Covered Entity Details

DSH330059BR MONTEFIORE MEDICAL CENTER (Terminated) - information as of 4/23/2025 10:53:48 PM

Main Details

Name

MONTEFIORE MEDICAL CENTER

Subdivision Name

Hutchinson Metro Center - Orthopaedics

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330059BR

Medicare Provider Number

330059

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2018

Participating Start Date

4/1/2018

Participating Approval Date

1/25/2018

Last Recertification Date

9/4/2023

Termination Date
Termination Reason

1/1/2024
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

Montefiore Medical Center
David Menashy, Vice President of Finance
(917) 280-2722

Primary Contact

MONTEFIORE MEDICAL CENTER
PHILIP MANNING, DIRECTOR SPECIALTY PHARMACY
(347) 597-2576

Addresses

Street Address

1250 Waters Place
Orthopaedics
Bronx, NY 10461

Billing Address
Same as Street Address

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
NY	02998167,00243554	1952476988

Shipping Addresses

Shipping Address 1

Montefiore Medical Center Hutchinson Campus
1250 Waters Place
Department of Pharmacy, 6th Floor, Tower 2
Bronx, NY 10461

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/16/2018	07/01/2018	01/01/2024	01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/16/2018	07/01/2018	01/01/2024	01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/16/2018	07/01/2018	01/01/2024	01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/16/2018	07/01/2018	01/01/2024	01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/16/2018	07/01/2018	01/01/2024	01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/16/2018	07/01/2018	01/01/2024	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330059A	Child	DSH	MONTEFIORE MEDICAL CENTER	COMPREHENSIVE HEALTH CARE CENTER (CHCC)	305 E 161ST STREET	BRONX	NY	Active
DSH330059AB	Child	DSH	MONTEFIORE MEDICAL CENTER	STD CENTER	3230 BAINBRIDGE AVENUE	BRONX	NY	Terminated
DSH330059AC	Child	DSH	MONTEFIORE MEDICAL CENTER	MARBLE HILL FAMILY PRACTICE	5525 BROADWAY	BRONX	NY	Active
DSH330059AD	Child	DSH	MONTEFIORE MEDICAL CENTER	MMG/WILLIAMSBRIDGE	3011 BOSTON ROAD	BRONX	NY	Active
DSH330059AE	Child	DSH	MONTEFIORE MEDICAL CENTER	WALTON HIGH SCHOOL	2780 RESERVOIR AVENUE	BRONX	NY	Active
DSH330059AF	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 8	3010 BRIGGS AVENUE	BRONX	NY	Active
DSH330059AH	Child	DSH	MONTEFIORE MEDICAL CENTER	CASTLE HILL FAMILY PRACTICE	2175 WESTCHESTER AVENUE	BRONX	NY	Active
DSH330059AI	Child	DSH	MONTEFIORE MEDICAL CENTER	MONTEFIORE MEDICAL CENTER - SOUTH B	871 PROSPECT AVE	BRONX	NY	Active
DSH330059AJ	Child	DSH	MONTEFIORE MEDICAL CENTER	MONTEFIORE ONCOLOGY/PHARM/EAST	1695 EASTCHESTER ROAD	BRONX	NY	Active
DSH330059AL	Child	DSH	MONTEFIORE MEDICAL CENTER	Theodore Roosevelt High School	500 East Fordham Road	Bronx	NY	Active
DSH330059AM	Child	DSH	MONTEFIORE MEDICAL CENTER	Evander Childs High School	800 East Gun Hill Road	Bronx	NY	Active
DSH330059AN	Child	DSH	MONTEFIORE MEDICAL CENTER	Lehman High School	3000 East Tremont Street	Bronx	NY	Active
DSH330059AP	Child	DSH	MONTEFIORE MEDICAL CENTER	John Philip Sousa Middle School 142	3750 Baychester Avenue	Bronx	NY	Active
DSH330059AQ	Child	DSH	MONTEFIORE MEDICAL CENTER	P.S. 64	1425 Walton Avenue	Bronx	NY	Terminated
DSH330059AR	Child	DSH	MONTEFIORE MEDICAL CENTER	W.H. Taft Educational Campus	240 East 172nd Street	Bronx	NY	Active
DSH330059AS	Child	DSH	MONTEFIORE MEDICAL CENTER	Mott Haven Campus School Health	730 Concourse Village East	Bronx	NY	Active
DSH330059AT	Child	DSH	MONTEFIORE MEDICAL CENTER	South Bronx Health Center (Center for Child Health and Resiliency)	890 Prospect Avenue	Bronx	NY	Active
DSH330059AU	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health New Settlement School	1501 Jerome Avenue	BRONX	NY	Active
DSH330059AV	Child	DSH	MONTEFIORE MEDICAL CENTER	WAKEFIELD	600E 233RD ST	BRONX	NY	Terminated
DSH330059AW	Child	DSH	MONTEFIORE MEDICAL CENTER	JACK D WEILER HOSP OF A EINSTEIN COLL OF MED	1825 EASTCHESTER ROAD	BRONX	NY	Terminated
DSH330059AX	Child	DSH	MONTEFIORE MEDICAL CENTER	MORRIS EDUCATIONAL CAMPUS	1110 BOSTON RD	BRONX	NY	Active
DSH330059AY	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health Program at Columbus High School	925 Astor Ave	Bronx	NY	Active
DSH330059AZ	Child	DSH	MONTEFIORE MEDICAL CENTER	MMC AT ADLAI E STEVENSON CAMPUS	1980 LAFAYETTE AVE	BRONX	NY	Active
DSH330059B	Child	DSH	MONTEFIORE MEDICAL CENTER	FORDHAM FAMILY PRACTICE	ONE FORDHAM PLAZA	BRONX	NY	Terminated
