Covered Entity Details

DSH030014M HONORHEALTH JOHN C. LINCOLN MED CTR (Active) - information as of 6/14/2025 10:09:34 AM

Main Details

Name

HONORHEALTH JOHN C. LINCOLN MED CTR

Subdivision Name

OR Preop/PACU - OP

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030014M

Medicare Provider Number

030014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/18/2024

Participating Start Date

4/1/2024

Participating Approval Date

1/23/2024

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

HonorHealth
Lisa Montman, SVP/CFO
(480) 587-5120

Primary Contact

HonorHealth
Kristjon Lindgren, 340B Program Director
(602) 793-5509

Addresses

Street Address

9250 N 3rd St #1001
Phoenix, AZ 85020

Billing Address

HONORHEALTH JOHN C. LINCOLN MED CTR
PO Box 14890
Scottsdale, AZ 85267

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting- 4/1/2018 Terminated starting- 1/1/2019 Reinstated- 4/1/2024	01/22/2024

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
CO	860181654,9000195815,95190112	1770690695
CT	008047201,003054129	1770690695
FL	092474100,860117301,245412000,860181654,ND895,1326503	1770690695
GA	003176592A,003116091A,003176648A,000487946X,860181654,003118615A,N1425,NR - REVAL	1770690695
IA	1770690695,02885297,1983767,0983767	1770690695
ID	1770690695,002925100	1770690695
IL	860181654006,N1425,860181654,860117301001,1770690695	1770690695
IN	201035820A,860181654,300042446,1770690695	1770690695
MI	1770690695,860117301,860181654,30-4908703,40-4908712	1770690695
MN	1770690695,00500080007,447317500,860181654,300969	1770690695
OR	128579,1770690695,860117301,P00000979846,860181654	1770690695
PA	1007457650007,43957,1770690695,30245244,1007632800001,VC9417	1770690695
SC	12148B,11680A	1770690695
AK	HS757OP,HS757IP,1006416,1753122	1770690695
AL	JOH0014N	1770690695
AR	189215105	1770690695
CA	1770690695,860181654,XHSP32340,XHSP42340,1386608859,860181654WV,QMP000004946960,90367,PRV006826	1770690695
DC	60404343,055575200,1770690695	1770690695
HI	1770690695,860181654,010156	1770690695
KS	02885297,100100590C,860181654	1770690695
KY	01220136,0122013600,N1098839,N1425,PDZ000001481293,ND895	1770690695
LA	10025901,1770690695,1749982,3868172,60065488	1770690695
MA	35974,0964397,110027159A,110027159B	1770690695
MD	860181654,531209400,1770690695,02885297,70025901,488644	1770690695
ME	191160000,1770690695	1770690695
MO	1770690695,011380201,N1425	1770690695
MS	1770690695,001074063	1770690695
MT	1770690695	1770690695
NC	1770690695,9300014	1770690695
NE	10026210700,10026374906	1770690695
NJ	1770690695,02885297,10025901,60159345	1770690695
NM	860181654,24051837,01201026,201080235	1770690695
NV	02885297,1770690695,001188961,860181654	1770690695
NY	488644,111031000122,860181654,01619396	1770690695
OH	860181654,860117301001,6921880,5187257,860181654D	1770690695
OK	100704870A	1770690695
RI	1770690695	1770690695
TN	02885297,0012108,Q013661,0030014	1770690695
TX	02885297,QMP000005075548,1770690695,071480001	1770690695
UT	1770690695,1023425,QMP000003687930	1770690695
VA	860181654,1770690695	1770690695
VT	0030014	1770690695
WA	02885297,151234,QMP000004937946,1770690695,1018702	1770690695
WI	03996805,1770690695,100102520,100056786,80517700	1770690695
WV	1770690695,860181654,9810047000	1770690695
WY	1770690695	1770690695
AZ	022241	1770690695
DE		1770690695

