Covered Entity Details

DSH030064Y Banner - University Medical Center Tucson (Terminated) - information as of 4/28/2025 1:50:16 AM

Main Details

Name

Banner - University Medical Center Tucson

Subdivision Name

Surgery 4OPC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030064Y

Medicare Provider Number

030064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/17/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/28/2017

Last Recertification Date

9/4/2020

Termination Date
Termination Reason

7/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Banner University Medical Centers Tucson and South
Brad Hipp, Chief Financial Officer
(520) 694-3446

Primary Contact

Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061

Addresses

Street Address

3838 N Campbell Ave
Tucson, AZ 85719

Billing Address

Banner University Medical Center Tucson
1625 North Campbell Avenue
Tucson, AZ 85719

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
NV	100542115	1265820179,1508809427,1649668450
AZ	020470-01,988439	1265820179,1508809427,1649668450
CO	9000142345	1265820179,1508809427,1649668450
NE	10026590500	1265820179,1508809427,1649668450
WY	145728400	1265820179,1508809427,1649668450

Shipping Addresses

Shipping Address 1

Banner University Medical Center Tucson
1625 North Campbell Avenue
(Drachman & Warren Ave)
Tucson, AZ 85719

Shipping Address 2

Banner Health
7300 W. Detroit St.
Chandler, AZ 85226

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
DSH030064A	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-PANTANO	7901 EAST 22ND STREET	TUCSON	AZ	Terminated
DSH030064AA	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Orthopedics-clinic	265 West Ina Road	Tucson	AZ	Active
DSH030064AB	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Internal Med Clinic	265 West Ina Road	Tucson	AZ	Terminated
DSH030064AC	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Nephrology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AD	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Internal Med Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AE	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Podiatry-clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AF	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Urology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AG	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Cardiology-clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AH	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC - GV Gynecology Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AJ	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC GV Otolaryngology-Clin	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AK	Child	DSH	Banner - University Medical Center Tucson	Alvernon - Alvernon Orthopedics-Clinic	707 North Alvernon Way	Tucson	AZ	Active
DSH030064AL	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Pediatrics Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AM	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC-Pan Geriatrics-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AN	Child	DSH	Banner - University Medical Center Tucson	Pantano - Pantano Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AP	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Internal Med-Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AQ	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-Pan Gynecology-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AR	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-CardioThoracic-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Urology-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AT	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Vascular-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Support Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064AV	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurosurgery-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AW	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Int Med/Geriatrics-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AX	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Nephrology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AY	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Endo-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AZ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurology Gen-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064B	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-NORTH HILLS	265 WEST INA ROAD	TUCSON	AZ	Active
DSH030064BA	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-ENT-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BB	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Infect Disease-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BC	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Diagnostic Cardiol-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BD	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pacemaker-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BE	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Gastroenterology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BF	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pulmonary Fnct Test-Cli-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BG	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Rheumatology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BH	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Podiatry-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BJ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Radiation Oncology-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BK	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Primary Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BL	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-OB/GYN-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BM	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Ambdom Transplant-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BN	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Trauma/Burn-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BP	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Sleep-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BQ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Allergy-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BR	Child	DSH	Banner - University Medical Center Tucson	Clinic F Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - Surg OP-20PC-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BT	Child	DSH	Banner - University Medical Center Tucson	Clinic H Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Cardiology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BV	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic-Hosp	3838 North Campbell Ave	Tucson	AZ	Terminated