DSH330059BA	Child	DSH	MONTEFIORE MEDICAL CENTER	MMG - VIA VERDE	730 BROOK AVE	BRONX	NY	Active
DSH330059BB	Child	DSH	MONTEFIORE MEDICAL CENTER	New York Children's Health Project	853 LONGWOOD AVE	BRONX	NY	Active
DSH330059BC	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Dermatology	1250 Waters Place	Bronx	NY	Active
DSH330059BD	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Internal Medicine	1250 Waters Place	Bronx	NY	Active
DSH330059BE	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Neurology	1250 Water Place	Bronx	NY	Active
DSH330059BF	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Diagnostic Radiology	1250 Waters Place	Bronx	NY	Active
DSH330059BG	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Gastroenterology	1250 Waters Place	Bronx	NY	Active
DSH330059BH	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Cardiology	1250 Waters Place	Bronx	NY	Active
DSH330059BJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Pediatrics	1250 Waters Place	Bronx	NY	Active
DSH330059BK	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Otolaryngology	1250 Waters Place	Bronx	NY	Active
DSH330059BL	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Plastic Surgery	1250 Waters Place	Bronx	NY	Active
DSH330059BM	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Medicine Sub-Specialties	1250 Waters Place	Bronx	NY	Active
DSH330059BN	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - General Surgery	1250 Waters Place	Bronx	NY	Active
DSH330059BP	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Urology	1250 Waters Place	Bronx	NY	Active
DSH330059BQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Pain Medicine	1250 Waters Place	Bronx	NY	Active
DSH330059BR	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Orthopaedics	1250 Waters Place	Bronx	NY	Terminated
DSH330059BS	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Ophthalmology	1250 Waters Place	Bronx	NY	Active
DSH330059BT	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Anesthesia	1250 Waters Place (3rd Floor)	Bronx	NY	Terminated
DSH330059BU	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - PACU & Recovery - PACU & Recovery	1250 Waters Place	Bronx	NY	Terminated
DSH330059BV	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - PERIOP	1250 Waters Place	Bronx	NY	Active
DSH330059BW	Child	DSH	MONTEFIORE MEDICAL CENTER	Montefiore Medical Center - PS18 John Peter Zenger School Health	502 Morris Ave	Bronx	NY	Active
DSH330059BX	Child	DSH	MONTEFIORE MEDICAL CENTER	Montefiore Medical Center - Middle School 145 Teller Education Campus	1000 Teller Ave	Bronx	NY	Active
DSH330059BY	Child	DSH	MONTEFIORE MEDICAL CENTER	Family Immunology Center - Family Immunology Center	1621 Eastchester Road	Bronx	NY	Active
DSH330059BZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Endocrinology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059C	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 55	450 ST PAULS PLACE	BRONX	NY	Active
DSH330059CA	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - MG Infectious Disease	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CB	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Rheumatology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CC	Child	DSH	MONTEFIORE MEDICAL CENTER	Port Morris Wellness Center - Internal Medicine	804 East 138th Street	Bronx	NY	Active
DSH330059CD	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - MG Internal Medicine	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CE	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Infectious Disease	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CF	Child	DSH	MONTEFIORE MEDICAL CENTER	Melrose Wellness Center - Internal Medicine	260 East 161st Street	Bronx	NY	Active
DSH330059CG	Child	DSH	MONTEFIORE MEDICAL CENTER	Waters Place Wellness Center - Internal Medicine	1510 Waters Place	Bronx	NY	Active
DSH330059CH	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - MG Pediatrics	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Dermatology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059CK	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Geriatrics	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CL	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Gastroenterology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CM	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Dermatology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CN	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Pulmonary	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CP	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Allergy and Immunology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Nephrology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059CR	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Labor Delivery Periop	600 East 233rd Street	Bronx	NY	Active
