Covered Entity Details

DSH490024EP CARILION MEDICAL CENTER (Active) - information as of 4/23/2025 10:53:44 PM

Main Details

Name

CARILION MEDICAL CENTER

Subdivision Name

Carilion Clinic Imaging - Crystal Spring - Carilion Clinic Imaging- Crystal Spring

Type

Disproportionate Share Hospital

Rural

340B ID

DSH490024EP

Medicare Provider Number

490024

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/24/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/31/2017

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Carilion Clinic
Tim Auwarter, VP Hospital Operations
(540) 981-7804

Primary Contact

Carilion
Trina Epperly, 340B Program Director
(540) 224-3004

Addresses

Street Address

2001 Crystal Spring Ave SW
Roanoke, VA 24014

Billing Address

Carilion Roanoke Memorial Hospital
1906 Belleview Ave SE
Roanoke, VA 24014

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
VA		1033102942,1730123472
WV		1730123472
NC		1730123472

Shipping Addresses

Shipping Address 1

Carilion Roanoke Memorial Hospital
1906 Belleview Ave SE
Pharmacy Att:14W Inpatient
Roanoke, VA 24014

Shipping Address 2

Carilion Medical Center - Central Pharmacy Distribution
2823 Franklin Rd, SW
Bldg C
Roanoke, VA 24014

