Covered Entity Details

DSH450037M GOOD SHEPHERD MEDICAL CENTER (Terminated) - information as of 4/29/2025 12:33:10 AM

Main Details

Name

GOOD SHEPHERD MEDICAL CENTER

Subdivision Name

Cardiac Rehabilitation

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450037M

Medicare Provider Number

450037

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/17/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/25/2017

Last Recertification Date

8/28/2018

Termination Date
Termination Reason

7/1/2019
Other

Contacts

Authorizing Official

Christus Good Shepherd Medical Center
Jason Adams, COO
(903) 315-2440

Primary Contact

Christus Good Shepherd Medical Center
Jonathan Taylor Brown, Director
(903) 315-2019

Addresses

Street Address

3133 GOOD SHEPHERD WAY
LONGVIEW, TX 75605-7921

Billing Address

Good Shepherd Medical Center - Longview
700 E. Marshall Ave
Longview, TX 75601

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
TX	094095902

Shipping Addresses

Shipping Address 1

Good Shepherd Medical Center - Longview
700 E. Marshall Ave
700 E. Marshall Ave
Longview, TX 75601

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
DSH450037A	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	The Neurological Clinic	701 E. Marshall Ave	Longview	TX	Terminated
DSH450037B	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Good Shepherd Medicine Clinic	103 W Loop 281	Longview	TX	Terminated
DSH450037C	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	East Texas Gastroenteroogy Associates	701 E. Marshall Ave.	Longview	TX	Terminated
DSH450037D	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Kilgore ED	1612 South Henderson Blvd.	Kilgore	TX	Terminated
DSH450037E	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Longview NorthPark Emergency Department	323 EAST HAWKINS PARKWAY	LONGVIEW	TX	Terminated
DSH450037G	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Outpatient Imaging	701 E. Marshall Ave, Suite 104	Longview	TX	Terminated
DSH450037H	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Infusion Clinic	700 E MARSHALL AVE	LONGVIEW	TX	Terminated
DSH450037J	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Outpatient Imaging	323 East Hawkins Parkway Suite B	Longview	TX	Terminated
DSH450037K	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Breast Center at Good Shepherd	705 E MARSHALL AVE SUITE 1003	LONGVIEW	TX	Terminated
DSH450037L	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Center for Wound Healing and Hyperbaric Medicine	705 E. Marshall Ave, Suite 1004	Longview	TX	Terminated
DSH450037M	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Cardiac Rehabilitation	3133 GOOD SHEPHERD WAY	LONGVIEW	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/1/2018 12:00:00 AM	6/13/2019 11:36 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/13/2019 11:36 AM
Terminations	Termination Comments	Update	Termination Request		GSMC Longview location consolidated under GSMC Marshall 340BID (DSH450032) when hospitals merged.	6/13/2019 11:36 AM
Terminations	Termination Date	Update	Termination Request		7/1/2019 12:00:00 AM	6/13/2019 11:36 AM
Terminations	Termination Effective Date	Update	Termination Request		1/1/2018 12:00:00 AM	6/13/2019 11:36 AM
Terminations	Termination Reason	Update	Termination Request		Other	6/13/2019 11:36 AM
Details	Last Recertification Date	Update	Recertification	11/27/2017 3:24:01 PM	8/28/2018 5:06:06 PM	8/28/2018 5:06 PM
Contacts	Primary Contact	Update	Change Request	Osburg, Brad Director of Pharmacy CHRISTUS Good Shepherd Medical Center 9033152938	Brown, Jonathan Taylor Director Christus Good Shepherd Medical Center 9033152019	6/14/2018 11:26 AM
Contacts	Primary Contact	Insert	Recertification		Osburg, Brad Director of Pharmacy CHRISTUS Good Shepherd Medical Center 9033152938	11/27/2017 3:24 PM
Details	Last Recertification Date	Update	Recertification		11/27/2017 3:24:01 PM	11/27/2017 3:24 PM
Contacts	Authorizing Official	Update	AO Change Request	ADAMS, JASON COO 9033152440	Adams, Jason COO Christus Good Shepherd Medical Center 9033152440	11/16/2017 10:55 AM
Contacts	Authorizing Official	Update		SHORT, RON EXECUTIVE VICE PRESIDENT/CAO 9033151121	ADAMS, JASON COO 9033152440	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			SHORT, RON EXECUTIVE VICE PRESIDENT/CAO 9033151121	6/15/2017 8:42 AM
Contacts	Signed By	Insert			SHORT, RON EXECUTIVE VICE PRESIDENT/CAO 9033151121	6/15/2017 8:42 AM
Addresses	Main Address	Insert			3133 GOOD SHEPHERD WAY LONGVIEW, TX 75605-7921	4/25/2017 2:04 PM
Addresses	Billing Address	Insert			Good Shepherd Medical Center - Longview 700 E. Marshall Ave Longview, TX 75601	4/25/2017 2:04 PM
Addresses	Shipping Address	Insert			Good Shepherd Medical Center - Longview 700 E. Marshall Ave 700 E. Marshall Ave Longview, TX 75601	4/25/2017 2:04 PM
Dates	Participating Approval Date	Update			4/25/2017 12:00:00 AM	4/25/2017 2:04 PM
Details	State	Update		Pending	Active	4/25/2017 2:04 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/25/2017 2:04 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_77401	DSH450037M	4/18/2017 11:42 AM
Details	Entity Subname	Update		GOOD SHEPHERD MEDICAL CENTER	Cardiac Rehabilitation	4/18/2017 11:30 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_77401	4/17/2017 5:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 5:47 PM
Medicaid Billing	Medicaid: Number	Insert			094095902	4/17/2017 5:47 PM
Medicaid Billing	Medicaid: State	Insert			TX	4/17/2017 5:47 PM
Details	Last Recertification Date	Insert				4/17/2017 5:47 PM
Details	Grant Number	Insert				4/17/2017 5:47 PM
Details	340B ID	Insert				4/17/2017 5:47 PM
Details	Is Authorizing Official EHB Data	Insert				4/17/2017 5:47 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/17/2017 5:47 PM
Details	Medicare Provider Number	Insert			450037	4/17/2017 5:47 PM
Details	Entity Name	Insert			GOOD SHEPHERD MEDICAL CENTER	4/17/2017 5:47 PM
Details	Program Code	Insert			DSH	4/17/2017 5:47 PM
Details	Entity Subname	Insert			GOOD SHEPHERD MEDICAL CENTER	4/17/2017 5:47 PM
Dates	Participating Approval Date	Insert				4/17/2017 5:47 PM
Details	State	Insert			Pending	4/17/2017 5:47 PM
Dates	Registration Date	Insert			4/17/2017 12:00:00 AM	4/17/2017 5:47 PM
Dates	Signed By Date	Insert			4/17/2017 12:00:00 AM	4/17/2017 5:47 PM
Dates	Start Date	Insert				4/17/2017 5:47 PM
Terminations	Termination Comments	Insert				4/17/2017 5:47 PM
Terminations	Termination Date	Insert				4/17/2017 5:47 PM
Terminations	Termination Effective Date	Insert				4/17/2017 5:47 PM
Terminations	Termination Reason	Insert				4/17/2017 5:47 PM