DSH330059CS	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Labor and Delivery Periop	1825 Eastchester Road	Bronx	NY	Active
DSH330059CT	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Hyperbaric Unit	600 East 233rd Street	Bronx	NY	Terminated
DSH330059CU	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Mammography	600 East 233rd Street	Bronx	NY	Active
DSH330059CV	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - CT	1825 Eastchester Road	Bronx	NY	Active
DSH330059CW	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - MRI	600 East 233rd Street	Bronx	NY	Active
DSH330059CX	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Hyperbaric Procedures	600 East 233rd Street	Bronx	NY	Active
DSH330059CY	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Vascular	1825 Eastchester Road	Bronx	NY	Active
DSH330059CZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Blood Bank Laboratory	600 East 233rd Street	Bronx	NY	Terminated
DSH330059D	Child	DSH	MONTEFIORE MEDICAL CENTER	HELP USA	1 WARD ISLAND	NEW YORK	NY	Terminated
DSH330059DA	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Speech Language Pathology	1825 Eastchester Road	Bronx	NY	Active
DSH330059DB	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Diagnostic Cardiology	1825 Eastchester Road	Bronx	NY	Active
DSH330059DC	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - CT	600 East 233rd Street	Bronx	NY	Active
DSH330059DD	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Internal Medicine	600 East 233rd Street	Bronx	NY	Active
DSH330059DE	Child	DSH	MONTEFIORE MEDICAL CENTER	MS 113 - Pediatrics	3710 Barnes Avenue	Bronx	NY	Active
DSH330059DF	Child	DSH	MONTEFIORE MEDICAL CENTER	PS 198 - Pediatrics	1180 Tinton Avenue	Bronx	NY	Active
DSH330059DG	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Ultrasound	1825 Eastchester Road	Bronx	NY	Active
DSH330059DH	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Physical Therapy	1825 Eastchester Road	Bronx	NY	Active
DSH330059DJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Cadiac Cath	1825 Eastchester Road	Bronx	NY	Active
DSH330059DK	Child	DSH	MONTEFIORE MEDICAL CENTER	MS 174 - Behavioral Health	456 White Plains Road	Bronx	NY	Terminated
DSH330059DL	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Obstetrics/Gynecology	600 East 233rd Street	Bronx	NY	Active
DSH330059DM	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Respiratory Therapy	600 East 233rd Street	Bronx	NY	Active
DSH330059DN	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Respiratory Therapy	1825 Eastchester Road	Bronx	NY	Active
DSH330059DP	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Diagnostic Cardiology	600 East 233rd Street	Bronx	NY	Active
DSH330059DQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Outpatient Dialysis	600 East 233rd Street	Bronx	NY	Active
DSH330059DR	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Dialysis	1825 Eastchester Road	Bronx	NY	Active
DSH330059DS	Child	DSH	MONTEFIORE MEDICAL CENTER	MS 174 - Pediatrics	456 White Plains Road	Bronx	NY	Active
DSH330059DT	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Pulmonary Function Test	1825 Eastchester Road	Bronx	NY	Active
DSH330059DU	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Occupational Therapy	600 East 233rd Street	Bronx	NY	Active
DSH330059DV	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - EEG Lab	600 East 233rd Street	Bronx	NY	Terminated
DSH330059DW	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Emergency Department	600 East 233rd Street	Bronx	NY	Active
DSH330059DX	Child	DSH	MONTEFIORE MEDICAL CENTER	MS 113 - Behavioral Health	3710 Barnes Avenue	Bronx	NY	Active
DSH330059DY	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Interventional Radiology	1825 Eastchester Road	Bronx	NY	Active
DSH330059DZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Blood Bank Laboratory	1825 Eastchester Road	Bronx	NY	Terminated
DSH330059E	Child	DSH	MONTEFIORE MEDICAL CENTER	WEST FARMS FAMILY PRACTICE CENTER	1055 EAST TREMONT AVE	BRONX	NY	Active
DSH330059EA	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Speech Language Pathology	600 East 233rd Street	Bronx	NY	Active
