Covered Entity Details

DSH360003BK University of Cincinnati Medical Center LLC (Terminated) - information as of 5/15/2025 11:37:53 PM

Main Details

Name

University of Cincinnati Medical Center LLC

Subdivision Name

HOSP BASED PULMONARY CLINIC - UCH SARCO ILD MAB

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360003BK

Medicare Provider Number

360003

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2018

Participating Start Date

1/1/2019

Participating Approval Date

10/23/2018

Last Recertification Date

9/8/2023

Termination Date
Termination Reason

10/1/2024
Site closure

Contacts

Authorizing Official

University of Cincinnati Medical Center
Jeffrey Akers, VP Pharmacy Administration UC Health
(513) 585-8005

Primary Contact

University of Cincinnati Medical Center LLC
Sue Ann Janson, 340B Medication Program Manager
(513) 585-7008

Addresses

Street Address

222 PIEDMONT AVE
CINCINNATI, OH 45219

Billing Address

UC Health
3200 BURNET AVE
Attn: 3 EAST, AP
Cincinnati, OH 45229

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
OH	034-9331	1033154026
IN	100369340A	1033154026
KY		1033154026,1245394469,1891302626,1780259291

Shipping Addresses

Shipping Address 1

University of Cincinnati Medical Center
234 GOODMAN ST.
CINCINNATI, OH 45219

Shipping Address 2

UNIVERSITY OF CINCINNATI MEDICAL CENTER LLC
3188 BELLEVUE AVENUE
CINCINNATI, OH 45219

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
DSH360003AA	Child	DSH	University of Cincinnati Medical Center LLC	INFECTIOUS DISEASE	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003AB	Child	DSH	University of Cincinnati Medical Center LLC	MED/PEDS CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003AC	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE FACULTY PRAC	3130 HIGHLAND AVENUE	CINCINNATI	OH	Active
DSH360003AD	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE - ENDOCRINOLOGY	222 Piedmont Ave	CINCINNATI	OH	Active
DSH360003AE	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS -CLINIC - MAB	222 Piedmont Ave	CINCINNATI	OH	Active
DSH360003AF	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS CLINIC-MONTGOMERY	9275 MONTGOMERY ROAD	CINCINNATI	OH	Active
DSH360003AG	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE - INFECTIOUS DISEASE - MAB	222 Piedmont Ave	Cincinnati	OH	Active
DSH360003AH	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE FLORENCE	68 Cavalier Boulevard	Florence	KY	Active
DSH360003AJ	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS CLINIC-WEST BLDG	5575 Cheviot Road	Cincinnati	OH	Active
DSH360003AK	Child	DSH	University of Cincinnati Medical Center LLC	MIDTOWN DIAGNOSTICS	3590 Lucille Drive	Cincinnati	OH	Terminated
DSH360003AL	Child	DSH	University of Cincinnati Medical Center LLC	FLORENCE DIAGNOSTICS-IMAGING	68 Cavalier Boulevard, Suite 1000	Florence	KY	Terminated
DSH360003AM	Child	DSH	University of Cincinnati Medical Center LLC	NEUROLOGY FLORENCE	68 Cavalier Boulevard	Florence	KY	Active
DSH360003AN	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE CLINIC-MIDTOWN	3590 Lucille Drive	Cincinnati	OH	Active
DSH360003AP	Child	DSH	University of Cincinnati Medical Center LLC	OTOLARYNGOLOGY UCGNI	3113 BELLEVUE AVENUE	Cincinnati	OH	Active
DSH360003AQ	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE-MONTGOMERY	9275 Montgomery Road	Cincinnati	OH	Active
DSH360003AR	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS CLINIC-FLORENCE	68 Cavalier Boulevard	Florence	KY	Active
DSH360003AS	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY BMT CLINIC	3229 Burnet Avenue	Cincinnati	OH	Active
DSH360003AT	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS CLINIC-HOLMES	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003AU	Child	DSH	University of Cincinnati Medical Center LLC	ORTHO CLINIC-EASTSIDE	7981 BEECHMONT AVE	CINCINNATI	OH	Terminated
DSH360003AV	Child	DSH	University of Cincinnati Medical Center LLC	EMERGENCY MENTAL HEALTH SERVICES	3200 BURNET AVE	CINCINNATI	OH	Active