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
DSH490024A	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC ONCOLOGY/ HEMATOLOGY	1906 Belleview Ave	ROANOKE	VA	Terminated
DSH490024AB	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC CLINIC	4348 Electric Road	ROANOKE	VA	Active
DSH490024AC	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC GASTROENTEROLOGY	4348 Electric Road	ROANOKE	VA	Active
DSH490024AD	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC SURGERY	4348 Electric Road	ROANOKE	VA	Active
DSH490024AE	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC PULMONOLOGY AND ALLERGY CLINIC	4348 Electric Road	ROANOKE	VA	Active
DSH490024AG	Child	DSH	CARILION MEDICAL CENTER	GYN ONCOLOGY ASSOCIATES	1 RIVERSIDE CIRCLE SUITE 300	ROANOKE	VA	Active
DSH490024AH	Child	DSH	CARILION MEDICAL CENTER	NEUROSURG CCR3	2331 Franklin Rd SW	ROANOKE	VA	Active
DSH490024AJ	Child	DSH	CARILION MEDICAL CENTER	CARILION PEDIATRIC OTO ENT CCR3	4348 Electric Rd	ROANOKE	VA	Active
DSH490024AL	Child	DSH	CARILION MEDICAL CENTER	BREAST SURGERY CCR3	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024AN	Child	DSH	CARILION MEDICAL CENTER	UROGYNECOLOGY ELM	101 ELM AVENUE	ROANOKE	VA	Active
DSH490024AO	Child	DSH	CARILION MEDICAL CENTER	CARDIOTHORACIC SRG RKE	2001 CRYSTAL SPRING AVE SUITE 201	ROANOKE	VA	Active
DSH490024AP	Child	DSH	CARILION MEDICAL CENTER	RADIOLOGY	1906 BELLEVIEW AVE.	ROANOKE	VA	Terminated
DSH490024AR	Child	DSH	CARILION MEDICAL CENTER	PEDS BEHAVIORAL MED / DEVELOPMENT	4348 Electric Road	ROANOKE	VA	Active
DSH490024AT	Child	DSH	CARILION MEDICAL CENTER	CARILION SLEEP CENTER WESTLAKE	35 MEDICAL COURT	HARDY	VA	Terminated
DSH490024AU	Child	DSH	CARILION MEDICAL CENTER	HEART FAILURE CLINIC	2001 Crystal Spring Ave SW	ROANOKE	VA	Active
DSH490024AV	Child	DSH	CARILION MEDICAL CENTER	Carilion Infusion Center	1 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024AW	Child	DSH	CARILION MEDICAL CENTER	GENETICS COUNSELING	1 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024AX	Child	DSH	CARILION MEDICAL CENTER	PAIN MANAGEMENT	1 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024AY	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY WESTLAKE	35 MEDICAL COURT	Hardy	VA	Active
DSH490024BA	Child	DSH	CARILION MEDICAL CENTER	PULMONOLOGY CRYSTAL SP	2001 CRYSTAL SPRING AVE	ROANOKE	VA	Active
DSH490024BB	Child	DSH	CARILION MEDICAL CENTER	DERMATOLOGY GEN CCR1	1 Riverside Circle	ROANOKE	VA	Active
DSH490024BC	Child	DSH	CARILION MEDICAL CENTER	ENDOCRINOLOGY	102 HIGHLAND AVE.	ROANOKE	VA	Terminated
DSH490024BD	Child	DSH	CARILION MEDICAL CENTER	FAMILY PRACTICE SALEM	150 SPARTAN DRIVE	SALEM	VA	Terminated
DSH490024BE	Child	DSH	CARILION MEDICAL CENTER	CFM SALEM - WEST MAIN STREET	1935 WEST MAIN STREET	SALEM	VA	Terminated
DSH490024BF	Child	DSH	CARILION MEDICAL CENTER	PALLIATIVE MEDICINE	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BH	Child	DSH	CARILION MEDICAL CENTER	TRAUMA SURGERY	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BJ	Child	DSH	CARILION MEDICAL CENTER	CRITICAL CARE SURGERY	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BK	Child	DSH	CARILION MEDICAL CENTER	ORTHOPEDICS CLINIC - FRANKLIN	390 S. MAIN ST	ROCKY MOUNT	VA	Active
DSH490024BL	Child	DSH	CARILION MEDICAL CENTER	PAIN MANAGEMENT ORTHO	ION 2331 Franklin Road	ROANOKE	VA	Active
DSH490024BM	Child	DSH	CARILION MEDICAL CENTER	ORTHOPEDIC SURGERY WESTLAKE	35 MEDICAL COURT	HARDY	VA	Terminated
DSH490024BN	Child	DSH	CARILION MEDICAL CENTER	ROANOKE ORTHO IMAGING	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024BP	Child	DSH	CARILION MEDICAL CENTER	PEDS GENETICS	4348 Electric Road, Main Entrance	ROANOKE	VA	Active
