Covered Entity Details

DSH220052C BROCKTON HOSPITAL, INC (Terminated) - information as of 5/20/2025 11:44:27 PM

Main Details

Name

BROCKTON HOSPITAL, INC

Subdivision Name

Signature Healthcare Brockton Hospital Raynham Internal Medicine - Internal Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220052C

Medicare Provider Number

220052

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/24/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/26/2018

Last Recertification Date

9/5/2023

Termination Date
Termination Reason

4/1/2024
Business decision by the Covered Entity

Contacts

Authorizing Official

Brockton Hospital
Stephen Borges, Vice President, Finance Operations
(508) 941-7571

Primary Contact

Brockton Hospital
Margaret Clapp, Enterprise Director of Pharmacy
(508) 941-7750

Addresses

Street Address

1215 Broadway
Raynham, MA 02767

Billing Address

Signature Healthcare Brockton Hospital Inc
680 Centre Street
Brockton, MA 02302

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
MA	110026502C	1063431286

Shipping Addresses

Shipping Address 1

Signature Healthcare Brockton Hospital Inc.
680 Centre Street
Brockton, MA 02302

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
DSH220052A	Child	DSH	BROCKTON HOSPITAL, INC	Clinic	130 Quincy Avenue	Brockton	MA	Active
DSH220052AA	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital-BH CT Scan - BH CT Scan	110 Liberty Street	Brockton	MA	Active
DSH220052AB	Child	DSH	BROCKTON HOSPITAL, INC	Green Cancer Center-Surgery Clinic - Surgery Clinic	25 Libby Street	Brockton	MA	Active
DSH220052AC	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- BH R ECHO LAB - BH R ECHO LAB	25 Libby Street	Brockton	MA	ToBeTerminated
DSH220052AD	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- BH NUCMED - BH R NUC Hospital	25 Libby Street	Brockton	MA	ToBeTerminated
DSH220052AE	Child	DSH	BROCKTON HOSPITAL, INC	BH Raynham Eye Services - Eye Services	1215 Broadway	Raynham	MA	Active
DSH220052AF	Child	DSH	BROCKTON HOSPITAL, INC	BH Urgent Care 650 Centre - Urgent Care	650 Centre Street	Brockton	MA	Terminated
DSH220052AG	Child	DSH	BROCKTON HOSPITAL, INC	BH Pain Clinic Hanson - Pain Clinic	430 Liberty Street	Hanson	MA	ToBeTerminated
DSH220052AH	Child	DSH	BROCKTON HOSPITAL, INC	BH Urgent Care Liberty - Urgent Care	110 Liberty Street	Brockton	MA	Terminated
DSH220052AJ	Child	DSH	BROCKTON HOSPITAL, INC	BH Rad Hanson - Radiology	430 Liberty Street	Hanson	MA	ToBeTerminated
DSH220052AK	Child	DSH	BROCKTON HOSPITAL, INC	BH Pulmonary Clinic EB - Pulmonary	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AL	Child	DSH	BROCKTON HOSPITAL, INC	BH DERMATOLOG CLINIC EB - Dermatology	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AM	Child	DSH	BROCKTON HOSPITAL, INC	BH IM CLINIC EB - Internal Medicine	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AN	Child	DSH	BROCKTON HOSPITAL, INC	BH FP CLINIC EB - Family Medicine Practice	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052B	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Signature Healthcare Cancer Treatment Center	25 Libby Street	Brockton	MA	Active
DSH220052C	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital Raynham Internal Medicine - Internal Medicine	1215 Broadway	Raynham	MA	Terminated
DSH220052D	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center - Cardiology Services	25 Libby Street	Brockton	MA	Active
DSH220052E	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Rheumatology Clinic OPD - Rheumatology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052F	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Gastroenterology Clinic OPD - Gastroenterology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052G	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - BH Raynham FP Clinic - Raynham Family Practice Clinic	1215 Broadway	Raynham	MA	Active
DSH220052H	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- Pulmonology Clinic - Pulmonology	25 Libby Street	Brockton	MA	Active
DSH220052J	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Infectious Disease OPD - Infectious Disease - OPD	130 Quincy Avenue	Brockton	MA	Active
