Covered Entity Details

DSH280013V THE NEBRASKA MEDICAL CENTER (Active) - information as of 4/23/2025 10:51:43 PM

Main Details

Name

THE NEBRASKA MEDICAL CENTER

Subdivision Name

Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH280013V

Medicare Provider Number

280013

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/30/2017

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Nebraska Medical Center
Stephanie Daubert, CFO
(402) 552-2889

Primary Contact

Nebraska Medicine
BILL BARNES, BUSINESS DIRECTOR, PHARMACY
(402) 559-9537

Addresses

Street Address

111 N 175th Street
Suite 10401
Omaha, NE 68118

Billing Address

Nebraska Medical Center
989200 Nebraska Medical Center
Omaha, NE 68198

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
NE	91185843326	1356307581,1467529727,1780135319,1942368352,1972247799,1285394049,1477264596,1770266546,1750130118
IA		1942368352,1780135319,1356307581,1467529727,1972247799,1285394049,1477264596,1770266546,1750130118

Shipping Addresses

Shipping Address 1

UNIVERSITY HOSPITAL PHARMACY DBA NEBRASKA MEDICINE
981090 Nebraska Medical Center
Omaha, NE 68198-1090

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
DSH280013AA	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - HICSA Cinic	730 S. 38th Ave	Omaha	NE	Active
DSH280013AB	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Millard-Millard Health Center	13325 Millard Ave	Omaha	NE	Active
DSH280013AC	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center Clinic - Bellevue Clinic	2510 Bellevue Medical Center Drive	Bellevue	NE	Active
DSH280013AD	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Bellevue Clinic - Immediate Care	2510 Bellevue Medical Center Drive	Bellevue	NE	Active
DSH280013AE	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Ortho Clinic	17405 Burke St.	Omaha	NE	Active
DSH280013AF	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Heart and Vascular Center	17405 Burke St.	Omaha	NE	Active
DSH280013AG	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Brentwood Clinic	8604 Giles Road	LaVista	NE	Active
DSH280013AH	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Eagle Run Clinic - Immediate Care	3685 N. 129th Street	Omaha	NE	Active
DSH280013AJ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - MRI - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013AK	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Procedure Center	111 N 175th Street	Omaha	NE	Active
DSH280013AL	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - MRI	111 N 175th Street	Omaha	NE	Terminated
DSH280013AM	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - ENT Clinic - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013AN	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Radiation Therapy	111 N 175th Street	Omaha	NE	Active
DSH280013AP	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Lab	111 N 175th Street	Omaha	NE	Active
DSH280013AQ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Ultrasound - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Terminated
DSH280013AR	Child	DSH	THE NEBRASKA MEDICAL CENTER	Elkhorn Clinic - Immediate Care Clinic	20310 Blue Sage Parkway	Omaha	NE	Terminated
DSH280013AS	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Radiology Diagnostic - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013AT	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Oral Facial Prosthetics Clinic	4014 Leavenworth Street	Omaha	NE	Active
DSH280013AU	Child	DSH	THE NEBRASKA MEDICAL CENTER	Elkhorn Clinic - Primary Care Clinic	20310 Blue Sage Parkway	Omaha	NE	Active
DSH280013AV	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICAL CENTER CLINIC - Chalco Clinic	8343 South 168th Avenue	OMAHA	NE	Active
DSH280013AW	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Radiology	111 N 175th Street	Omaha	NE	Active
DSH280013AX	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Fritch Surgery Center - Lauritzen OP Center	4014 LEAVENWORTH ST	Omaha	NE	Active
DSH280013AY	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Ortho Clinic - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013AZ	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICAL CENTER CHALCO - Immediate Care Clinic	8343 South 168th Avenue	OMAHA	NE	Active