DSH490024BQ	Child	DSH	CARILION MEDICAL CENTER	PEDS CRITICAL CARE	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BR	Child	DSH	CARILION MEDICAL CENTER	PEDS BEHAVIORAL HLTH CLINIC	4348 Electric Road, Main Entrance	ROANOKE	VA	Active
DSH490024BS	Child	DSH	CARILION MEDICAL CENTER	PEDS ENDOCRINOLOGY CLINIC	4348 Electric Road	ROANOKE	VA	Active
DSH490024BT	Child	DSH	CARILION MEDICAL CENTER	PEDS INFECTIOUS DISEASE	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BU	Child	DSH	CARILION MEDICAL CENTER	PEDS HOSPITALISTS	1906 BELLEVIEW AVE	ROANOKE	VA	Terminated
DSH490024BV	Child	DSH	CARILION MEDICAL CENTER	PEDS NEUROLOGY CLINIC	4348 Electric Road, Main Entrance	ROANOKE	VA	Active
DSH490024BW	Child	DSH	CARILION MEDICAL CENTER	OB-GYN MATERNAL FETAL HEALTH	101 ELM AVE, Suite 400	ROANOKE	VA	Active
DSH490024BX	Child	DSH	CARILION MEDICAL CENTER	OB-GYN SALEM	150 SPARTAN DR	SALEM	VA	Terminated
DSH490024BY	Child	DSH	CARILION MEDICAL CENTER	ROANOKE PSYCHIATRY	2017 S JEFFERSON ST., 2ND FLOOR	ROANOKE	VA	Active
DSH490024BZ	Child	DSH	CARILION MEDICAL CENTER	CCMOB GASTROENTEROLOGY	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024C	Child	DSH	CARILION MEDICAL CENTER	CENTER FOR HEALTH AGING	2001 CRYSTAL SPRING AVENUE SW	ROANOKE	VA	Active
DSH490024CA	Child	DSH	CARILION MEDICAL CENTER	CCMOB GENERAL INTERNAL MED	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024CB	Child	DSH	CARILION MEDICAL CENTER	ALLERGY	46 Wesley Road	Daleville	VA	Terminated
DSH490024CC	Child	DSH	CARILION MEDICAL CENTER	CCMOB NEUROSCIENCES	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024CD	Child	DSH	CARILION MEDICAL CENTER	ION CCMOB PHYSICAL MEDICINE	2331 Franklin Road SW	ROANOKE	VA	Active
DSH490024CE	Child	DSH	CARILION MEDICAL CENTER	CCMOB PULMONARY	3 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024CF	Child	DSH	CARILION MEDICAL CENTER	CCMOB GENERAL SURGERY	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024CG	Child	DSH	CARILION MEDICAL CENTER	CCMOB NEUROSURGERY / SPINE CTR	3 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024CH	Child	DSH	CARILION MEDICAL CENTER	CCMOB PM & REHAB/SPINE CENTER	3 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024CJ	Child	DSH	CARILION MEDICAL CENTER	ION CCMOB ORTHO / SPINE CENTER	ION 2331 Franklin Road SW	ROANOKE	VA	Active
DSH490024CK	Child	DSH	CARILION MEDICAL CENTER	CCMOB TRAUMA / CRITICAL CARE SUR	4348 Electric Rd	ROANOKE	VA	Active
DSH490024CL	Child	DSH	CARILION MEDICAL CENTER	BEHAVIORAL HEALTH SPINE CENTER	3 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024CM	Child	DSH	CARILION MEDICAL CENTER	GENETICS NRV CANCER	2900 Lamb Circle, STE 202	Christiansburg	VA	Terminated
DSH490024CN	Child	DSH	CARILION MEDICAL CENTER	CARILION GENETICS - CLINICAL	102 Highland Ave	Roanoke	VA	Terminated
DSH490024CP	Child	DSH	CARILION MEDICAL CENTER	GENETICSRKE CANCER ONC	1 Riverside Circle	Roanoke	VA	Active
DSH490024CQ	Child	DSH	CARILION MEDICAL CENTER	OB GYN DALEVILLE	150 Market Ridge LN	Daleville	VA	Active
DSH490024CR	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY CRYSTAL SPR	2001 Crystal Spring Ave SW	Roanoke	VA	Terminated
DSH490024CS	Child	DSH	CARILION MEDICAL CENTER	CARD CONGENIT HEART	2001 CRYSTAL SPRING AVE	Roanoke	VA	Active
DSH490024CT	Child	DSH	CARILION MEDICAL CENTER	CARDIO DEVICE CLINIC	2001 CRYSTAL SPRING AVE SW	Roanoke	VA	Active
DSH490024CU	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY VALVE	2001 Crystal Spring Ave SW	Roanoke	VA	Active