DSH220052K	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Endocrinology Clinic OPD - Endocrinology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052L	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Raynham Pediatric Clinic - Raynham Pediatric Clinic	1215 Broadway	Raynham	MA	Terminated
DSH220052M	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-Endocrinology Clinic - Endocrine	25 Libby Street	Brockton	MA	Active
DSH220052N	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Liberty DPH Dermatology Clinic	110 Liberty Street 2nd Floor	Brockton	MA	Active
DSH220052P	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-Plastic Clinic - Plastic Clinic	25 Libby Street	Brockton	MA	Active
DSH220052Q	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Endocrinology Clinic Liberty - BH Endo Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052R	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Same Day Clinic Liberty - BH Same Day Clin Liberty	110 Liberty Street	Brockton	MA	Terminated
DSH220052S	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Pulmonology Clinic Liberty - BH Pulm Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052T	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Nephrology Clinic Liberty - BH Nephr Clinic Liberty	110 Liberty St	Brockton	MA	Active
DSH220052U	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-BH Thoracic Surgery - BH Thor Surg Clinic Libby	25 Libby St	Brockton	MA	Active
DSH220052V	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Internal Med Clinic Liberty - BH IM Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052W	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Rheumatology Clinic Liberty - BH Rheum Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052X	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Neurology Clinic Liberty - BH Neuro Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052Y	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Bariatric Clinic Liberty - BH Bariat Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052Z	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital-BH Family Practice - BH FP Clinic Liberty	110 Liberty St	Brockton	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/8/2024 12:00:00 AM	1/8/2024 2:29 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/8/2024 2:29 PM
Terminations	Termination Date	Update	Termination Request		4/1/2024 12:00:00 AM	1/8/2024 2:29 PM
Terminations	Termination Effective Date	Update	Termination Request		1/8/2024 12:00:00 AM	1/8/2024 2:29 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/8/2024 2:29 PM
Contacts	Primary Contact	Update	Profile Change Request	Clapp, Margaret Pharmacy Director Brockton Hospital 5089417178	Clapp, Margaret Enterprise Director of Pharmacy Brockton Hospital 5089417750	12/5/2023 11:13 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 8:37:09 AM	9/5/2023 10:32:38 AM	9/5/2023 10:32 AM
Contacts	Authorizing Official	Update	Change Request	Radzevich, Jason Chief Financial Officer Brockton Hospital 5089417006	Borges, Stephen Vice President, Finance Operations Brockton Hospital 5089417571	7/18/2023 12:34 PM
Contacts	Authorizing Official	Update	Change Request	Borges, Stephen Vice President, Hospital Operations Brockton Hospital 5089417571	Radzevich, Jason Chief Financial Officer Brockton Hospital 5089417006	3/24/2023 11:20 AM
Details	Last Recertification Date	Update	Recertification	9/1/2021 12:32:45 PM	9/6/2022 8:37:09 AM	9/6/2022 8:37 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 1:19:23 PM	9/1/2021 12:32:45 PM	9/1/2021 12:32 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110026502 (MA)		2/10/2021 12:44 PM
Addresses	Shipping Address	Insert	Change Request		Signature Healthcare Brockton Hospital Inc. 680 Centre Street Brockton, MA 02302	10/14/2020 7:16 AM
Medicaid Billing	NPI: State	Update	Recertification		MA	8/27/2020 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 5:15:56 PM	8/27/2020 1:19:23 PM	8/27/2020 1:19 PM
Addresses	Billing Address	Update	Change Request	Signature Healthcare Brockton Hospital 680 Centre Street Brockton, MA 02302	Signature Healthcare Brockton Hospital Inc 680 Centre Street Brockton, MA 02302	6/30/2020 1:45 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1689695405 ( )		6/30/2020 1:45 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1770504599 ( )		6/30/2020 1:45 PM