DSH360003AW	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY PLASTICS CLINIC - HOLMES	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003AX	Child	DSH	University of Cincinnati Medical Center LLC	HEART FAILURE PROGRAM	3130 HIGHLAND AVE	CINCINNATI	OH	Terminated
DSH360003AY	Child	DSH	UNIVER.OF CINCINNATI MED CENTER LLC	Ortho Clinic	234 GOODMAN ST	CINCINNATI	OH	Terminated
DSH360003AZ	Child	DSH	University of Cincinnati Medical Center LLC	PSYCHIATRY DUAL DIAGNOSIS CLINIC	3131 HARVEY AVE	CINCINNATI	OH	Active
DSH360003BA	Child	DSH	University of Cincinnati Medical Center LLC	ORTHOPAEDICS CLINIC - MIDTOWN	3590 LUCILLE DRIVE	CINCINNATI	OH	Active
DSH360003BB	Child	DSH	University of Cincinnati Medical Center LLC	HOSP BASED ARRHYTHMIA CENTER - CARDIOLOGY	3130 HIGHLAND AVE	CINCINNATI	OH	Terminated
DSH360003BC	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE HEM/ONC INFUSION SERVICE-BCHC	3229 Burnet Avenue	CINCINNATI	OH	Active
DSH360003BD	Child	DSH	University of Cincinnati Medical Center LLC	BURN CENTER	200 ALBERT SABIN WAY	CINCINNATI	OH	Terminated
DSH360003BE	Child	DSH	University of Cincinnati Medical Center LLC	RADIOLOGY MAB	3113 BELLEVUE AVENUE	CINCINNATI	OH	Terminated
DSH360003BF	Child	DSH	University of Cincinnati Medical Center LLC	SAME DAY SURGERY - HD	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003BG	Child	DSH	University of Cincinnati Medical Center LLC	NEUROLOGY INFUSION SERVICES - UCGNI	3113 Bellevue Ave	CINCINNATI	OH	Active
DSH360003BH	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY - SAME DAY SURGERY CENTER HD	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003BJ	Child	DSH	University of Cincinnati Medical Center LLC	DELIVERY ROOM & LABOR ROOM	3188 Bellevue Avenue	CINCINNATI	OH	Terminated
DSH360003BK	Child	DSH	University of Cincinnati Medical Center LLC	HOSP BASED PULMONARY CLINIC - UCH SARCO ILD MAB	222 PIEDMONT AVE	CINCINNATI	OH	Terminated
DSH360003BL	Child	DSH	University of Cincinnati Medical Center LLC	BRAIN TUMOR	3113 Bellevue Avenue	CINCINNATI	OH	Terminated
DSH360003BM	Child	DSH	University of Cincinnati Medical Center LLC	NEUROSURGERY CLINIC	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003BN	Child	DSH	University of Cincinnati Medical Center LLC	CARDIAC REHAB & WELLNESS CLINIC	222 PIEDMONT AVE	CINCINNATI	OH	Active
DSH360003BP	Child	DSH	University of Cincinnati Medical Center LLC	INTEGRATIVE MEDICINE - UCGNI	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003BQ	Child	DSH	University of Cincinnati Medical Center LLC	TRANSPLANT CLINIC - UH TACU	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003BR	Child	DSH	University of Cincinnati Medical Center LLC	NEUROLOGY - NEURODIAGNOSTIC - UCGNI	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003BS	Child	DSH	University of Cincinnati Medical Center LLC	UH PSYCHIATRY RESIDENT CLINIC	3120 BURNET AVE	CINCINNATI	OH	Active
DSH360003BT	Child	DSH	University of Cincinnati Medical Center LLC	NEUROSURGERY BACK/NECK/SPINE CLINIC - UCGNI	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003BU	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY CLINIC - UH SUR TRAUMA CNTR MAB	222 PIEDMONT AVE	CINCINNATI	OH	Terminated
DSH360003BV	Child	DSH	University of Cincinnati Medical Center LLC	ANESTHESIA PAIN MEDICINE CLINIC - MAB	222 PIEDMONT AVE	Cincinnati	OH	Active
DSH360003BW	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY CLINIC - WOUND CARE- PODIATRY CENTER	222 PIEDMONT AVE	Cincinnati	OH	Active
DSH360003BX	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE HEM/ONC - APHERESIS CLINIC	3229 Burnet Avenue	CINCINNATI	OH	Active
DSH360003BY	Child	DSH	University of Cincinnati Medical Center LLC	HOSP BASED VASCULAR LAB - VASCULAR SURGERY	222 PIEDMONT AVE	CINCINNATI	OH	Active
DSH360003BZ	Child	DSH	University of Cincinnati Medical Center LLC	INTRAVENOUS THERAPY - INFUSION SERVICE - RIDGEWAY	3200 BURNET AVE	CINCINNATI	OH	Terminated
DSH360003CA	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY TRANSPLANT CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003CB	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE HEMATOLOGY-ONCOLOGY-BMT CLINIC	68 Cavalier BLVD	Florence	KY	Active