DSH330059EB	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Emergency Department	1825 Eastchester Road	Bronx	NY	Active
DSH330059EC	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Diagnostic Radiology	600 East 233rd Street	Bronx	NY	Active
DSH330059ED	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Ultrasound	600 East 233rd Street	Bronx	NY	Active
DSH330059EE	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Mammography	1825 Eastchester Road	Bronx	NY	Terminated
DSH330059EF	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Phlebotomy Lab	600 East 233rd Street	Bronx	NY	Terminated
DSH330059EG	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Pathology Lab	1825 Eastchester Road	Bronx	NY	Terminated
DSH330059EH	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Dialysis	600 East 233rd Street	Bronx	NY	Active
DSH330059EJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - GI Suite	600 East 233rd Street	Bronx	NY	Active
DSH330059EK	Child	DSH	MONTEFIORE MEDICAL CENTER	PS 198 - Behavioral Health	1180 Tinton Avenue	Bronx	NY	Terminated
DSH330059EL	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Diagnostic Radiology	1825 Eastchester Road	Bronx	NY	Active
DSH330059EM	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Nuclear Medicine	600 East 233rd Street	Bronx	NY	Active
DSH330059EN	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Physical Therapy	600 East 233rd Street	Bronx	NY	Active
DSH330059EP	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Labor and Delivery Scheduled Procedures	600 East 233rd Street	Bronx	NY	Terminated
DSH330059EQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Vascular	600 East 233rd Street	Bronx	NY	Active
DSH330059ER	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Obstetrics	1825 Eastchester Road	Bronx	NY	Active
DSH330059ES	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Labor and Delivery Scheduled Procedures	1825 Eastchester Road	Bronx	NY	Terminated
DSH330059ET	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Nuclear Medicine	1825 Eastchester Road	Bronx	NY	Active
DSH330059EU	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Cardiology Rapid Access Unit	1825 Eastchester Road	Bronx	NY	Active
DSH330059EV	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Gastroenterology	1825 Eastchester Road	Bronx	NY	Active
DSH330059EW	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Pathology Lab	600 East 233rd Street	Bronx	NY	Terminated
DSH330059EX	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Heart Failure	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059EY	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Gastroenterology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059EZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Nephrology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059F	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 28	1861 ANTHONY AVENUE	BRONX	NY	Active
DSH330059FA	Child	DSH	MONTEFIORE MEDICAL CENTER	Glebe Avenue at 2527 - Internal Medicine	2527 Glebe Avenue	Bronx	NY	Active
DSH330059FB	Child	DSH	MONTEFIORE MEDICAL CENTER	Westchester Square Campus - Emergency Department	2475 St. Raymonds Avenue	Bronx	NY	Active
DSH330059FC	Child	DSH	MONTEFIORE MEDICAL CENTER	Glebe Avenue at 2527 - Behavioral Health	2527 Glebe Avenue	Bronx	NY	Active
DSH330059FD	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - General Surgery	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059FE	Child	DSH	MONTEFIORE MEDICAL CENTER	Melrose Wellness Center - Psychiatry	260 East 161st Street	Bronx	NY	Active
DSH330059FF	Child	DSH	MONTEFIORE MEDICAL CENTER	Eastchester Practice at 1628 - Cardiology	1628 Eastchester Road	Bronx	NY	Active
DSH330059FG	Child	DSH	MONTEFIORE MEDICAL CENTER	Carpenter Avenue at 4141 - Ophthalmology	4141 Carpenter Avenue	Bronx	NY	Active
DSH330059FH	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Park at 1625 Poplar - CT	1625 Poplar Street	Bronx	NY	Active
DSH330059FJ	Child	DSH	MONTEFIORE MEDICAL CENTER	126th Street at 104-106 - MG Infectious Disease	104-106 East 126th Street	New York	NY	Active
DSH330059FK	Child	DSH	MONTEFIORE MEDICAL CENTER	Montefiore Home Health - Home Health	1 Fordham Plaza	Bronx	NY	Active
DSH330059FL	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Periop	1250 Waters Place	Bronx	NY	Terminated
DSH330059FM	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - MG Comprehensive	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059FN	Child	DSH	MONTEFIORE MEDICAL CENTER	Bronx Boulevard at 4401 - Chemical Dependency	4401 Bronx Boulevard	Bronx	NY	Active