DSH490024CV	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY LIPID	2001 Crystal Spring Ave, STE 300	Roanoke	VA	Terminated
DSH490024CW	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY LIPID	2001 Crystal Spring Ave, STE 300	Roanoker	VA	Terminated
DSH490024CX	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY ROANOKE	2001 Crystal Spring Ave SW	Roanoke	VA	Active
DSH490024CY	Child	DSH	CARILION MEDICAL CENTER	CARDIO VALVE	2001 CRYSTAL SPRING AVE, SUITE 201	Roanoke	VA	Terminated
DSH490024CZ	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY VASC	2001 CRYSTAL SPRING AVE, SUITE 203	Roanoke	VA	Active
DSH490024D	Child	DSH	CARILION MEDICAL CENTER	SOUTHEAST FAMILY MEDICINE	2145 MOUNT PLEASANT BLVD SE	ROANOKE	VA	Active
DSH490024DA	Child	DSH	CARILION MEDICAL CENTER	PEDS ID ROANOKE	101 Elm Avenue, S.E.	Roanoke	VA	Terminated
DSH490024DB	Child	DSH	CARILION MEDICAL CENTER	SLEEP MED ROANOKE	1030 SOUTH JEFFERSON	Roanoke	VA	Active
DSH490024DC	Child	DSH	CARILION MEDICAL CENTER	SLEEP CTR WESTLAKE	35 Medical Court	Hardy	VA	Terminated
DSH490024DD	Child	DSH	CARILION MEDICAL CENTER	NEUROPSYCHOLOGY GER	2001 Crystal Spring Ave	Roanoke	VA	Active
DSH490024DE	Child	DSH	CARILION MEDICAL CENTER	NEUROPSYCHOLOGY NRV	2900 Lamb Circle	Christiansburg	VA	Terminated
DSH490024DF	Child	DSH	CARILION MEDICAL CENTER	CARDIOLOGY FOR WOMEN/OB CLINIC	902 S Jefferson St	Roanoke	VA	Active
DSH490024DG	Child	DSH	CARILION MEDICAL CENTER	ORTHO SPINE CNRV	2900 Lamb Cr Ste 380	Christiansburg	VA	Terminated
DSH490024DH	Child	DSH	CARILION MEDICAL CENTER	ION ORTHO BONEJT	ION 2331 Franklin Road	Roanoke	VA	Terminated
DSH490024DJ	Child	DSH	CARILION MEDICAL CENTER	ORTHO SPORTS MED NRV	2900 Lamb Circle, STE L760	Christiansburg	VA	Terminated
DSH490024DK	Child	DSH	CARILION MEDICAL CENTER	PLASTIC SURGERY CCR3	3 Riverside Circle	Roanoke	VA	Active
DSH490024DL	Child	DSH	CARILION MEDICAL CENTER	PEDS SURGERY ROANOKE	102 HIGHLAND AVENUE	Roanoke	VA	Terminated
DSH490024DM	Child	DSH	CARILION MEDICAL CENTER	ORTHOPEDICS IMAGING	3 Riverside Circle	Roanoke	VA	Terminated
DSH490024DN	Child	DSH	CARILION MEDICAL CENTER	OB GYN RCHMOB	102 Highland Ave, STE 455	Roanoke	VA	Terminated
DSH490024DP	Child	DSH	CARILION MEDICAL CENTER	PEDS CARDIOLOGY RADFORD	2900 Lamb Circle	Christiansburg	VA	Terminated
DSH490024DQ	Child	DSH	CARILION MEDICAL CENTER	PEDS ADOL MED PAT HNRY	2102 Grandin Rd SW	Roanoke	VA	Terminated
DSH490024DR	Child	DSH	CARILION MEDICAL CENTER	PEDS ADOL MED 902 PSY	902 S Jefferson St	Roanoke	VA	Terminated
DSH490024DS	Child	DSH	CARILION MEDICAL CENTER	CARILION CLINIC AMBULATORY SURGERY CENTER- COMMUNITY HOSP	101 Elm Avenue	Roanoke	VA	Active
DSH490024DT	Child	DSH	CARILION MEDICAL CENTER	PEDS ADOL MED WM FLM	3649 Ferncliff Ave NW	Roanoke	VA	Terminated
DSH490024DU	Child	DSH	CARILION MEDICAL CENTER	PEDS ADOL MED PH PSY	2102 Grandin Rd SW	Roanoke	VA	Terminated
DSH490024DV	Child	DSH	CARILION MEDICAL CENTER	PEDS ADOL MED WF PSY	3649 Ferncliff Ave NW	Roanoke	VA	Terminated
DSH490024DW	Child	DSH	CARILION MEDICAL CENTER	PSYCHIATRY ROANOKE INP	2017 S Jefferson St. R4/5	Roanoke	VA	Terminated
DSH490024DX	Child	DSH	CARILION MEDICAL CENTER	PSY BEH MED CHILDJPLZA	1030 South Jefferson St, Suite 106	Roanoke	VA	Terminated
DSH490024DY	Child	DSH	CARILION MEDICAL CENTER	PSY BEH MED HOPE TREE	860 Mount Vernon Lane	Salem	VA	Terminated
DSH490024DZ	Child	DSH	CARILION MEDICAL CENTER	SLEEP CTR LAMB CIRCLE	2900 Lamb Circle	Christiansburg	VA	Terminated
DSH490024E	Child	DSH	CARILION MEDICAL CENTER	CARILION DENTAL CARE - PEDIATRICS	101 ELM AVE	ROANOKE	VA	Terminated
DSH490024EA	Child	DSH	CARILION MEDICAL CENTER	PSY BEH MED CHILD ADOL	2017 S Jefferson St, 2nd Floor	Roanoke	VA	Active