Shipping Addresses

Shipping Address 1

JOHN C LINCOLN MEDICAL CENTER
250 E Dunlap Ave
Phoenix, AZ 85020

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
DSH030014A	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Outpatient / Medical Imaging	9250 N 3rd St #1002	Phoenix	AZ	Terminated
DSH030014AA	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Wound Clinic OP	9202 N 2nd St #101	Phoenix	AZ	Active
DSH030014AB	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Pulmonary Hypertension Clinic	9250 N 3rd St #2030	Phoenix	AZ	Active
DSH030014AC	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper CCN-Apache Junction	750 S Ironwood Dr #102	Apache Junction	AZ	Terminated
DSH030014AD	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Biltmore	2222 E Highland Ave #400	Phoenix	AZ	Active
DSH030014AE	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Tempe	7695 S Research Dr	Tempe	AZ	Active
DSH030014AF	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - GynOnc Shea	10197 N 92nd St #101	Scottsdale	AZ	Active
DSH030014AG	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	BMT Outpatient	10460 N 92nd St #300	Scottsdale	AZ	Active
DSH030014AH	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HHRI Oncology Clinical Trials	10510 N 92nd St	Scottsdale	AZ	Active
DSH030014AJ	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Home Health	3634 N Drinkwater Blvd	Scottsdale	AZ	Active
DSH030014B	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln Outpatient Imaging - 27th Ave. / Medical Imaging	19636 N 27th Ave. #LL1	Phoenix	AZ	Terminated
DSH030014C	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Outpatient Surgery	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014D	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln-Tatum / Outpatient Medical Imaging	18404 N Tatum Blvd. #103	Phoenix	AZ	Terminated
DSH030014E	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center-Glendale	6220 W Bell Rd #110	Glendale	AZ	Active
DSH030014F	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Pharmacy Care Coordination	9109 North Central Avenue	Phoenix	AZ	Terminated
DSH030014G	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Clinic / Outpatient Center	9225 North 3rd Street	Phoenix	AZ	Terminated
DSH030014H	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Center / Senior Support Services	9225 N 3rd St	Phoenix	AZ	Terminated
DSH030014J	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Happy Valley Infusion Care Clinic	10230 W. Happy Valley Parkway	Peoria	AZ	Terminated
DSH030014K	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - John C. Lincoln	9250 N 3rd St #3010	Phoenix	AZ	Active
DSH030014L	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Deer Valley	19646 N 27th Ave #301	Phoenix	AZ	Active
DSH030014M	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Preop/PACU - OP	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014N	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Osborn	3621 N Wells Fargo Ave	Scottsdale	AZ	Active
DSH030014P	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Gilbert	3645 S Rome St #209	Gilbert	AZ	Active
DSH030014Q	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Chandler	1110 S Dobson Rd #1	Chandler	AZ	Active
DSH030014R	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Thompson Peak	20745 N Scottsdale Rd #115	Scottsdale	AZ	Active
DSH030014S	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Avondale	10320 W McDowell Rd Bldg H	Avondale	AZ	Active
DSH030014T	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Surprise	14674 W Mountain View Blvd #105	Surprise	AZ	Active
DSH030014U	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper Cancer Care Network-Wickenburg	519 Rose Ln	Wickenburg	AZ	Terminated
DSH030014V	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Fountain Hills	16716 E Palisades Blvd #103	Fountain Hills	AZ	Active
DSH030014W	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Glendale	15000 N 83rd Ave #300	Peoria	AZ	Active
DSH030014X	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Shea	10460 N 92nd St #200 and #400	Scottsdale	AZ	Active
DSH030014Y	Child	DSH	JOHN C. LINCOLN MEDICAL CENTER	JCLMC Infusion Center	3501 N Scottsdale Rd #136	Scottsdale	AZ	Terminated
DSH030014Z	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center - NSI	7242 E Osborn Rd #340, #400, and #500	Scottsdale	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1753122	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AK	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1006416	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AK	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		ME	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		010156	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		HI	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/10/2024 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		860181654	9/10/2024 2:25 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NV	9/10/2024 2:25 PM
Addresses	Billing Address	Update	Recertification	HONORHEALTH JOHN C. LINCOLN MED CTR 250 E Dunlap Ave Phoenix, AZ 85020	HONORHEALTH JOHN C. LINCOLN MED CTR PO Box 14890 Scottsdale, AZ 85267	8/15/2024 12:02 PM
Details	Last Recertification Date	Update	Recertification		8/15/2024 12:02:48 PM	8/15/2024 12:02 PM
Details	Entity Subname	Update	Recertification	OR Preop/PACU - OR Preop/PACU	OR Preop/PACU - OP	8/15/2024 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1770690695 (DE)		6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		PDZ000001481293	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026374906	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		90367	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		PRV006826	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		N1425	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		NR - REVAL	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		ND895	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		60065488	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		488644	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		N1425	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		60159345	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		201080235	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		VC9417	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP000003687930	6/12/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	6/12/2024 12:13 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		003118615A	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		3868172	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	3/12/2024 11:04 AM
Addresses	Billing Address	Insert	Reinstatement		HONORHEALTH JOHN C. LINCOLN MED CTR 250 E Dunlap Ave Phoenix, AZ 85020	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		HS757OP	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		AK	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		HS757IP	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		AK	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		JOH0014N	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		AL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		189215105	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		AR	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		XHSP32340	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		XHSP42340	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1386608859	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654WV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		QMP000004946960	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		9000195815	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CO	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		95190112	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CO	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		003054129	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CT	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		60404343	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		DC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		055575200	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		DC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		DC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860117301	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		245412000	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		ND895	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1326503	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		003116091A	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		GA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		