DSH330059FP	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - OB and GYN Ultrasound	600 East 233rd Street	Bronx	NY	Terminated
DSH330059FQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Audiology	1250 Waters Place	Bronx	NY	Active
DSH330059FR	Child	DSH	MONTEFIORE MEDICAL CENTER	Williamsbridge Practice at 3011 - MG Medication Management	3011 Boston Road	Bronx	NY	Terminated
DSH330059FS	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Interventional Radiology	600 East 233rd Street	Bronx	NY	Active
DSH330059FT	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Cardiology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059FU	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Social Work	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059FV	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Heart Failure	1250 Waters Place	Bronx	NY	Active
DSH330059FW	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Periop	600 East 233rd Street	Bronx	NY	Active
DSH330059FX	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - Ambulatory Surgery Unit	600 East 233rd Street	Bronx	NY	Terminated
DSH330059FY	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Consultative Asthma Center - Adult	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059FZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Clinical Neurology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059G	Child	DSH	MONTEFIORE MEDICAL CENTER	COMPREHENSIVE FAMILY CARE CENTER (CFCC)	1621 EASTCHESTER ROAD	BRONX	NY	Active
DSH330059GA	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Vascular Surgery	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GB	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Rheumatology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GC	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Pulmonary Function Test	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GD	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Diagnostic Cardiology	1250 Waters Place	Bronx	NY	Active
DSH330059GE	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Dermatology Surgery	4234 Bronx Boulevard	Bronx	NY	Terminated
DSH330059GF	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Ambulatory Surgery Unit	1825 Eastchester Road	Bronx	NY	Terminated
DSH330059GG	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Pulmonary Failure	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GH	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Urology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Orthopedic Surgery	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GK	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Otorhinolaryngology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GL	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Pediatric Urology	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059GM	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Diagnostic Cardiology	3400 Bainbridge Avenue	Bronx	NY	Terminated
DSH330059GN	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Endocrinology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GP	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Pediatric Dermatology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Internal Medicine	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GR	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - Pediatrics	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GS	Child	DSH	MONTEFIORE MEDICAL CENTER	Westchester Square Campus - Periop	2475 St. Raymonds Avenue	Bronx	NY	Terminated
DSH330059GT	Child	DSH	MONTEFIORE MEDICAL CENTER	Weiler Campus - Periop	1825 Eastchester Road	Bronx	NY	Active
DSH330059GU	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - MG Internal Medicine	2100 Bartow Avenue	Bronx	NY	Active
DSH330059GV	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Spine Neurosurgery	1250 Waters Place	Bronx	NY	Terminated
DSH330059GW	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health Program MS 147 - Pediatrics	1600 Webster Avenue	Bronx	NY	Active
DSH330059GX	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Nutrition	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059GY	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - Cardiology	2100 Bartow Avenue	Bronx	NY	Terminated
DSH330059GZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Function Neurosurgery	1250 Waters Place	Bronx	NY	Active