DSH030064BW	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic	3838 North Campbell Ave	Tucson	AZ	Active
DSH030064BX	Child	DSH	Banner - University Medical Center Tucson	C/P-NC Hemonc - Clinic - Hematology / Oncology	3838 N. Campbell Avenue,	Tucson	AZ	Active
DSH030064BY	Child	DSH	Banner - University Medical Center Tucson	PBC UC-NH Pediatrics - Clinic - Pediatrics	265 West Ina Road	Tucson	AZ	Active
DSH030064BZ	Child	DSH	Banner - University Medical Center Tucson	C/P-Imaging-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CA	Child	DSH	Banner - University Medical Center Tucson	ENT Audiology-Clinic-NC - Audiology	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CB	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Gen Surg - Clinic - General Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CC	Child	DSH	Banner - University Medical Center Tucson	PBC UG-GV Vascular Surg Clinic - Vascular Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CD	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Psych-Clinic-NC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064CE	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Cancer Genetics Counsel-Hosp	3838 N Campbell Ave	Tucson	AZ	Active
DSH030064CF	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Pantano Clinic	7901 E 22ND ST	TUCSON	AZ	Active
DSH030064CG	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Green Valley Clinic-Clinic	1141 S LA CANADA DR	GREEN VALLEY	AZ	Active
DSH030064CH	Child	DSH	Banner - University Medical Center Tucson	NORTH HILLS - PBC-UC Pain Mgmt-Clinic	1891 WEST ORANGE GROVE ROAD	Tucson	AZ	Active
DSH030064CJ	Child	DSH	Banner - University Medical Center Tucson	CLINIC - Plastics Surg-Clinic-NC	3838 NORTH CAMPBELL AVE, BUILDING 2, CLINIC H, 3RD FLOOR	Tucson	AZ	Active
DSH030064H	Child	DSH	Banner - University Medical Center Tucson	Outpatient Infusion-Hosp	3838 North Campbell Avenue	Tucson	AZ	Active
DSH030064I	Child	DSH	Banner - University Medical Center Tucson	C/P-OG Hemeonc-Clinic	1891 W. ORANGE GROVE RD	TUCSON	AZ	Active
DSH030064J	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Primary Care-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064K	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon Surgery Center	750 North Alvernon Way	Tucson	AZ	Terminated
DSH030064L	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon	707 North Alvernon Way	Tucson	AZ	Terminated
DSH030064M	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC La Cholla Clinic	6261 North La Cholla	Tucson	AZ	Terminated
DSH030064N	Child	DSH	Banner - University Medical Center Tucson	Banner - University Medical Imaging (UMI)	4291 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064P	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Urology	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064Q	Child	DSH	Banner - University Medical Center Tucson	C/P-Mohs Dermatology Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064R	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Radiation Oncology at Orange Grove	1891 W. Orange Grove Rd	Tucson	AZ	Terminated
DSH030064S	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Bone Marrow Transplant Adult	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064T	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - North Campus Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064U	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC Bone Marrow Transplant (BMT)	1625 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064V	Child	DSH	Banner - University Medical Center Tucson	Banner - Arizona Cancer Center - Lab - North Campus	3838 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064W	Child	DSH	Banner - University Medical Center Tucson	Surgery 6OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064X	Child	DSH	Banner - University Medical Center Tucson	Surgery 5OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Y	Child	DSH	Banner - University Medical Center Tucson	Surgery 4OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Z	Child	DSH	Banner - University Medical Center Tucson	Medicine 2OPC	3838 N Campbell Ave	Tucson	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/1/2020 12:00:00 AM	4/16/2021 12:55 PM
Details	State	Update	Termination Request	Active	To Be Terminated	4/16/2021 12:55 PM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	4/16/2021 12:55 PM
Terminations	Termination Effective Date	Update	Termination Request		4/15/2021 12:00:00 AM	4/16/2021 12:55 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	4/16/2021 12:55 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	425805300 (MD)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MI)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200784450A (OK)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100564160 (KY)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500707030 (OR)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387902 (TX)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387901 (TX)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0635921 (MT)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1657501 (AK)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (CT)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003189644A (GA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (IA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (ID)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2432435 (LA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MN)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00096009 (MS)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (NC)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	19852088 (NM)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1031106620001 (PA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11566A (SC)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q028631 (TN)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (UT)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2017276884 (VA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2060663 (WA)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100063007 (WI)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0596345 (NJ)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TX)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TX)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TX)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MS)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MS)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MS)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (GA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (GA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (GA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NJ)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NJ)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NJ)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (PA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (PA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (PA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (SC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (SC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (SC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (CT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (CT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (CT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (IA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (IA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (IA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (ID)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (ID)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (ID)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MN)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MN)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MN)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NC)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (UT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (UT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (UT)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MI)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (AK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (AK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (AK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NM)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NM)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NM)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OK)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (VA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (VA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (VA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (LA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (LA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (LA)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MD)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MD)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MD)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OR)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OR)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OR)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (KY)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (KY)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (KY)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TN)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TN)		2/3/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TN)		2/3/2021 4:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2020 1:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100542115	12/14/2020 1:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/14/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/14/2020 1:37 PM
Contacts	Signed By	Update	Profile Change Request	Buehrle, Jeff Allen CFO Banner Ironwood Medical Center 4803944446	Buehrle, Jeff Allen CFO Banner Ironwood Medical Center 4803944396	10/2/2020 6:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 11:35 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		395387901	9/4/2020 11:35 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/4/2020 11:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 11:35 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0635921	9/4/2020 11:35 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265820179	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	9/4/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265820179 ( )		9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649668450 ( )		9/4/2020 11:35 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1508809427 ( )		9/4/2020 11:35 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 2:14:14 PM	9/4/2020 11:35:05 AM	9/4/2020 11:35 AM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1625 N Campbell Ave Tucson, AZ 85719	Banner University Medical Center Tucson 1625 North Campbell Avenue Tucson, AZ 85719	2/3/2020 3:02 PM
Addresses	Shipping Address	Delete	Change Request	Banner University Medical Center Tucson 1625 N Campbell Ave (Drachman & Warren Ave) Tucson, AZ 85719		2/3/2020 3:02 PM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Tucson 1625 North Campbell Avenue (Drachman & Warren Ave) Tucson, AZ 85719	2/3/2020 3:02 PM
Addresses	Shipping Address	Insert	Change Request		Banner Health 7300 W. Detroit St. Chandler, AZ 85226	2/3/2020 3:02 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 2:02:22 PM	8/28/2019 2:14:14 PM	8/28/2019 2:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		425805300	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200784450A	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100564160	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500707030	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		395387902	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	8/28/2019 1:58 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	020470	020470-01	8/28/2019 1:58 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1588614911 ( )		8/28/2019 1:58 PM
Contacts	Authorizing Official	Update	Change Request	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	7/29/2019 3:24 PM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724	Banner University Medical Center Tucson 1625 N Campbell Ave Tucson, AZ 85719	5/6/2019 10:19 AM