DSH490024EB	Child	DSH	CARILION MEDICAL CENTER	PSY BEHAV MED CAR RHB	127 McClannahan St	Roanoke	VA	Active
DSH490024EC	Child	DSH	CARILION MEDICAL CENTER	PSY BEH MED / FAMILY SERVICES	360 CAMPBELL AVE	ROANOKE	VA	Terminated
DSH490024ED	Child	DSH	CARILION MEDICAL CENTER	CCMOB / VEIN CENTER	3 RIVERSIDE CIRCLE	ROANOKE	VA	Terminated
DSH490024EF	Child	DSH	CARILION MEDICAL CENTER	PSY BEH / Dept of Social Services	1510 WILLIAMSON RD	ROANOKE	VA	Terminated
DSH490024EG	Child	DSH	CARILION MEDICAL CENTER	ION ORTHO / GEN SVCS	ION 2331 Franklin Road SW	ROANOKE	VA	Active
DSH490024EH	Child	DSH	CARILION MEDICAL CENTER	GEN SURGERY / WESTLAKE	35 MEDICAL COURT	HARDY	VA	Active
DSH490024EJ	Child	DSH	CARILION MEDICAL CENTER	ION ORTHO / HAND&UPPER EXTREM-RKE	ION 2331 Franklin Road SW	ROANOKE	VA	Active
DSH490024EK	Child	DSH	CARILION MEDICAL CENTER	CCMOB / ENDOCRINOLOGY	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024EL	Child	DSH	CARILION MEDICAL CENTER	Carilion Community Care	101 Elm Ave	Roanoke	VA	Terminated
DSH490024EM	Child	DSH	CARILION MEDICAL CENTER	CRCH Endo/Anesthesia	101 Elm Ave	Roanoke	VA	Active
DSH490024EN	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Imaging - Daleville - Carilion Clinic Imaging - Daleville	150 Market Ridge Ln	Daleville	VA	Active
DSH490024EP	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Imaging - Crystal Spring - Carilion Clinic Imaging- Crystal Spring	2001 Crystal Spring Ave SW	Roanoke	VA	Active
DSH490024EQ	Child	DSH	CARILION MEDICAL CENTER	Urogynecology- Westlake - Urogynecology - Westlake	35 Medical Court	Hardy	VA	Active
DSH490024ER	Child	DSH	CARILION MEDICAL CENTER	Carilion Adolescent Medicine Clinic - Carilion Adolescent Medicine Clinic	4348 Electric Rd., Mall Interior 2nd Floor Ent. 4	Roanoke	VA	Active
DSH490024ES	Child	DSH	CARILION MEDICAL CENTER	General Surgery - Rocky Mount - General Surgery - Rocky Mount	390 S Main St	Rocky Mount	VA	Active
DSH490024ET	Child	DSH	CARILION MEDICAL CENTER	Carilion Aortic Center - Carilion Aortic Center	2001 Crystal Spring Ave SW	Roanoke	VA	Active
DSH490024EU	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho Trauma & Fracture- Roanoke - Carilion Ortho Trauma & Fracture- Roanoke	2331 Franklin Rd SW	Roanoke	VA	Active
DSH490024EV	Child	DSH	CARILION MEDICAL CENTER	Carilion Pediatric Medicine-Franklin - Carilion Pediatric Medicine Franklin	490 South Main	Rocky Mount	VA	Active
DSH490024EW	Child	DSH	CARILION MEDICAL CENTER	Carilion Pediatric Otolaryngology ENT Clinic - Carilion Pediatric Otolaryngology ENT Clinic	3 Riverside Circle	Roanoke	VA	Terminated
DSH490024EX	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Breast Care Imaging - Carilion Clinic Breast Care Imaging	102 Highland Ave	Roanoke	VA	Active
DSH490024EY	Child	DSH	CARILION MEDICAL CENTER	Carilion Cleft Clinic - Carilion Cleft Clinic	4348 Electric Rd	Roanoke	VA	Active
DSH490024EZ	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho Foot/Ankle- Roanoke - Carilion Ortho Foot/Ankle- Roanoke	2331 Franklin Rd SW	Roanoke	VA	Active
DSH490024F	Child	DSH	CARILION MEDICAL CENTER	CARILION DENTAL CARE - HOSPITAL	2017 S. JEFFERSON ST., 2nd Floor	ROANOKE	VA	Terminated
DSH490024FA	Child	DSH	CARILION MEDICAL CENTER	Carilion Bariatric/General Surgery - Carilion Bariatric Medicine	3 Riverside Circle	Roanoke	VA	Active
DSH490024FB	Child	DSH	CARILION MEDICAL CENTER	Carilion Nuclear Medicine - Carilion Nuclear Medicine	102 Highland Ave	Roanoke	VA	Terminated
DSH490024FC	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho General -Franklin - Carilion Ortho General- Franklin	390 South Main St.	Rocky Mount	VA	Active
