Covered Entity Details

DSH460004D MCKAY-DEE HOSPITAL CENTER (Terminated) - information as of 5/26/2025 12:55:41 AM

Main Details

Name

MCKAY-DEE HOSPITAL CENTER

Subdivision Name

Physical Therapy Ortho - OP - McKay Dee Physical Therapy and Rehab

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH460004D

Medicare Provider Number

460004

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2018

Participating Start Date

4/1/2018

Participating Approval Date

2/2/2018

Last Recertification Date

Termination Date
Termination Reason

7/1/2018
DSH percentage below statutory minimum

Contacts

Authorizing Official

Intermountain Healthcare
Trever Porter, Finance Dir-MK
(801) 387-3767

Primary Contact

Intermountain Healthcare
Kevin Jones, 340B Program Director
(801) 284-1023

Addresses

Street Address

3895 Harrison Blvd
Suite 400
Ogden, UT 84403

Billing Address

McKay-Dee Hospital Center
4401 Harrison Blvd.
Ogden, UT 84403

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
AK	1005766
AZ	024737
AR	148293105
CO	95432514
FL	014726400
GA	003140736A
IL	942854057004
IN	003140736A
KS	100101240B
KY	01640168
LA	1764647
MS	00095778
NE	10026356301
NM	000A8978
NY	01496708
ND	2356
OH	0663170
OK	100706200A
OR	073056
PA	1007738210033
SC	11857B
TN	1505886
WY	108302300
		1194749580

Shipping Addresses

Shipping Address 1

McKay-Dee Hospital Center
4401 Harrison Blvd.
Ogden, UT 84403

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
DSH460004A	Child	DSH	MCKAY-DEE HOSPITAL	Summit Day Treatment	4387 Harrison Blvd. Suite C4	Ogden	UT	Terminated
DSH460004B	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Layton Clinic Imaging Service	2075 N 1200 West	Layton	UT	Terminated
DSH460004C	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy-Layton	2075 North 1200 West	Layton	UT	Terminated
DSH460004D	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy Ortho - OP - McKay Dee Physical Therapy and Rehab	3895 Harrison Blvd	Ogden	UT	Terminated
DSH460004E	Child	DSH	MCKAY-DEE HOSPITAL	Anti-Coagulation Clinic - Anti-Coagulation Clinic	4421 Harrison Blvd.	Ogden	UT	Terminated
DSH460004F	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy Complex - OP - Stewart Rehabilitation	3903 Harrison Blvd	Ogden	UT	Terminated
DSH460004G	Child	DSH	IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital	Infusion Center - Infusion Services	201 W Layton Pkwy Suite 2050	Layton	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Reinstatement	Gillespie, Kerry CFO-Specialty Based Care Intermountain Healthcare 8014422459	Porter, Trever Finance Dir-MK Intermountain Healthcare 8013873767	6/5/2020 12:13 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/30/2018 12:00:00 AM	6/1/2018 7:40 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/1/2018 7:40 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	6/1/2018 7:40 AM
Terminations	Termination Effective Date	Update	Termination Request		5/30/2018 12:00:00 AM	6/1/2018 7:40 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/1/2018 7:40 AM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Gillespie, Kerry CFO-Specialty Based Care Intermountain Healthcare 8014422459	2/2/2018 2:20 PM
Details	340B ID	Update	New Registration		DSH460004D	2/2/2018 2:20 PM
Details	Entity Subname	Update	New Registration	Physical Therapy Ortho - OP	Physical Therapy Ortho - OP - McKay Dee Physical Therapy and Rehab	2/2/2018 2:20 PM
Dates	Participating Approval Date	Update	New Registration		2/2/2018 2:20:28 PM	2/2/2018 2:20 PM
Details	State	Update	New Registration	Pending	Approved	2/2/2018 2:20 PM
Dates	Signed By Date	Update	New Registration		1/16/2018 11:57:43 AM	2/2/2018 2:20 PM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	2/2/2018 2:20 PM
Addresses	Main Address	Insert	New Registration		3895 Harrison Blvd Suite 400 Ogden, UT 84403	1/12/2018 3:24 PM
Addresses	Billing Address	Insert	New Registration		McKay-Dee Hospital Center 4401 Harrison Blvd. Ogden, UT 84403	1/12/2018 3:24 PM
Addresses	Shipping Address	Insert	New Registration		McKay-Dee Hospital Center 4401 Harrison Blvd. Ogden, UT 84403	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1005766	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		024737	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		148293105	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		95432514	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		014726400	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003140736A	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		942854057004	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003140736A	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100101240B	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01640168	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1764647	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00095778	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10026356301	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000A8978	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01496708	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2356	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0663170	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100706200A	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		073056	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007738210033	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11857B	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1505886	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		108302300	1/12/2018 3:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WY	1/12/2018 3:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1194749580	1/12/2018 3:24 PM
Contacts	Primary Contact	Insert	New Registration		Jones, Kevin 340B Program Director Intermountain Healthcare 8012841023	1/12/2018 3:24 PM
Contacts	Authorizing Official	Insert	New Registration		Gillespie, Kerry CFO-Specialty Based Care Intermountain Healthcare 8014422459	1/12/2018 3:24 PM
Details	Last Recertification Date	Insert	New Registration			1/12/2018 3:24 PM
Details	Grant Number	Insert	New Registration			1/12/2018 3:24 PM
Details	340B ID	Insert	New Registration			1/12/2018 3:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2018 3:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2018 3:24 PM
Details	Medicare Provider Number	Insert	New Registration		460004	1/12/2018 3:24 PM
Details	Entity Name	Insert	New Registration		MCKAY-DEE HOSPITAL CENTER	1/12/2018 3:24 PM
Details	Program Code	Insert	New Registration		DSH	1/12/2018 3:24 PM
Details	Entity Subname	Insert	New Registration		Physical Therapy Ortho - OP	1/12/2018 3:24 PM
Dates	Participating Approval Date	Insert	New Registration			1/12/2018 3:24 PM
Details	State	Insert	New Registration		Pending	1/12/2018 3:24 PM
Dates	Registration Date	Insert	New Registration		1/12/2018 3:24:16 PM	1/12/2018 3:24 PM
Dates	Signed By Date	Insert	New Registration			1/12/2018 3:24 PM
Dates	Start Date	Insert	New Registration			1/12/2018 3:24 PM
Terminations	Termination Comments	Insert	New Registration			1/12/2018 3:24 PM
Terminations	Termination Date	Insert	New Registration			1/12/2018 3:24 PM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2018 3:24 PM
Terminations	Termination Reason	Insert	New Registration			1/12/2018 3:24 PM