DSH330059H	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 105	725 BRADY AVENUE	BRONX	NY	Active
DSH330059HA	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Cardiac Surgery	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059HB	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Podiatry	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059HC	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - MG Social Work	2100 Bartow Avenue	Bronx	NY	Terminated
DSH330059HD	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Function Rehab Medicine	1250 Waters Place	Bronx	NY	Active
DSH330059HE	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health Program PS 199 - Pediatrics	1449 Shakespeare Avenue	Bronx	NY	Active
DSH330059HF	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Park at 1625 Poplar - Radiation Oncology	1625 Poplar Street	Bronx	NY	Active
DSH330059HG	Child	DSH	MONTEFIORE MEDICAL CENTER	Neuroscience Center - CT	3316 Rochambeau Avenue	Bronx	NY	Active
DSH330059HH	Child	DSH	MONTEFIORE MEDICAL CENTER	Bronx Boulevard at 4401 - Family Medicine	4401 Bronx Boulevard	Bronx	NY	Active
DSH330059HJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Otolaryngology Speech	1250 Waters Place	Bronx	NY	Active
DSH330059HK	Child	DSH	MONTEFIORE MEDICAL CENTER	Bronx Regional High School - Pediatrics	979 Rogers Place	Bronx	NY	Active
DSH330059HL	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health Program IS 98 - Pediatrics	1619 Boston Road	Bronx	NY	Active
DSH330059HM	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Adult Congenital Heart Disease	3400 Bainbridge Avenue	Bronx	NY	Terminated
DSH330059HN	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - MG Psychology	2100 Bartow Avenue	Bronx	NY	Active
DSH330059HP	Child	DSH	MONTEFIORE MEDICAL CENTER	Children's Evaluation and Rehabilitation Center - Primary Care	1225 Morris Park Avenue	Bronx	NY	Active
DSH330059HQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Psychology	4234 Bronx Boulevard	Bronx	NY	Terminated
DSH330059HR	Child	DSH	MONTEFIORE MEDICAL CENTER	Bronx Boulevard at 4401 - Adult Psychiatry	4401 Bronx Boulevard	Bronx	NY	Active
DSH330059HS	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - MG Pediatrics	2100 Bartow Avenue	Bronx	NY	Active
DSH330059HT	Child	DSH	MONTEFIORE MEDICAL CENTER	Glebe Avenue at 2527 - Psychiatry	2527 Glebe Avenue	Bronx	NY	Active
DSH330059HU	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Cardiac Surgery	1250 Waters Place	Bronx	NY	Active
DSH330059HV	Child	DSH	MONTEFIORE MEDICAL CENTER	Schiff Practice at 3444 Kossuth - Dental	3444 Kossuth Avenue	Bronx	NY	Active
DSH330059HW	Child	DSH	MONTEFIORE MEDICAL CENTER	Children's Evaluation and Rehabilitation Center - Developmental Behavioral Pediatrics	1225 Morris Park Avenue	Bronx	NY	Active
DSH330059HX	Child	DSH	MONTEFIORE MEDICAL CENTER	School Health Program PS 151 - Pediatrics	250 East 156th Street	Bronx	NY	Active
DSH330059HY	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Vascular Surgery	1250 Waters Place	Bronx	NY	Active
DSH330059HZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Clinical Neurology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059I	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM DEWITT CLINTON HIGH SCHOOL	100 W. MOSHOLU PARKWAY SO.	BRONX	NY	Active
DSH330059J	Child	DSH	MONTEFIORE MEDICAL CENTER	UNIVERSITY AVENUE FAMILY PRACTICE CENTER	105 WEST 188TH STREET	BRONX	NY	Active
DSH330059JA	Child	DSH	MONTEFIORE MEDICAL CENTER	Williamsbridge Practice at 3011 - MG Podiatry	3011 Boston Road	Bronx	NY	Active
DSH330059JB	Child	DSH	MONTEFIORE MEDICAL CENTER	Bronx Boulevard at 4401 - Child Psychiatry	4401 Bronx Boulevard	Bronx	NY	Active
DSH330059JC	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG General Surgery	4234 Bronx Boulevard	Bronx	NY	Terminated
DSH330059JD	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Pulmonary	4234 Bronx Boulevard	Bronx	NY	Terminated
DSH330059JE	Child	DSH	MONTEFIORE MEDICAL CENTER	Morris Park at 1225 - Developmental Behavioral Pediatrics	1225 Morris Park Avenue	Bronx	NY	Terminated
DSH330059JF	Child	DSH	MONTEFIORE MEDICAL CENTER	Bainbridge Avenue at 3230 - Infectious Disease	3230 Bainbridge Avenue	Bronx	NY	Active
DSH330059JG	Child	DSH	MONTEFIORE MEDICAL CENTER	Carpenter Avenue at 4141 - Orthopedic Surgery	4141 Carpenter Avenue	Bronx	NY	Active
DSH330059JH	Child	DSH	MONTEFIORE MEDICAL CENTER	Bainbridge Avenue at 3340 - Child Psychiatry	3340 Bainbridge Avenue	Bronx	NY	Active