DSH490024FD	Child	DSH	CARILION MEDICAL CENTER	Carilion Otolaryngology Clinic- Westlake - Carilion Otolaryngology Clinic - Westlake	35 Medical Ct	Hardy	VA	Active
DSH490024FE	Child	DSH	CARILION MEDICAL CENTER	Carilion OBYGN -General - Carilion OBGYN- General	3 Riverside Circle	Roanoke	VA	Active
DSH490024FF	Child	DSH	CARILION MEDICAL CENTER	Carilion Pulmonary Function Lab (Respiratory Services) - Carilion Pulmonary Function Lab (Respiratory Services)	2001 Crystal Spring Ave	Roanoke	VA	Active
DSH490024FG	Child	DSH	CARILION MEDICAL CENTER	Carilion Westlake Sleep Center Physicians - Carilion Westlake Sleep Center Physicians	35 Medical Court	Hardy	VA	Terminated
DSH490024FH	Child	DSH	CARILION MEDICAL CENTER	Carilion Transgender Clinic - Carilion Gender Care	3 Riverside Circle	Roanoke	VA	Active
DSH490024FK	Child	DSH	CARILION MEDICAL CENTER	CARILION ORTHOPEDIC SURGERY WESTLAKE - SURGERY	35 Medical Ct	HARDY	VA	Terminated
DSH490024FL	Child	DSH	CARILION MEDICAL CENTER	CARILION CRYSTAL SPRING NUCLEAR MEDICINE - RADIOLOGY	2001 Crystal Spring Ave SW	ROANOKE	VA	Active
DSH490024FM	Child	DSH	CARILION MEDICAL CENTER	CARILION RADIOGRAPHIC CLINIC - RADIOLOGY	35 Medical Court Hardy	HARDY	VA	Active
DSH490024FN	Child	DSH	CARILION MEDICAL CENTER	CARILION CLINICAL GENETICS - CLINIC	102 Highland Ave SE	ROANOKE	VA	Terminated
DSH490024FP	Child	DSH	CARILION MEDICAL CENTER	CARILION CT SCAN - CT	35 Medical Ct	HARDY	VA	Active
DSH490024FQ	Child	DSH	CARILION MEDICAL CENTER	CARILION COLORECTAL SURGERY - COLORECTAL SURGERY	3 Riverside Circle	ROANOKE	VA	Active
DSH490024FR	Child	DSH	CARILION MEDICAL CENTER	CARILION FRACTURE LIAISON - FRACTURE LIAISON	3 Riverside Circle	ROANOKE	VA	Active
DSH490024FS	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Community Care OBOT Program - Opioid Treatment	3 Riverside Circle	Roanoke	VA	Terminated
DSH490024FT	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Medical Bariatrics - Bariatrics	3 Riverside Circle	Roanoke	VA	Active
DSH490024FU	Child	DSH	CARILION MEDICAL CENTER	CCMOB Physical Medicine - Community Rehab	101 Elm Ave SE	Roanoke	VA	Active
DSH490024FV	Child	DSH	CARILION MEDICAL CENTER	Carilion Brain Injury Center - Neurology	2331 Franklin Rd SW	Roanoke	VA	Active
DSH490024FW	Child	DSH	CARILION MEDICAL CENTER	Carilion Pediatric Audiology - Electric Rd - Pediatric Audiology	4348 Electric Rd	Roanoke	VA	Active
DSH490024FX	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Family Medicine Salem- West Main - Family Medicine	1935 West Main St	Salem	VA	Terminated
DSH490024FY	Child	DSH	CARILION MEDICAL CENTER	Carilion Clinic Pediatric Neurosurgery - Pediatric Neurosurgery	4348 Electric Rd	Roanoke	VA	Active
DSH490024FZ	Child	DSH	CARILION MEDICAL CENTER	Carilion Plastic Surgery - Electric Rd - Plastic Surgery	4348 Electric Rd	Roanoke	VA	Active
DSH490024G	Child	DSH	CARILION MEDICAL CENTER	ROANOKE SALEM FAMILY MEDICINE	1314 PETERS CREEK ROAD	ROANOKE	VA	Active
DSH490024GA	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho Gen CCR3 - Carilion Ortho Gen CCR3	3 Riverside Circle	Roanoke	VA	Active
DSH490024GB	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho Sports Medicine ION - Carilion Ortho Sports Medicine ION	2331 Franklin Rd SW	Roanoke	VA	Active
DSH490024GC	Child	DSH	CARILION MEDICAL CENTER	Carilion Radiation Oncology - Carilion Radiation Oncology	2013 S. Jefferson St.	Roanoke	VA	Active
DSH490024GD	Child	DSH	CARILION MEDICAL CENTER	Carilion Ortho Reconstructive Surgery - Carilion Ortho Reconstructive Surgery	2331 Franklin Rd SW	Roanoke	VA	Active