Contacts	Authorizing Official	Update	Change Request	Walsh, Kimberly SR VP Patient Services, CNO Signature Healthcare Brockton Hospital 5089417015	Borges, Stephen Vice President, Hospital Operations Brockton Hospital 5089417571	1/28/2020 4:08 PM
Contacts	Authorizing Official	Update	Change Request	Borges, Stephen Interim CFO & Treasurer Brockton Hospital 5089417007	Walsh, Kimberly SR VP Patient Services, CNO Signature Healthcare Brockton Hospital 5089417015	1/2/2020 3:55 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 11:32:10 AM	8/28/2019 5:15:56 PM	8/28/2019 5:15 PM
Contacts	Authorizing Official	Update	Change Request	Papadakos, James N. Chief Financial Officer Brockton Hospital 5089417570	Borges, Stephen Interim CFO & Treasurer Brockton Hospital 5089417007	4/26/2019 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/18/2019 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110026502C	4/18/2019 10:00 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/18/2019 10:00 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1063431286	4/18/2019 10:00 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1689695405	4/18/2019 10:00 AM
Details	Last Recertification Date	Update	Recertification		8/27/2018 11:32:10 AM	8/27/2018 11:32 AM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Papadakos, James N. Chief Financial Officer Brockton Hospital 5089417570	4/26/2018 6:48 AM
Details	340B ID	Update	New Registration		DSH220052C	4/26/2018 6:48 AM
Details	Entity Subname	Update	New Registration	Signature Healthcare Brockton Hospital Raynham Internal Medicine	Signature Healthcare Brockton Hospital Raynham Internal Medicine - Internal Medicine	4/26/2018 6:48 AM
Dates	Participating Approval Date	Update	New Registration		4/26/2018 6:48:32 AM	4/26/2018 6:48 AM
Details	State	Update	New Registration	Pending	Approved	4/26/2018 6:48 AM
Dates	Signed By Date	Update	New Registration		4/24/2018 4:00:39 PM	4/26/2018 6:48 AM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/26/2018 6:48 AM
Addresses	Main Address	Insert	New Registration		1215 Broadway Raynham, MA 02767	4/24/2018 4:00 PM
Addresses	Billing Address	Insert	New Registration		Signature Healthcare Brockton Hospital 680 Centre Street Brockton, MA 02302	4/24/2018 4:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/24/2018 4:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026502	4/24/2018 4:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/24/2018 4:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770504599	4/24/2018 4:00 PM
Contacts	Authorizing Official	Insert	New Registration		Papadakos, James N. Chief Financial Officer Brockton Hospital 5089417570	4/24/2018 4:00 PM
Contacts	Primary Contact	Insert	New Registration		Clapp, Margaret Pharmacy Director Brockton Hospital 5089417178	4/24/2018 4:00 PM
Details	Last Recertification Date	Insert	New Registration			4/24/2018 4:00 PM
Details	Grant Number	Insert	New Registration			4/24/2018 4:00 PM
Details	340B ID	Insert	New Registration			4/24/2018 4:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/24/2018 4:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/24/2018 4:00 PM
Details	Medicare Provider Number	Insert	New Registration		220052	4/24/2018 4:00 PM
Details	Entity Name	Insert	New Registration		BROCKTON HOSPITAL, INC	4/24/2018 4:00 PM
Details	Program Code	Insert	New Registration		DSH	4/24/2018 4:00 PM
Details	Entity Subname	Insert	New Registration		Signature Healthcare Brockton Hospital Raynham Internal Medicine	4/24/2018 4:00 PM
Dates	Participating Approval Date	Insert	New Registration			4/24/2018 4:00 PM
Details	State	Insert	New Registration		Pending	4/24/2018 4:00 PM
Dates	Registration Date	Insert	New Registration		4/24/2018 4:00:37 PM	4/24/2018 4:00 PM
Dates	Signed By Date	Insert	New Registration			4/24/2018 4:00 PM
Dates	Start Date	Insert	New Registration			4/24/2018 4:00 PM
Terminations	Termination Comments	Insert	New Registration			4/24/2018 4:00 PM
Terminations	Termination Date	Insert	New Registration			4/24/2018 4:00 PM
Terminations	Termination Effective Date	Insert	New Registration			4/24/2018 4:00 PM
Terminations	Termination Reason	Insert	New Registration			4/24/2018 4:00 PM