DSH330059JJ	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Park at 1500 - Rehabilitation Medicine	1500 Blondell Avenue	Bronx	NY	Active
DSH330059JK	Child	DSH	MONTEFIORE MEDICAL CENTER	Neuroscience Center - Interventional Radiology	3316 Rochambeau Avenue	Bronx	NY	Active
DSH330059JL	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Arrhythmia Center	1250 Waters Place	Bronx	NY	Active
DSH330059JM	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Hepatology	1250 Waters Place	Bronx	NY	Active
DSH330059JN	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Campus - General Surgery	600 East 233rd Street	Bronx	NY	Active
DSH330059JP	Child	DSH	MONTEFIORE MEDICAL CENTER	Waters Place Wellness Center - Psychiatry	1510 Waters Place	Bronx	NY	Active
DSH330059JQ	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Urology	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059JR	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - MG Medication Management	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059JS	Child	DSH	MONTEFIORE MEDICAL CENTER	Wakefield Ambulatory Care Center - CMO Certified Diabetic Educator	4234 Bronx Boulevard	Bronx	NY	Active
DSH330059JT	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - MG Medication Management	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059JU	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - COVID Recovery	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059JV	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - CMO Certified Diabetic Educator	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059JW	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Urogynecology	1250 Waters Place	Bronx	NY	Active
DSH330059JX	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Thoracic Surgery	1250 Waters Place	Bronx	NY	Active
DSH330059JY	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Structural Heart	1250 Waters Place	Bronx	NY	Active
DSH330059JZ	Child	DSH	MONTEFIORE MEDICAL CENTER	Hutchinson Metro Center - Cardiology Pulmonary Hypertension	1250 Waters Place	Bronx	NY	Active
DSH330059K	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 95	3961 HILLMAN AVENUE	BRONX	NY	Active
DSH330059KA	Child	DSH	MONTEFIORE MEDICAL CENTER	Coop City at Bartow - CMO Certified Diabetic Educator	2100 Bartow Avenue	Bronx	NY	Active
DSH330059KB	Child	DSH	MONTEFIORE MEDICAL CENTER	Medical Arts Pavilion - Internal Medicine	3400 Bainbridge Avenue	Bronx	NY	Active
DSH330059L	Child	DSH	MONTEFIORE MEDICAL CENTER	MMG/BAY PLAZA PRIMARY CARE CENTER	2100 BARTOW AVE	BRONX	NY	Terminated
DSH330059M	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM PS 85	2400 MARION AVENUE	BRONX	NY	Active
DSH330059N	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM M NIELSON HIGH SCHOOL	1010 REV J A POLITE AVE	BRONX	NY	Terminated
DSH330059P	Child	DSH	MONTEFIORE MEDICAL CENTER	MMTP I	3550 JEROME AVENUE	BRONX	NY	Active
DSH330059Q	Child	DSH	MONTEFIORE MEDICAL CENTER	GOTTSCHO CHILDREN'S DIALYSIS CENTER	FROST VALLEY YMCA	OLIVEREA	NY	Terminated
DSH330059R	Child	DSH	MONTEFIORE MEDICAL CENTER	METHADONE CLINIC II & III	2058 JEROME AVE	BRONX	NY	Active
DSH330059S	Child	DSH	MONTEFIORE MEDICAL CENTER	COMMUNITY SCHOOL 214, SO BRONX HIGH SCHOOL	701 ST ANN'S AVENUE	BRONX	NY	Active
DSH330059U	Child	DSH	MONTEFIORE MEDICAL CENTER	JACKSON AVENUE FAMILY RESIDENCE	691 E 138TH STREET	BRONX	NY	Terminated
DSH330059V	Child	DSH	MONTEFIORE MEDICAL CENTER	PRIMARY CARE NETWORK (FHC)	1 Fordham Plaza (5th Floor)	BRONX	NY	Active
DSH330059W	Child	DSH	MONTEFIORE MEDICAL CENTER	NELSON AVENUE FAMILY RESIDENCE	1605-11 NELSON AVENUE	BRONX	NY	Terminated
DSH330059X	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM IS 216 AND IS 217	977 FOX STREET	BRONX	NY	Active
DSH330059Y	Child	DSH	MONTEFIORE MEDICAL CENTER	SCHOOL HEALTH PROGRAM I S 45	2502 LORRILARD AVE	BRONX	NY	Active
DSH330059Z	Child	DSH	MONTEFIORE MEDICAL CENTER	CHILD PROTECTION CENTER	3314 STEUBEN AVENUE	BRONX	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/8/2023 12:00:00 AM	11/9/2023 8:48 AM
Details	State	Update	Termination Request	Active	To Be Terminated	11/9/2023 8:48 AM
Terminations	Termination Date	Update	Termination Request		1/1/2024 12:00:00 AM	11/9/2023 8:48 AM
Terminations	Termination Effective Date	Update	Termination Request		11/8/2023 12:00:00 AM	11/9/2023 8:48 AM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	11/9/2023 8:48 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 3:11:51 PM	9/4/2023 4:14:00 PM	9/4/2023 4:14 PM