DSH490024GE	Child	DSH	CARILION MEDICAL CENTER	Carilion Nuclear Medicine Imaging - Carilion Nuclear Medicine Imaging	3 Riverside Circle	Roanoke	VA	Active
DSH490024GF	Child	DSH	CARILION MEDICAL CENTER	Carilion Pediatric Urology - Carilion Pediatric Urology	4348 Electric Rd	Roanoke	VA	Active
DSH490024GG	Child	DSH	CARILION MEDICAL CENTER	Carilion Urology - Riverside 3 - Carilion Urology - Riverside 3	3 Riverside Cir	Roanoke	VA	Active
DSH490024GH	Child	DSH	CARILION MEDICAL CENTER	Carilion Pediatric Allergy and Immunology - Carilion Pediatric Allergy and Immunology	4348 Electric Rd	Roanoke	VA	Active
DSH490024I	Child	DSH	CARILION MEDICAL CENTER	PRENATAL DIAGNOSTIC CENTER	102 HIGHLAND AVE SUITE 455	ROANOKE	VA	Terminated
DSH490024J	Child	DSH	CARILION MEDICAL CENTER	PEDS CARDIOLOGY PED	4348 Electric Road	ROANOKE	VA	Active
DSH490024K	Child	DSH	CARILION MEDICAL CENTER	CARILION CLINIC GYNECOLOGY-HIGHLAND	102 HIGHLAND AVE SE	ROANOKE	VA	Active
DSH490024L	Child	DSH	CARILION MEDICAL CENTER	INFERTILITY ENDOCRINE	1231 South Jefferson St	ROANOKE	VA	Terminated
DSH490024N	Child	DSH	CARILION MEDICAL CENTER	PEDIATRIC NEURO-DEVELOPMENTAL CLINIC	4348 Electric Rd	ROANOKE	VA	Active
DSH490024Q	Child	DSH	CARILION MEDICAL CENTER	BONE & JOINT	3 Riverside Circle	ROANOKE	VA	Active
DSH490024R	Child	DSH	CARILION MEDICAL CENTER	ION Ortho BONE & JOINT - ROANOKE	2331 Franklin Road	ROANOKE	VA	Terminated
DSH490024S	Child	DSH	CARILION MEDICAL CENTER	INFECTIOUS DISEASE ROA	2001 CRYSTAL SPRING AVE SW	ROANOKE	VA	Active
DSH490024T	Child	DSH	CARILION MEDICAL CENTER	WOUND CARE RCH	101 ELM AVE.	ROANOKE	VA	Active
DSH490024U	Child	DSH	CARILION MEDICAL CENTER	NEUROPSYCHOLOGY CCR3	3 Riverside Circle	ROANOKE	VA	Active
DSH490024V	Child	DSH	CARILION MEDICAL CENTER	CARILION ROANOKE MEMORIAL HOSPITAL HOSPITALISTS	1906 BELLEVIEW AVE.	ROANOKE	VA	Terminated
DSH490024X	Child	DSH	CARILION MEDICAL CENTER	RHEUMATOLOGY CCR3	3 RIVERSIDE CIRCLE	ROANOKE	VA	Active
DSH490024Y	Child	DSH	CARILION MEDICAL CENTER	INTENSIVISTS / CARILION ROANOKE MEMORIAL HOSPITAL	1906 BELLEVIEW AVE.	ROANOKE	VA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/10/2023 1:03:50 PM	9/5/2024 1:39:41 PM	9/5/2024 1:39 PM
Addresses	Shipping Address	Delete	Group Change Request	Carilion Medical Center - Central Pharmacy Distribution 2823 Franklin Rd, SW Bldg A Roanoke, VA 24014		8/6/2024 11:13 AM
Addresses	Shipping Address	Insert	Group Change Request		Carilion Medical Center - Central Pharmacy Distribution 2823 Franklin Rd, SW Bldg C Roanoke, VA 24014	8/6/2024 11:13 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730123472	9/10/2023 1:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/10/2023 1:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1730123472	9/10/2023 1:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/10/2023 1:03 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 7:20:29 AM	9/10/2023 1:03:50 PM	9/10/2023 1:03 PM
Addresses	Main Address	Update	Change Request	2001 Crystal Spring Ave Roanoke, VA 24014	2001 Crystal Spring Ave SW Roanoke, VA 24014	12/21/2022 9:05 AM
Addresses	Shipping Address	Insert	Group Change Request		Carilion Medical Center - Central Pharmacy Distribution 2823 Franklin Rd, SW Bldg A Roanoke, VA 24014	12/19/2022 7:22 AM
Addresses	Shipping Address	Insert	Group Change Request		Carilion Roanoke Memorial Hospital 1906 Belleview Ave SE Pharmacy Att:14W Inpatient Roanoke, VA 24014	12/19/2022 7:22 AM