003176648A	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		GA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		000487946X	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		GA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		GA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		HI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		HI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1983767	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0983767	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		002925100	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		ID	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		N1425	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860117301001	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IL	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		300042446	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		IN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KS	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		100100590C	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KS	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KS	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		01220136	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0122013600	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		N1098839	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		N1425	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		KY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		10025901	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		LA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		LA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1749982	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		LA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		35974	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0964397	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		110027159A	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		110027159B	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		531209400	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		70025901	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		191160000	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		ME	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860117301	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		30-4908703	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		40-4908712	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		00500080007	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		447317500	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		300969	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MO	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		011380201	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MO	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MS	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		001074063	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MS	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MT	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		9300014	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		10026210700	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NE	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NJ	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NJ	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		10025901	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NJ	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NM	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		24051837	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NM	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		01201026	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NM	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		001188961	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		488644	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		111031000122	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		01619396	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		NY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860117301001	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		6921880	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		5187257	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654D	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		100704870A	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OK	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OR	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860117301	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OR	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		P00000979846	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OR	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OR	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		43957	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		30245244	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1007632800001	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		RI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		11680A	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		SC	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0012108	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		Q013661	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0030014	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TN	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TX	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		QMP000005075548	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TX	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TX	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		071480001	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TX	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		UT	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1023425	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		UT	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		VA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		VA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		0030014	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		VT	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		02885297	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		151234	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		QMP000004937946	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1018702	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		03996805	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		100102520	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		100056786	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		80517700	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		860181654	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		9810047000	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WV	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		WY	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		DE	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1770690695 ( )		1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		AK	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		AL	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		AR	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		CA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		CO	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		AZ	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		CT	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		DC	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		FL	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		GA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		HI	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		IA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		ID	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		IL	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		IN	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		KS	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		KY	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		LA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MD	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		ME	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MI	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MN	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MO	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MS	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MT	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NC	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NE	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NJ	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NM	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NV	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		NY	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		OH	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		OK	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		OR	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		PA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		RI	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		SC	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		TN	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		TX	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		UT	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		VA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		VT	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		WA	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		WI	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		WV	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		WY	1/23/2024 8:06 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1770690695	1/23/2024 8:06 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		DE	1/23/2024 8:06 AM