Addresses	Shipping Address	Delete	Change Request	Banner University Medical Center Tucson 1501 N Campbell Ave (Drachman & Warren Ave) Tucson, AZ 85724		5/6/2019 10:19 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Tucson 1625 N Campbell Ave (Drachman & Warren Ave) Tucson, AZ 85719	5/6/2019 10:19 AM
Contacts	Signed By	Update	Profile Change Request	Buehrle, Jeff Allen CFO Banner Payson Medical Center 4803944396	Buehrle, Jeff Allen CFO Banner Ironwood Medical Center 4803944446	3/25/2019 11:51 AM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	9/27/2018 7:35 AM
Details	Last Recertification Date	Update	Recertification	12/4/2017 7:14:39 PM	8/30/2018 2:02:22 PM	8/30/2018 2:02 PM
Addresses	Shipping Address	Delete	Change Request	Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724		7/27/2018 10:58 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Tucson 1501 N Campbell Ave (Drachman & Warren Ave) Tucson, AZ 85724	7/27/2018 10:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/27/2018 10:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0596345	7/27/2018 10:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	7/27/2018 10:58 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1154384899 ( )		7/27/2018 10:58 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1306908355 ( )		7/27/2018 10:58 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1275921082 ( )		7/27/2018 10:58 AM
Addresses	Billing Address	Insert	Change Request		Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724	3/22/2018 11:44 AM
Addresses	Shipping Address	Insert	Change Request		Banner University Medical Center Tucson 1501 N Campbell Ave Tucson, AZ 85724	3/22/2018 11:44 AM
Addresses	Main Address	Update	Change Request	1501 N CAMPBELL AVE Room 4401 Tucson, AZ 85724	3838 N Campbell Ave Tucson, AZ 85719	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1657501	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000142345	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003189644A	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2432435	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00096009	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026590500	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		19852088	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1031106620001	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11566A	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q028631	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2017276884	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2060663	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100063007	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		145728400	3/22/2018 11:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	3/22/2018 11:44 AM
Details	Entity Name	Update	Recertification	BANNER UNIVERSITY MED CENTER TUCSON	Banner - University Medical Center Tucson	12/5/2017 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/4/2017 7:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		988439	12/4/2017 7:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	12/4/2017 7:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649668450	12/4/2017 7:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1508809427	12/4/2017 7:14 PM
Details	Last Recertification Date	Update	Recertification		12/4/2017 7:14:39 PM	12/4/2017 7:14 PM
Contacts	Primary Contact	Update		Weibel, Kurt Director of Pharmacy Services 5206946061	Weibel, Kurt Director of Pharmacy Services Banner University Medical Center Tucson 5206946061	10/13/2017 4:14 PM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance 5206943446	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	10/10/2017 3:53 PM
Contacts	Signed By	Update		Buehrle, Jeff CFO Banner Payson Medical Center 4803944396	Buehrle, Jeff Allen CFO Banner Payson Medical Center 4803944396	9/26/2017 6:13 PM
Contacts	Signed By	Update	Change Request	Buehrle, Jeff CFO 4803944396	Buehrle, Jeff CFO Banner Payson Medical Center 4803944396	9/26/2017 2:56 PM
Contacts	Authorizing Official	Update		Buehrle, Jeff CFO 4803944396	Polashek, Maurene Sr Dir Finance 5206943446	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Buehrle, Jeff CFO 4803944396	8/14/2017 5:46 PM
Contacts	Signed By	Insert			Buehrle, Jeff CFO 4803944396	8/14/2017 5:46 PM
Contacts	Primary Contact	Insert			Weibel, Kurt Director of Pharmacy Services 5206946061	6/22/2017 10:57 AM
Addresses	Main Address	Insert			1501 N CAMPBELL AVE Room 4401 Tucson, AZ 85724	4/28/2017 6:03 PM
Dates	Participating Approval Date	Update			4/28/2017 12:00:00 AM	4/28/2017 6:03 PM
Details	State	Update		Pending	Active	4/28/2017 6:03 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/28/2017 6:03 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_77442	DSH030064Y	4/25/2017 10:18 AM
Details	Entity Subname	Update		4OPC	Surgery 4OPC	4/25/2017 10:18 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_77442	4/17/2017 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			020470	4/17/2017 7:52 PM
Medicaid Billing	Medicaid: State	Insert			AZ	4/17/2017 7:52 PM
Medicaid Billing	NPI: Number	Insert			1154384899	4/17/2017 7:52 PM
Medicaid Billing	NPI: Number	Insert			1306908355	4/17/2017 7:52 PM
Medicaid Billing	NPI: Number	Insert			1588614911	4/17/2017 7:52 PM
Medicaid Billing	NPI: Number	Insert			1265820179	4/17/2017 7:52 PM
Medicaid Billing	NPI: Number	Insert			1275921082	4/17/2017 7:52 PM
Details	Last Recertification Date	Insert				4/17/2017 7:52 PM
Details	Grant Number	Insert				4/17/2017 7:52 PM
Details	340B ID	Insert				4/17/2017 7:52 PM
Details	Is Authorizing Official EHB Data	Insert				4/17/2017 7:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/17/2017 7:52 PM
Details	Medicare Provider Number	Insert			030064	4/17/2017 7:52 PM
Details	Entity Name	Insert			BANNER UNIVERSITY MED CENTER TUCSON	4/17/2017 7:52 PM
Details	Program Code	Insert			DSH	4/17/2017 7:52 PM
Details	Entity Subname	Insert			4OPC	4/17/2017 7:52 PM
Dates	Participating Approval Date	Insert				4/17/2017 7:52 PM
Details	State	Insert			Pending	4/17/2017 7:52 PM
Dates	Registration Date	Insert			4/17/2017 12:00:00 AM	4/17/2017 7:52 PM
Dates	Signed By Date	Insert			4/17/2017 12:00:00 AM	4/17/2017 7:52 PM
Dates	Start Date	Insert				4/17/2017 7:52 PM
Terminations	Termination Comments	Insert				4/17/2017 7:52 PM
Terminations	Termination Date	Insert				4/17/2017 7:52 PM
Terminations	Termination Effective Date	Insert				4/17/2017 7:52 PM
Terminations	Termination Reason	Insert				4/17/2017 7:52 PM