DSH280013B	Child	DSH	THE NEBRASKA MEDICAL CENTER	UNIVERSITY HOSPITAL-CLINICAL CANCER CTR	989200 NEBRASKA MEDICAL CENTER	OMAHA	NE	Terminated
DSH280013BA	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - CT - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013BB	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Ultrasound	111 N 175th Street	Omaha	NE	Terminated
DSH280013BC	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Surgery Clinic - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013BD	Child	DSH	THE NEBRASKA MEDICAL CENTER	Lauritzen Outpatient Center - Oral Surgery Clinic - Lauritzen OP Center	4014 Leavenworth Street	Omaha	NE	Active
DSH280013BE	Child	DSH	THE NEBRASKA MEDICAL CENTER	Clarkson Family Medicine - Clinic - Clarkson Family Medicine	1319 Leavenworth St	Omaha	NE	Active
DSH280013BF	Child	DSH	THE NEBRASKA MEDICAL CENTER	Clarkson Family Medicine - Clarkson Family Medicine - ICC	1319 Leavenworth Street	Omaha	NE	Terminated
DSH280013BG	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - CT	111 N 175th Street	Omaha	NE	Terminated
DSH280013BH	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Outpatient Surgery Center	110 N 175th Street	Omaha	NE	Active
DSH280013BJ	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICAL CENTER - LOC Dermatology Clinic	4014 Leavenworth Street	Omaha	NE	Active
DSH280013BK	Child	DSH	THE NEBRASKA MEDICAL CENTER	The Nebraska Medical Center VP Int Med Rheumatology Clinic - Int Med Rheumatology Clinic	110 North 175th Street	Omaha	NE	Terminated
DSH280013BL	Child	DSH	THE NEBRASKA MEDICAL CENTER	The Nebraska Medical Center Bellevue Orthopaedics - Bellevue Ortho Clinic	2510 Bellevue Medical Center Drive	Bellevue	NE	Active
DSH280013BM	Child	DSH	THE NEBRASKA MEDICAL CENTER	The Nebraska Medical Center Twin Creek - Twin Creek Clinic	3802 Raynor Parkway	Bellevue	NE	Active
DSH280013BN	Child	DSH	THE NEBRASKA MEDICAL CENTER	Aesthetic Surgery - Aesthetic Surgery	17617 Burke Street	Omaha	NE	Terminated
DSH280013BP	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICINE INTERNAL MEDICAL - GRAND ISLAND HEALTH CENTER	729 N CUSTER AVE	GRAND ISLAND	NE	Active
DSH280013BQ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Bellevue Infusion Therapy	2500 Bellevue Medical Center Dr	Bellevue	NE	Active
DSH280013BR	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Cancer Clinic	111 N 175th Street	Omaha	NE	Active
DSH280013BS	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Facial Plastics Clinic	110 North 175th Street	Omaha	NE	Active
DSH280013BT	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Nebraska Medical Center - Village Pointe - Primary Care	110 North 175th Street	Omaha	NE	Active
DSH280013BU	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Urology	17405 BURKE ST.	Omaha	NE	Active
DSH280013BV	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Nebraska Medical Center - Clinic - Bellevue ENT	3802 Raynor Parkway	Bellevue	NE	Active
DSH280013BW	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Neurology	17405 BURKE ST.	Omaha	NE	Active
DSH280013BX	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medical Center - Village Pointe - Gastroenterology	17405 BURKE ST.	Omaha	NE	Active
DSH280013BY	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Nebraska Medical Center - Clinic - Bellevue Cardiology	2510 Bellevue Medical Center Drive	Bellevue	NE	Active
DSH280013BZ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Internal Medicine Clinic	17405 BURKE ST.	Omaha	NE	Active
DSH280013CA	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Neurophysiology	17405 BURKE ST.	Omaha	NE	Active
DSH280013CB	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Pulmonary Lab	17405 BURKE ST.	Omaha	NE	Active
DSH280013CC	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Rheumatology	110 North 175th Street	Omaha	NE	Active
DSH280013CD	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - PMED & Rehab	110 North 175th Street	Omaha	NE	Active
DSH280013CE	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Nebraska Medicine - Village Pointe - Dermatology	17405 BURKE ST.	Omaha	NE	Active
DSH280013CF	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Lauritzen Outpatient Center - Urology Clinic	4014 Leavenworth Street	Omaha	NE	Active
DSH280013CG	Child	DSH	THE NEBRASKA MEDICAL CENTER	Westroads - Clinic	10170 Nicholas St	Omaha	NE	Active
