Covered Entity Details

DSH150169B COMMUNITY HOSPITAL OF INDIANA INC. (Terminated) - information as of 4/30/2025 10:55:10 PM

Main Details

Name

COMMUNITY HOSPITAL OF INDIANA INC.

Subdivision Name

COMMUNITY BACK NECK AND SPINE CENTE - Back, Neck, Spine Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH150169B

Medicare Provider Number

150169

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/11/2018

Participating Start Date

10/1/2018

Participating Approval Date

8/3/2018

Last Recertification Date

Termination Date
Termination Reason

1/1/2019
Business decision by the Covered Entity

Contacts

Authorizing Official

Community Hospital Indianapolis Region
David Kiley, President
(317) 621-9337

Primary Contact

Community Health Network North Hospital
Derek McMichael, Director of Pharmacy, North Hospital
(317) 621-5388

Addresses

Street Address

6970 HILLSDALE CT
INDIANAPOLIS, IN 46250-2040

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?
No

Shipping Addresses

Same as Street Address

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
DSH150169A	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	REHAB & SPORTS MEDICINE CASTLETON - Rehab & Sports Medicine - Castleton	7930 SHADELAND AVE	INDIANAPOLIS	IN	Terminated
DSH150169B	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY BACK NECK AND SPINE CENTE - Back, Neck, Spine Center	6970 HILLSDALE CT	INDIANAPOLIS	IN	Terminated
DSH150169C	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY IMAGING CENTER NORTH - Community Imaging Center North	8181 CLEARVISTA PARKWAY	INDIANAPOLIS	IN	Terminated
DSH150169D	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY OP PHYSICAL THERAPY AND R - Community OP Physical Therapy & Rehab	13121 OLIO RD	FISHERS	IN	Terminated
DSH150169E	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	REHAB & SPORTS MEDICINE CARMEL - Rehab & Sports Medicine - Carmel	11911 N MERIDIAN ST	CARMEL	IN	Terminated
DSH150169F	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY BREAST MRI - Community Breast MRI	7250 CLEARVISTA DR	INDIANAPOLIS	IN	Terminated
DSH150169G	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY BREAST CARE NORTH - Community Breast Care North	7120 CLEARVISTA DR	INDIANAPOLIS	IN	Terminated
DSH150169H	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	REHAB & SPORTS MEDICINE NORTH - Rehab & Sports Medicine - North	6922 HILLSDALE CT	INDIANAPOLIS	IN	Terminated
DSH150169J	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY BREAST DIAGNOSTIC CENTER - Community Breast Diagnostic Center	7120 CLEARVISTA DR	INDIANAPOLIS	IN	Terminated
DSH150169K	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY IMAGAING CENTER NOBLESVIL - Community Imaging Center - Noblesville	9669 E 146TH ST	NOBLESVILLE	IN	Terminated
DSH150169L	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	REHAB & SPORTS MEDICINE NOBLESVILLE - Rehab & Sports Medicine - Noblesville	9669 E 146TH ST	NOBLESVILLE	IN	Terminated
DSH150169M	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	COMMUNITY IMAGING CENTER CARMEL - Community Imaging Center - Carmel	11911 N MERIDIAN ST	CARMEL	IN	Terminated
DSH150169N	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	REHAB & SPORTS MEDICINE CENTER GEIS - Rehab & Sports Medicine Center - Geist	8150 OAKLANDON RD	INDIANAPOLIS	IN	Terminated
DSH150169P	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	Noblesville Infusion Center - Infusion Center	9669 E 146th St.	Noblesville	IN	Active
DSH150169Q	Child	DSH	COMMUNITY HOSPITAL OF INDIANA INC.	Cancer Center Carmel - CRCC Carmel	11911 N Meridian St	Carmel	IN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Kiley, David President Community Hospital East 3176219337	Kiley, David President Community Hospital Indianapolis Region 3176219337	7/23/2019 10:09 AM
Contacts	Authorizing Official	Update	AO Change Request	Moonesinghe, Dee Physician Executive Community Hospital North 7654372959	Kiley, David President Community Hospital East 3176219337	7/23/2019 8:25 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Contacts	Authorizing Official	Update	AO Change Request	Krusie, Kathleen R. SVP President North Region Community Health Network 3176216095	Moonesinghe, Dee Physician Executive Community Hospital North 7654372959	12/10/2018 8:20 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/30/2018 12:00:00 AM	10/1/2018 7:30 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/1/2018 7:30 AM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	10/1/2018 7:30 AM
Terminations	Termination Effective Date	Update	Termination Request		9/30/2018 12:00:00 AM	10/1/2018 7:30 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	10/1/2018 7:30 AM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Krusie, Kathleen R. SVP President North Region Community Health Network 3176216095	8/3/2018 1:09 PM
Details	340B ID	Update	New Registration		DSH150169B	8/3/2018 1:09 PM
Details	Entity Subname	Update	New Registration	COMMUNITY BACK NECK AND SPINE CENTE	COMMUNITY BACK NECK AND SPINE CENTE - Back, Neck, Spine Center	8/3/2018 1:09 PM
Dates	Participating Approval Date	Update	New Registration		8/3/2018 1:09:44 PM	8/3/2018 1:09 PM
Details	State	Update	New Registration	Pending	Approved	8/3/2018 1:09 PM
Dates	Signed By Date	Update	New Registration		7/13/2018 2:20:57 PM	8/3/2018 1:09 PM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	8/3/2018 1:09 PM
Addresses	Main Address	Insert	New Registration		6970 HILLSDALE CT INDIANAPOLIS, IN 46250-2040	7/11/2018 2:39 PM
Contacts	Authorizing Official	Insert	New Registration		Krusie, Kathleen R. SVP President North Region Community Health Network 3176216095	7/11/2018 2:39 PM
Contacts	Primary Contact	Insert	New Registration		McMichael, Derek Director of Pharmacy, North Hospital Community Health Network North Hospital 3176215388	7/11/2018 2:39 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2018 2:39 PM
Details	Grant Number	Insert	New Registration			7/11/2018 2:39 PM
Details	340B ID	Insert	New Registration			7/11/2018 2:39 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2018 2:39 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2018 2:39 PM
Details	Medicare Provider Number	Insert	New Registration		150169	7/11/2018 2:39 PM
Details	Entity Name	Insert	New Registration		COMMUNITY HOSPITAL OF INDIANA INC.	7/11/2018 2:39 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2018 2:39 PM
Details	Entity Subname	Insert	New Registration		COMMUNITY BACK NECK AND SPINE CENTE	7/11/2018 2:39 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2018 2:39 PM
Details	State	Insert	New Registration		Pending	7/11/2018 2:39 PM
Dates	Registration Date	Insert	New Registration		7/11/2018 2:39:23 PM	7/11/2018 2:39 PM
Dates	Signed By Date	Insert	New Registration			7/11/2018 2:39 PM
Dates	Start Date	Insert	New Registration			7/11/2018 2:39 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2018 2:39 PM
Terminations	Termination Date	Insert	New Registration			7/11/2018 2:39 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2018 2:39 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2018 2:39 PM