Addresses	Billing Address	Insert	Group Change Request		Carilion Roanoke Memorial Hospital 1906 Belleview Ave SE Roanoke, VA 24014	12/13/2022 2:10 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1730123472	12/13/2022 2:10 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	12/13/2022 2:10 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 2:05:23 PM	9/14/2022 7:20:29 AM	9/14/2022 7:20 AM
Details	Entity Subname	Update	Recertification	Cariion Clinic Imaging - Crystal Springs - Carilion Clnic Imaging- Crystal Springs	Carilion Clinic Imaging - Crystal Spring - Carilion Clinic Imaging- Crystal Spring	9/14/2022 7:20 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 11:32:28 AM	9/10/2021 2:05:23 PM	9/10/2021 2:05 PM
Medicaid Billing	NPI: State	Update	Recertification		VA	9/11/2020 11:32 AM
Details	Last Recertification Date	Update	Recertification	9/13/2019 10:35:54 AM	9/11/2020 11:32:28 AM	9/11/2020 11:32 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 10:29:11 AM	9/13/2019 10:35:54 AM	9/13/2019 10:35 AM
Details	Last Recertification Date	Update	Recertification		9/10/2018 10:29:11 AM	9/10/2018 10:29 AM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Auwarter, Tim VP Hospital Operations Carilion Clinic 5409817804	10/31/2017 9:06 AM
Details	340B ID	Update	New Registration		DSH490024EP	10/31/2017 9:06 AM
Details	Entity Subname	Update	New Registration	Cariion Clinic Imaging - Crystal Springs	Cariion Clinic Imaging - Crystal Springs - Carilion Clnic Imaging- Crystal Springs	10/31/2017 9:06 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2017 9:06:44 AM	10/31/2017 9:06 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2017 9:06 AM
Dates	Signed By Date	Update	New Registration		10/25/2017 8:42:20 AM	10/31/2017 9:06 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/31/2017 9:06 AM
Addresses	Main Address	Insert	New Registration		2001 Crystal Spring Ave Roanoke, VA 24014	10/24/2017 11:35 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1033102942	10/24/2017 11:35 AM
Contacts	Primary Contact	Insert	New Registration		Epperly, Trina 340B Program Director Carilion 5402243004	10/24/2017 11:35 AM
Contacts	Authorizing Official	Insert	New Registration		Auwarter, Tim VP Hospital Operations Carilion Clinic 5409817804	10/24/2017 11:35 AM
Details	Last Recertification Date	Insert	New Registration			10/24/2017 11:35 AM
Details	Grant Number	Insert	New Registration			10/24/2017 11:35 AM
Details	340B ID	Insert	New Registration			10/24/2017 11:35 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/24/2017 11:35 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/24/2017 11:35 AM
Details	Medicare Provider Number	Insert	New Registration		490024	10/24/2017 11:35 AM
Details	Entity Name	Insert	New Registration		CARILION MEDICAL CENTER	10/24/2017 11:35 AM
Details	Program Code	Insert	New Registration		DSH	10/24/2017 11:35 AM
Details	Entity Subname	Insert	New Registration		Cariion Clinic Imaging - Crystal Springs	10/24/2017 11:35 AM
Dates	Participating Approval Date	Insert	New Registration			10/24/2017 11:35 AM
Details	State	Insert	New Registration		Pending	10/24/2017 11:35 AM
Dates	Registration Date	Insert	New Registration		10/24/2017 11:35:32 AM	10/24/2017 11:35 AM
Dates	Signed By Date	Insert	New Registration			10/24/2017 11:35 AM
Dates	Start Date	Insert	New Registration			10/24/2017 11:35 AM
Terminations	Termination Comments	Insert	New Registration			10/24/2017 11:35 AM
Terminations	Termination Date	Insert	New Registration			10/24/2017 11:35 AM
Terminations	Termination Effective Date	Insert	New Registration			10/24/2017 11:35 AM
Terminations	Termination Reason	Insert	New Registration			10/24/2017 11:35 AM