DSH280013CH	Child	DSH	THE NEBRASKA MEDICAL CENTER	Grand Island - Lab	729 N Custer Ave	Grand Island	NE	Active
DSH280013CJ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Girls Inc - Clinic	2811 N 45th St	Omaha	NE	Active
DSH280013CK	Child	DSH	THE NEBRASKA MEDICAL CENTER	Kearney - Heartland and Oncology Clinic	2232 Chancellor's Ave.	Kearney	NE	Active
DSH280013CL	Child	DSH	THE NEBRASKA MEDICAL CENTER	Oakview - DEM Clinic	2727 S. 144th Street	Omaha	NE	Active
DSH280013CM	Child	DSH	THE NEBRASKA MEDICAL CENTER	Kearney - Lab	2232 Chancellor's Ave.	Kearney	NE	Active
DSH280013CN	Child	DSH	THE NEBRASKA MEDICAL CENTER	Elkhorn - Virtual Care Clinic	20310 Blue Sage Parkway	Omaha	NE	Active
DSH280013CP	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Mammo	111 N 175th Street	Omaha	NE	Active
DSH280013CQ	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medicine - Village Pointe - Truhlsen Eye Refractive Services at Village Pointe	110 North 175th Street	Omaha	NE	Active
DSH280013CR	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICAL CENTER TRUHLSEN EYE - Refractive Services at Truhlsen Eye	3902 LEAVENWORTH ST	OMAHA	NE	Active
DSH280013CS	Child	DSH	THE NEBRASKA MEDICAL CENTER	NEBRASKA MEDICAL CENTER MIDTOWN - Midtown Immediate Care Clinic	139 S. 40TH ST.	OMAHA	NE	Active
DSH280013CT	Child	DSH	THE NEBRASKA MEDICAL CENTER	Bellevue - Multidisciplinary Clinic	2510 Bellevue Medical Center Drive	Bellevue	NE	Active
DSH280013CU	Child	DSH	THE NEBRASKA MEDICAL CENTER	Kearney - Heartland and Oncology Infusion	2232 Chancellor's Ave.	Kearney	NE	Active
DSH280013CV	Child	DSH	THE NEBRASKA MEDICAL CENTER	Village Pointe - Psychiatry	110 North 175th Street	Omaha	NE	Active
DSH280013CW	Child	DSH	THE NEBRASKA MEDICAL CENTER	Westroads - Infusion	10170 Nicholas St	Omaha	NE	Active
DSH280013CX	Child	DSH	THE NEBRASKA MEDICAL CENTER	Oakview - Diabetes Education	2727 S. 144th Street	Omaha	NE	Active
DSH280013CY	Child	DSH	THE NEBRASKA MEDICAL CENTER	Papillion - Health Center	249 Olson Dr.	Papillion	NE	Active
DSH280013D	Child	DSH	THE NEBRASKA MEDICAL CENTER	INFUSION CENTER AT VILLAGE POINTE	111 N 175th Street	OMAHA	NE	Active
DSH280013E	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Oakview - Laboratory	2727 S 144th ST.	OMAHA	NE	Active
DSH280013F	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Radiology	17405 Burke St.	OMAHA	NE	Active
DSH280013G	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - Cardiac Imaging	17405 Burke St.	OMAHA	NE	Active
DSH280013K	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center Bellevue Cancer Clinic	2510 Bellevue Medical Center Drive	BELLEVUE	NE	Active
DSH280013L	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Truhlsen Eye Institute	3902 Leavenworth St	OMAHA	NE	Active
DSH280013M	Child	DSH	THE NEBRASKA MEDICAL CENTER	SPECIALTY CARE CENTER	804 S 52nd Street	OMAHA	NE	Active
DSH280013N	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center Village Pointe - VP Eye Clinic	110 North 175th Street	Omaha	NE	Active
DSH280013P	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center Clinic - Fontenelle Clinic	5005 Ames Ave	Omaha	NE	Active
DSH280013Q	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP Plastics Clinic	17617 Burke Street	Omaha	NE	Active
DSH280013R	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP Multidisciplinary Clinic	110 North 175th Street	Omaha	NE	Terminated
DSH280013S	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP OB GYN Clinic	110 North 175th Street	Omaha	NE	Active
DSH280013T	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP ENT Clinic	110 North 175th Street	Omaha	NE	Active
DSH280013U	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP Pain Clinic	111 N 175th Street	Omaha	NE	Active
DSH280013V	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic	111 N 175th Street	Omaha	NE	Active
DSH280013W	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Midtown Clinic	139 S. 40th St.	Omaha	NE	Active
DSH280013X	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Plattsmouth Clinic	1938 Highway 34 East	Plattsmouth	NE	Active
DSH280013Y	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Bellevue Clinic - Primary Care	2510 Bellevue Medical Center	Bellevue	NE	Terminated
