| Contacts | Authorizing Official | Update | Change Request | Membel, Brad
CFO
Peacehealth
5412222303 | McGovern, James
Chief Hospital Executive, Oregon
PeaceHealth
5412222303 | 11/7/2024 1:24 PM |
| Details | Last Recertification Date | Update | Recertification | 8/14/2023 6:36:42 PM | 8/16/2024 10:52:55 AM | 8/16/2024 10:52 AM |
| Contacts | Primary Contact | Update | Change Request | Ripley, Greg
Director of Pharmacy
Peacehealth
5412221364 | Kindell, Adriane
340B System Program Supervisor
PeaceHealth
3604142137 | 1/8/2024 7:15 AM |
| Contacts | Authorizing Official | Update | Change Request | Hedden, Tyler Lewis
COO Oregon Network
PeaceHealth
5412222004 | Membel, Brad
CFO
Peacehealth
5412222303 | 9/11/2023 2:40 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2022 12:41:13 PM | 8/14/2023 6:36:42 PM | 8/14/2023 6:36 PM |
| Contacts | Authorizing Official | Update | Change Request | Morgan, Jeff Hunter
CFO Interim
Peacehealth
5412222513 | Hedden, Tyler Lewis
COO Oregon Network
PeaceHealth
5412222004 | 1/10/2023 3:57 PM |
| Contacts | Authorizing Official | Update | Change Request | Warda, Paul J
CFO
Peace Health - Riverbend
5412222034 | Morgan, Jeff Hunter
CFO Interim
Peacehealth
5412222513 | 10/24/2022 3:46 PM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 10:01:11 AM | 9/2/2022 12:41:13 PM | 9/2/2022 12:41 PM |
| Addresses | Shipping Address | Insert | Recertification | | Sacred Heart Medical Center
3333 Riverbend Dr.
Springfield, OR 97477 | 9/9/2021 10:01 AM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2020 5:59:10 PM | 9/9/2021 10:01:11 AM | 9/9/2021 10:01 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1083888515 ( ) | | 8/28/2020 5:59 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1083888515 | 8/28/2020 5:59 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | OR | 8/28/2020 5:59 PM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2019 11:01:18 AM | 8/28/2020 5:59:10 PM | 8/28/2020 5:59 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/8/2020 1:56 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 276221 | 3/8/2020 1:56 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 3/8/2020 1:56 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1083888515 | 3/8/2020 1:56 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2018 9:11:28 PM | 8/19/2019 11:01:18 AM | 8/19/2019 11:01 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Blake, Robert
Cheif Operating Officer
Peacehealth Sacred Heart Medical Center
5412222004 | Warda, Paul J
CFO
Peace Health - Riverbend
5412222034 | 3/27/2019 7:16 AM |
| Details | Last Recertification Date | Update | Recertification | 11/13/2017 1:45:26 PM | 8/26/2018 9:11:28 PM | 8/26/2018 9:11 PM |
| Contacts | Authorizing Official | Update | Change Request | McMurren, Mary Anne
Interim COO
PeaceHealth
5143381656 | Blake, Robert
Cheif Operating Officer
Peacehealth Sacred Heart Medical Center
5412222004 | 3/26/2018 2:55 PM |
| Details | Last Recertification Date | Update | Recertification | | 11/13/2017 1:45:26 PM | 11/13/2017 1:45 PM |
| Contacts | Authorizing Official | Update | | McMurren, Mary Anne
Interim COO
5143381656 | McMurren, Mary Anne
Interim COO
PeaceHealth
5143381656 | 9/25/2017 7:54 PM |
| Contacts | Signed By | Update | | McMurren, Mary Anne
Interim COO
5143381656 | McMurren, Mary Anne
Interim COO
PeaceHealth
5143381656 | 9/25/2017 7:54 PM |
| Contacts | Primary Contact | Update | | Ripley, Greg
Director of Pharmacy
5412221364 | Ripley, Greg
Director of Pharmacy
Peacehealth
5412221364 | 9/25/2017 7:13 PM |
| Addresses | Main Address | Insert | | |
3377 RiverBend Dr.
Springfield, OR 97477 | 8/1/2017 9:59 AM |
| Addresses | Billing Address | Insert | | | PeaceHealth System Services
1115 SE 164th Ave
Vancouver, WA 98683 | 8/1/2017 9:59 AM |
| Contacts | Primary Contact | Insert | | | Ripley, Greg
Director of Pharmacy
5412221364 | 8/1/2017 9:59 AM |
| Contacts | Authorizing Official | Insert | | | McMurren, Mary Anne
Interim COO
5143381656 | 8/1/2017 9:59 AM |
| Contacts | Signed By | Insert | | | McMurren, Mary Anne
Interim COO
5143381656 | 8/1/2017 9:59 AM |
| Details | State | Update | | Approved | Active | 8/1/2017 9:59 AM |
| Dates | Participating Approval Date | Update | | | 8/1/2017 12:00:00 AM | 8/1/2017 9:58 AM |
| Details | State | Update | | Pending | Approved | 8/1/2017 9:58 AM |
| Dates | Start Date | Update | | | 10/1/2017 12:00:00 AM | 8/1/2017 9:58 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_78465 | DSH380102A | 7/25/2017 10:56 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_78465 | 7/13/2017 2:26 PM |
| Details | Last Recertification Date | Insert | | | | 7/13/2017 2:26 PM |
| Details | Grant Number | Insert | | | | 7/13/2017 2:26 PM |
| Details | 340B ID | Insert | | | | 7/13/2017 2:26 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/13/2017 2:26 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/13/2017 2:26 PM |
| Details | Medicare Provider Number | Insert | | | 380102 | 7/13/2017 2:26 PM |
| Details | Entity Name | Insert | | | SHMC-RIVERBEND | 7/13/2017 2:26 PM |
| Details | Program Code | Insert | | | DSH | 7/13/2017 2:26 PM |
| Details | Entity Subname | Insert | | | RiverBend Pavilion / O/P Gastro Endo Lab | 7/13/2017 2:26 PM |
| Dates | Participating Approval Date | Insert | | | | 7/13/2017 2:26 PM |
| Details | State | Insert | | | Pending | 7/13/2017 2:26 PM |
| Dates | Registration Date | Insert | | | 7/13/2017 12:00:00 AM | 7/13/2017 2:26 PM |
| Dates | Signed By Date | Insert | | | 7/13/2017 12:00:00 AM | 7/13/2017 2:26 PM |
| Dates | Start Date | Insert | | | | 7/13/2017 2:26 PM |
| Terminations | Termination Comments | Insert | | | | 7/13/2017 2:26 PM |
| Terminations | Termination Date | Insert | | | | 7/13/2017 2:26 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/13/2017 2:26 PM |
| Terminations | Termination Reason | Insert | | | | 7/13/2017 2:26 PM |