Contacts	Primary Contact	Update	Reinstatement	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Director HonorHealth 6027935509	1/23/2024 8:06 AM
Contacts	Authorizing Official	Update	Reinstatement	Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	Montman, Lisa SVP/CFO HonorHealth 4805875120	1/23/2024 8:06 AM
Contacts	Signed By	Update	Reinstatement	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	Montman, Lisa SVP/CFO HonorHealth 4805875120	1/23/2024 8:06 AM
Details	Last Recertification Date	Update	Reinstatement	8/21/2018 2:38:24 PM		1/23/2024 8:06 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	12/21/2018 12:00:00 AM		1/23/2024 8:06 AM
Details	Entity Name	Update	Reinstatement	JOHN C LINCOLN MEDICAL CENTER	HONORHEALTH JOHN C. LINCOLN MED CTR	1/23/2024 8:06 AM
Dates	Participating Approval Date	Update	Reinstatement	2/13/2018 1:34:16 PM	1/23/2024 8:06:29 AM	1/23/2024 8:06 AM
Details	State	Update	Reinstatement	Terminated	Approved	1/23/2024 8:06 AM
Dates	Registration Date	Update	Reinstatement	1/10/2018 7:07:28 PM	1/18/2024 4:00:20 PM	1/23/2024 8:06 AM
Dates	Signed By Date	Update	Reinstatement	1/11/2018 4:04:22 PM	1/19/2024 11:22:10 AM	1/23/2024 8:06 AM
Dates	Start Date	Update	Reinstatement	4/1/2018 12:00:00 AM	4/1/2024 12:00:00 AM	1/23/2024 8:06 AM
Terminations	Termination Comments	Update	Reinstatement	Child site registration is unnecessary; HonorHealth JCLMC Outpatient Pre-Op Epic DEP .1 101001057 rolls up to service line 107470 which is already registered with DSH030014C.		1/23/2024 8:06 AM
Terminations	Termination Date	Update	Reinstatement	1/1/2019 12:00:00 AM		1/23/2024 8:06 AM
Terminations	Termination Effective Date	Update	Reinstatement	12/21/2018 12:00:00 AM		1/23/2024 8:06 AM
Terminations	Termination Reason	Update	Reinstatement	Other		1/23/2024 8:06 AM
Details	Comments Public	Insert	Reinstatement		Participated starting- 4/1/2018 Terminated starting- 1/1/2019 Reinstated- 4/1/2024	1/22/2024 3:23 PM
Contacts	Authorizing Official	Update	AO Change Request	Post, Kim EVP Chief Operations Officer HonorHealth 4805875087	Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	8/26/2019 6:42 AM
Contacts	Authorizing Official	Update	Profile Change Request	Post, Kim SVP-CEO HOS_CHF CLIN OFC HonorHealth 4805875087	Post, Kim EVP Chief Operations Officer HonorHealth 4805875087	7/19/2019 12:28 PM
Contacts	Authorizing Official	Update	Change Request	Pope, Alice Chief Financial Officer HonorHealth 4808825544	Post, Kim SVP-CEO HOS_CHF CLIN OFC HonorHealth 4805875087	7/1/2019 8:33 AM
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Supervisor HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	4/5/2019 2:38 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/21/2018 12:00:00 AM	12/31/2018 9:12 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/31/2018 9:12 AM
Terminations	Termination Comments	Update	Termination Request		Child site registration is unnecessary; HonorHealth JCLMC Outpatient Pre-Op Epic DEP .1 101001057 rolls up to service line 107470 which is already registered with DSH030014C.	12/31/2018 9:12 AM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	12/31/2018 9:12 AM
Terminations	Termination Effective Date	Update	Termination Request		12/21/2018 12:00:00 AM	12/31/2018 9:12 AM
Terminations	Termination Reason	Update	Termination Request		Other	12/31/2018 9:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		860181654	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008047201	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092474100	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003176592A	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1770690695	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1770690695	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		860181654006	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		201035820A	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1770690695	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1770690695	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		128579	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007457650007	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12148B	12/17/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	12/17/2018 11:46 AM
Details	Last Recertification Date	Update	Recertification		8/21/2018 2:38:24 PM	8/21/2018 2:38 PM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Authorizing Official	Update	Change Request	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	Pope, Alice Chief Financial Officer HonorHealth 4808825544	2/23/2018 3:14 PM
Contacts	Signed By	Insert	New Registration		Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	2/13/2018 1:34 PM
Details	340B ID	Update	New Registration		DSH030014M	2/13/2018 1:34 PM
Details	Entity Subname	Update	New Registration	OR Preop/PACU	OR Preop/PACU - OR Preop/PACU	2/13/2018 1:34 PM
Dates	Participating Approval Date	Update	New Registration		2/13/2018 1:34:16 PM	2/13/2018 1:34 PM
Details	State	Update	New Registration	Pending	Approved	2/13/2018 1:34 PM
Dates	Signed By Date	Update	New Registration		1/11/2018 4:04:22 PM	2/13/2018 1:34 PM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	2/13/2018 1:34 PM
Addresses	Main Address	Insert	New Registration		9250 N 3rd St #1001 Phoenix, AZ 85020	1/10/2018 7:07 PM
Addresses	Billing Address	Insert	New Registration		JOHN C LINCOLN MEDICAL CENTER 250 E Dunlap Ave Phoenix, AZ 85020	1/10/2018 7:07 PM
Addresses	Shipping Address	Insert	New Registration		JOHN C LINCOLN MEDICAL CENTER 250 E Dunlap Ave Phoenix, AZ 85020	1/10/2018 7:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2018 7:07 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		022241	1/10/2018 7:07 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	1/10/2018 7:07 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	1/10/2018 7:07 PM
Contacts	Primary Contact	Insert	New Registration		Lindgren, Kristjon 340B Program Supervisor HonorHealth 6028706060-331353	1/10/2018 7:07 PM
Contacts	Authorizing Official	Insert	New Registration		Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	1/10/2018 7:07 PM
Details	Last Recertification Date	Insert	New Registration			1/10/2018 7:07 PM
Details	Grant Number	Insert	New Registration			1/10/2018 7:07 PM
Details	340B ID	Insert	New Registration			1/10/2018 7:07 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2018 7:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2018 7:07 PM
Details	Medicare Provider Number	Insert	New Registration		030014	1/10/2018 7:07 PM
Details	Entity Name	Insert	New Registration		JOHN C LINCOLN MEDICAL CENTER	1/10/2018 7:07 PM
Details	Program Code	Insert	New Registration		DSH	1/10/2018 7:07 PM
Details	Entity Subname	Insert	New Registration		OR Preop/PACU	1/10/2018 7:07 PM
Dates	Participating Approval Date	Insert	New Registration			1/10/2018 7:07 PM
Details	State	Insert	New Registration		Pending	1/10/2018 7:07 PM
Dates	Registration Date	Insert	New Registration		1/10/2018 7:07:28 PM	1/10/2018 7:07 PM
Dates	Signed By Date	Insert	New Registration			1/10/2018 7:07 PM
Dates	Start Date	Insert	New Registration			1/10/2018 7:07 PM
Terminations	Termination Comments	Insert	New Registration			1/10/2018 7:07 PM
Terminations	Termination Date	Insert	New Registration			1/10/2018 7:07 PM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2018 7:07 PM
Terminations	Termination Reason	Insert	New Registration			1/10/2018 7:07 PM