DSH360003CC	Child	DSH	University of Cincinnati Medical Center LLC	EMERGENCY ROOM	3199 Highland Avenue	CINCINNATI	OH	Active
DSH360003CD	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTEGRATIVE MEDICINE - HOSPITAL BASED BARRET	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CE	Child	DSH	University of Cincinnati Medical Center LLC	RADIATION ONCOLOGY - RADIATION THERAPY	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CF	Child	DSH	University of Cincinnati Medical Center LLC	PORT ROOM NURSES CLINIC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CG	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - ORTHOPAEDICS -HOSPITAL BASED CLINIC - MAB--PODIATRY	222 Piedmont AVE	Cincinnati	OH	Terminated
DSH360003CH	Child	DSH	University of Cincinnati Medical Center LLC	UROLOGY RADIATION ONCOLOGY - SURGERY BCC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CJ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - CANCER -HEMATOLOGY ONCOLOGY HOSPITAL BASED-SYMPTOM MGMT BC	3151 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CK	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OPHTHALMOLOGY -CLINICAL OCULAR ONCOLOGY - HOSPITAL BASED CLINIC- BCC	3151 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CL	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OTOLARYNGOLOGY - HOSPITAL BASED CLINIC - UCGNI--BCC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CM	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE CRITICAL CARE - INTERVENTIONAL PULMONOLOGY	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CN	Child	DSH	University of Cincinnati Medical Center LLC	CANCER -RADIATION ONCOLOGY --PALLIATIVE CARE-SURVIVORSHIOP-PRIMARY CARE	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CP	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - RADIATION ONCOLOGY -RADIATION ONCOLOGY HOSPITAL BASED CLINIC - BCC-ESOPH BC	3151 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CQ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - CANCER -HEMATOLOGY ONCOLOGY HOSPITAL BASED-CARDIO ONC BC	3151 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CR	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - RADIATION ONCOLOGY -RADIATION ONCOLOGY HOSPITAL BASED CLINIC - BCC--HEPATOBILIARY	3151 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CS	Child	DSH	University of Cincinnati Medical Center LLC	RADIATION ONCOLOGY - PROTON CENTER	7777 Yankee Rd	Liberty Township	OH	Active
DSH360003CT	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - CANCER -HEMATOLOGY ONCOLOGY BC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CV	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTEGRATIVE MEDICINE - HOSPITAL BASED - UCGNI	3113 Bellevue Avenue	Cincinnati	OH	Terminated
DSH360003CW	Child	DSH	University of Cincinnati Medical Center LLC	90 - CLINIC--SURGERY - ONCOLOGY - HOSPITAL BASED CLINIC - BCC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CX	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - SURGERY -TRANSPLANT-PRE-ACQUISITION	3130 Highland AVE	Cincinnati	OH	Active
DSH360003CY	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY INFUSION SERVICES BCC	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003CZ	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -HEM/ONC INFUSION WOMEN'S CENTER	3151 Bellevue Avenue	Cincinnati	OH	Active
DSH360003DA	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY HOSPITAL BASED INFUSION CTR WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DB	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE - HEMATOLOGY ONCOLOGY - SICKLE CELL - BENIGN HEMATOLOGY CLINIC	3120 Burnet AVE	Cincinnati	OH	Active
DSH360003DC	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -CARDIOLOGY HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DD	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -INFECTIOUS DISEASES HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DE	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -NEPHROLOGY HYPERTENSION HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DF	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - LIVER TRANSPLANT TESTING	7675 Wellness Way	West Chester	OH	Active