DSH280013Z	Child	DSH	THE NEBRASKA MEDICAL CENTER	Nebraska Medical Center - Clinic - Eagle Run Clinic	3685 N. 129th Street	Omaha	NE	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 12:51:29 PM	8/22/2024 4:22:40 PM	8/22/2024 4:22 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1750130118	5/30/2024 10:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	5/30/2024 10:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1750130118	5/30/2024 10:57 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	5/30/2024 10:57 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1770266546	11/14/2023 10:42 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	11/14/2023 10:42 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1770266546	11/14/2023 10:42 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	11/14/2023 10:42 AM
Addresses	Shipping Address	Delete	Recertification	Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic 111 N 175th Street Suite 10401 Omaha, NE 68118		8/24/2023 12:51 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 12:14:18 PM	8/24/2023 12:51:29 PM	8/24/2023 12:51 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477264596	8/1/2023 11:48 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/1/2023 11:48 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1477264596	8/1/2023 11:48 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	8/1/2023 11:48 AM
Addresses	Main Address	Update	Change Request	111 North 175th Street Omaha, NE 68118	111 N 175th Street Suite 10401 Omaha, NE 68118	2/17/2023 7:28 AM
Addresses	Shipping Address	Update	Change Request	Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic 111 North 175th Street Omaha, NE 68118	Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic 111 N 175th Street Suite 10401 Omaha, NE 68118	2/17/2023 7:28 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0507459 (IA)		9/8/2022 12:14 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0507418 (IA)		9/8/2022 12:14 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	911858433-02 (NE)		9/8/2022 12:14 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	911858433-11 (NE)		9/8/2022 12:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972247799	9/8/2022 12:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/8/2022 12:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285394049	9/8/2022 12:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/8/2022 12:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972247799	9/8/2022 12:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/8/2022 12:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285394049	9/8/2022 12:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/8/2022 12:14 PM
Details	Last Recertification Date	Update	Recertification	9/2/2021 9:05:41 AM	9/8/2022 12:14:18 PM	9/8/2022 12:14 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 3:34:27 PM	9/2/2021 9:05:41 AM	9/2/2021 9:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1356307581	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/25/2020 3:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1467529727	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/25/2020 3:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1780135319	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/25/2020 3:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942368352	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	8/25/2020 3:34 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	8/25/2020 3:34 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 11:55:32 AM	8/25/2020 3:34:27 PM	8/25/2020 3:34 PM
Details	Last Recertification Date	Update	Recertification	9/5/2018 10:45:33 AM	8/21/2019 11:55:32 AM	8/21/2019 11:55 AM
Addresses	Shipping Address	Delete	Change Request	Nebraska Medical Center 111 North 175th Street Omaha, NE 68118		4/24/2019 1:09 PM
Addresses	Shipping Address	Insert	Change Request		Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic 111 North 175th Street Omaha, NE 68118	4/24/2019 1:09 PM
Addresses	Billing Address	Insert	Change Request		Nebraska Medical Center 989200 Nebraska Medical Center Omaha, NE 68198	4/16/2019 8:48 AM