Details	Last Recertification Date	Update	Recertification	9/1/2021 6:06:36 PM	9/16/2022 3:11:51 PM	9/16/2022 3:11 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 1:06:07 PM	9/1/2021 6:06:36 PM	9/1/2021 6:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 1:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		02998167	9/14/2020 1:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/14/2020 1:06 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/14/2020 1:06 PM
Details	Last Recertification Date	Update	Recertification	9/8/2019 7:26:04 AM	9/14/2020 1:06:07 PM	9/14/2020 1:06 PM
Addresses	Main Address	Update	Recertification	1250 Waters Place (8th Floor) Orthopaedics Bronx, NY 10461	1250 Waters Place Orthopaedics Bronx, NY 10461	9/8/2019 7:26 AM
Contacts	Primary Contact	Update	Recertification	Sosnowski, Frank P. Unified Director of Pharmacy Montefiore Medical Center 7189204529	MANNING, PHILIP DIRECTOR SPECIALTY PHARMACY MONTEFIORE MEDICAL CENTER 3475972576	9/8/2019 7:26 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 3:07:03 PM	9/8/2019 7:26:04 AM	9/8/2019 7:26 AM
Contacts	Authorizing Official	Update	AO Change Request	Blye, Colleen M. Executive Vice President-CFO Montefiore Medical Center 7189207602	Menashy, David Vice President of Finance Montefiore Medical Center 9172802722	8/26/2019 6:43 AM
Contacts	Primary Contact	Update	Recertification	Sosnowski, Frank Unified Director of Pharmacy Montefiore Medical Center 7189204529	Sosnowski, Frank P. Unified Director of Pharmacy Montefiore Medical Center 7189204529	9/6/2018 4:18 PM
Details	Last Recertification Date	Update	Recertification		9/6/2018 3:07:03 PM	9/6/2018 3:07 PM
Addresses	Shipping Address	Insert	Change Request		Montefiore Medical Center Hutchinson Campus 1250 Waters Place Department of Pharmacy, 6th Floor, Tower 2 Bronx, NY 10461	2/14/2018 7:42 AM
Details	State	Update	Change Request	Approved	Active	2/14/2018 7:42 AM
Contacts	Signed By	Insert	New Registration		Blye, Colleen M. Executive Vice President-CFO Montefiore Medical Center 7189207602	1/25/2018 10:46 AM
Details	340B ID	Update	New Registration		DSH330059BR	1/25/2018 10:46 AM
Details	Entity Subname	Update	New Registration	Hutchinson Metro Center	Hutchinson Metro Center - Orthopaedics	1/25/2018 10:46 AM
Dates	Participating Approval Date	Update	New Registration		1/25/2018 10:46:51 AM	1/25/2018 10:46 AM
Details	State	Update	New Registration	Pending	Approved	1/25/2018 10:46 AM
Dates	Signed By Date	Update	New Registration		1/12/2018 4:37:10 PM	1/25/2018 10:46 AM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	1/25/2018 10:46 AM
Addresses	Main Address	Insert	New Registration		1250 Waters Place (8th Floor) Orthopaedics Bronx, NY 10461	1/12/2018 4:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00243554	1/12/2018 4:30 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/12/2018 4:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1952476988	1/12/2018 4:30 PM
Contacts	Primary Contact	Insert	New Registration		Sosnowski, Frank Unified Director of Pharmacy Montefiore Medical Center 7189204529	1/12/2018 4:30 PM
Contacts	Authorizing Official	Insert	New Registration		Blye, Colleen M. Executive Vice President-CFO Montefiore Medical Center 7189207602	1/12/2018 4:30 PM
Details	Last Recertification Date	Insert	New Registration			1/12/2018 4:30 PM
Details	Grant Number	Insert	New Registration			1/12/2018 4:30 PM
Details	340B ID	Insert	New Registration			1/12/2018 4:30 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2018 4:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2018 4:30 PM
Details	Medicare Provider Number	Insert	New Registration		330059	1/12/2018 4:30 PM
Details	Entity Name	Insert	New Registration		MONTEFIORE MEDICAL CENTER	1/12/2018 4:30 PM
Details	Program Code	Insert	New Registration		DSH	1/12/2018 4:30 PM
Details	Entity Subname	Insert	New Registration		Hutchinson Metro Center	1/12/2018 4:30 PM
Dates	Participating Approval Date	Insert	New Registration			1/12/2018 4:30 PM
Details	State	Insert	New Registration		Pending	1/12/2018 4:30 PM
Dates	Registration Date	Insert	New Registration		1/12/2018 4:30:02 PM	1/12/2018 4:30 PM
Dates	Signed By Date	Insert	New Registration			1/12/2018 4:30 PM
Dates	Start Date	Insert	New Registration			1/12/2018 4:30 PM
Terminations	Termination Comments	Insert	New Registration			1/12/2018 4:30 PM
Terminations	Termination Date	Insert	New Registration			1/12/2018 4:30 PM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2018 4:30 PM
Terminations	Termination Reason	Insert	New Registration			1/12/2018 4:30 PM