital & Physician Services Mary Imogene Bassett Hospital 6075473736	10/26/2017 9:30 AM
Details	Last Recertification Date	Update	Recertification		10/26/2017 9:30:46 AM	10/26/2017 9:30 AM
Contacts	Authorizing Official	Update		Tengeres, Michael J. Corporate Vice President - CFO 6075473635	Tengeres, Michael J. Corporate Vice President - CFO Mary Imogene Bassett Hospital 6075473635	10/6/2017 3:51 PM
Contacts	Signed By	Update		Tengeres, Michael J. Corporate Vice President - CFO 6075473635	Tengeres, Michael J. Corporate Vice President - CFO Mary Imogene Bassett Hospital 6075473635	10/6/2017 3:51 PM
Contacts	Authorizing Official	Insert			Tengeres, Michael J. Corporate Vice President - CFO 6075473635	7/7/2017 6:34 PM
Contacts	Signed By	Insert			Tengeres, Michael J. Corporate Vice President - CFO 6075473635	7/7/2017 6:34 PM
Addresses	Main Address	Insert			STAMFORD CLINIC 28650 STATE HIGHWAY 23 STAMFORD, NY 12167	7/7/2017 6:34 PM
Addresses	Billing Address	Insert			MARY IMOGENE BASSETT HOSPITAL ONE ATWELL ROAD COOPERSTOWN, NY 13326	7/7/2017 6:34 PM
Dates	Participating Approval Date	Update			4/26/2017 12:00:00 AM	4/26/2017 5:46 PM
Details	State	Update		Pending	Active	4/26/2017 5:46 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/26/2017 5:46 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75854	SCH330136-73	4/26/2017 12:21 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75854	4/4/2017 10:10 AM
Details	Last Recertification Date	Insert				4/4/2017 10:10 AM
Details	Grant Number	Insert				4/4/2017 10:10 AM
Details	340B ID	Insert				4/4/2017 10:10 AM
Details	Is Authorizing Official EHB Data	Insert				4/4/2017 10:10 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/4/2017 10:10 AM
Details	Medicare Provider Number	Insert			330136	4/4/2017 10:10 AM
Details	Entity Name	Insert			MARY IMOGENE BASSETT HOSPITAL	4/4/2017 10:10 AM
Details	Program Code	Insert			SCH	4/4/2017 10:10 AM
Details	Entity Subname	Insert			STAMFORD CLINIC	4/4/2017 10:10 AM
Dates	Participating Approval Date	Insert				4/4/2017 10:10 AM
Details	State	Insert			Pending	4/4/2017 10:10 AM
Dates	Registration Date	Insert			4/4/2017 12:00:00 AM	4/4/2017 10:10 AM
Dates	Signed By Date	Insert			4/4/2017 12:00:00 AM	4/4/2017 10:10 AM
Dates	Start Date	Insert				4/4/2017 10:10 AM
Terminations	Termination Comments	Insert				4/4/2017 10:10 AM
Terminations	Termination Date	Insert				4/4/2017 10:10 AM
Terminations	Termination Effective Date	Insert				4/4/2017 10:10 AM
Terminations	Termination Reason	Insert				4/4/2017 10:10 AM