Addresses	Shipping Address	Insert	Change Request		Nebraska Medical Center 111 North 175th Street Omaha, NE 68118	4/16/2019 8:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		91185843326	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0507459	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0507418	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10025581200 (NE)		1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10025727800 (NE)		1/29/2019 2:20 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	282N00000X (IA)		1/29/2019 2:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1356307581	1/29/2019 2:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1467529727	1/29/2019 2:20 PM
Addresses	Shipping Address	Delete	Recertification	Nebraska Medical Center 981090 Nebraska Medical Center Omaha, NE 68198-1090		9/5/2018 10:45 AM
Addresses	Shipping Address	Insert	Recertification		UNIVERSITY HOSPITAL PHARMACY DBA NEBRASKA MEDICINE 981090 Nebraska Medical Center Omaha, NE 68198-1090	9/5/2018 10:45 AM
Details	Last Recertification Date	Update	Recertification		9/5/2018 10:45:33 AM	9/5/2018 10:45 AM
Addresses	Shipping Address	Insert	Change Request		Nebraska Medical Center 981090 Nebraska Medical Center Omaha, NE 68198-1090	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	91185843302	911858433-02	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		911858433-11	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025581200	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025727800	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		282N00000X	7/18/2018 3:02 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	7/18/2018 3:02 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942368352	7/18/2018 3:02 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780135319	7/18/2018 3:02 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Daubert, Stephanie CFO Nebraska Medical Center 4025522889	10/30/2017 12:43 PM
Details	340B ID	Update	New Registration		DSH280013V	10/30/2017 12:43 PM
Details	Entity Subname	Update	New Registration	Nebraska Medical Center - Village Pointe	Nebraska Medical Center - Village Pointe - VP Oral Surgery Clinic	10/30/2017 12:43 PM
Dates	Participating Approval Date	Update	New Registration		10/30/2017 12:43:03 PM	10/30/2017 12:43 PM
Details	State	Update	New Registration	Pending	Approved	10/30/2017 12:43 PM
Dates	Signed By Date	Update	New Registration		10/9/2017 3:17:18 PM	10/30/2017 12:43 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/30/2017 12:43 PM
Addresses	Main Address	Insert	New Registration		111 North 175th Street Omaha, NE 68118	10/9/2017 2:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/9/2017 2:58 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		91185843302	10/9/2017 2:58 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	10/9/2017 2:58 PM
Contacts	Primary Contact	Insert	New Registration		BARNES, BILL BUSINESS DIRECTOR, PHARMACY Nebraska Medicine 4025599537	10/9/2017 2:58 PM
Contacts	Authorizing Official	Insert	New Registration		Daubert, Stephanie CFO Nebraska Medical Center 4025522889	10/9/2017 2:58 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2017 2:58 PM
Details	Grant Number	Insert	New Registration			10/9/2017 2:58 PM
Details	340B ID	Insert	New Registration			10/9/2017 2:58 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2017 2:58 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2017 2:58 PM
Details	Medicare Provider Number	Insert	New Registration		280013	10/9/2017 2:58 PM
Details	Entity Name	Insert	New Registration		THE NEBRASKA MEDICAL CENTER	10/9/2017 2:58 PM
Details	Program Code	Insert	New Registration		DSH	10/9/2017 2:58 PM
Details	Entity Subname	Insert	New Registration		Nebraska Medical Center - Village Pointe	10/9/2017 2:58 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2017 2:58 PM
Details	State	Insert	New Registration		Pending	10/9/2017 2:58 PM
Dates	Registration Date	Insert	New Registration		10/9/2017 2:58:18 PM	10/9/2017 2:58 PM
Dates	Signed By Date	Insert	New Registration			10/9/2017 2:58 PM
Dates	Start Date	Insert	New Registration			10/9/2017 2:58 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2017 2:58 PM
Terminations	Termination Date	Insert	New Registration			10/9/2017 2:58 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2017 2:58 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2017 2:58 PM