DSH360003DG	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -ENDOCRINOLOGY DIABETES-ENDOCRINOLOGY HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DH	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DJ	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -DIGESTIVE DISEASES GASTRO CLINIC HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DK	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OB-GYN -ONCOLOGY GYNECOLOGIC ONCOLOGY - HOSPITAL BASED CLINIC WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DL	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE -PULMONARY CRITICAL CARE HOSPITAL BASED PULMONARY WCH	7675 Wellness Way	West Chester	OH	Active
DSH360003DM	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - NEUROLOGY -GENERAL NEUROLOGY HOSPITAL BASED CLINIC WCH	7690 Discovery Drive	West Chester	OH	Active
DSH360003DN	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - NEUROLOGY -NEUROPSYCH HOSPITAL BASED CLINIC	7690 Discovery Drive	West Chester	OH	Active
DSH360003DP	Child	DSH	University of Cincinnati Medical Center LLC	PHARMACIST CARE CLINIC HOXWORTH	3130 Highland AVE	Cincinnati	OH	Active
DSH360003DQ	Child	DSH	University of Cincinnati Medical Center LLC	PRIMARY CARE NETWORK -BURNET CLINIC	3120 Burnet Ave	Cincinnati	OH	Active
DSH360003DR	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PHARMACIST CARE CLINIC - WEST CHESTER	7675 Wellness Way	West Chester	OH	Active
DSH360003DS	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE - HEMATOLOGY ONCOLOGY - HOSPITAL BASED CLINIC - ADVANCED THERAPIES CLINIC	3229 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003DT	Child	DSH	University of Cincinnati Medical Center LLC	INTRAVENOUS THERAPY - INTERNAL MEDICINE - HEMATOLOGY ONCOLOGY - HOSPITAL BASED INFUSION - ADVANCED THERAPIES INFUSION	3229 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003DU	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - RADIOLOGY - INTERVENTIONAL HOSPITAL BASED CLINIC	222 PIEDMONT AVE	CINCINNATI	OH	Active
DSH360003DV	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - SURGERY -THORACIC HOSPITAL BASED SURGERY	222 PIEDMONT AVENUE	CINCINNATI	OH	Active
DSH360003DW	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - NEUROLOGY -GENERAL NEUROLOGY HOSPITAL BASED CLINIC- UCGNI	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003DX	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - NEUROSURGERY -CLINICAL HOSPITAL BASED CLINIC - FLORENCE	68 CAVALIER BOULEVARD	FLORENCE	KY	Active
DSH360003DY	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE - HEMATOLOGY ONCOLOGY - EXTENDED CARE - BCHC	3229 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003DZ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE - HEMATOLOGY ONCOLOGY - PORT ROOM - BCHC	3229 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003EA	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY BMT-CELLULAR THERAPY HOSPITAL BASED CLINIC	3229 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003EB	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - GENERAL SURGERY – HOSPITAL BASED CLINIC - MAB	222 PIEDMONT AVENUE	CINCINNATI	OH	Active
DSH360003EC	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - SURGERY - COLORECTAL - HOSPITAL BASED CLINIC - MAB	222 PIEDMONT AVENUE	CINCINNATI	OH	Active
DSH360003ED	Child	DSH	University of Cincinnati Medical Center LLC	OPERATING ROOM - OPERATING ROOM - HOLMES OUTPATIENT	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003EE	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PHARMACIST CARE CLINIC-BURNET	3200 BURNET AVENUE	CINCINNATI	OH	Active
DSH360003EF	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -GENERAL MEDICINE HOSPITAL BASED OP	3130 HIGHLAND AVENUE	CINCINNATI	OH	Active
DSH360003EG	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - SURGERY -VASCULAR HOSPITAL BASED SURGERY CLINIC MAB	222 PIEDMONT AVENUE	CINCINNATI	OH	Active
DSH360003EH	Child	DSH	University of Cincinnati Medical Center LLC	INTRAVENOUS THERAPY - GENERAL NEUROLOGY HOSPITAL BASED INFUSION SERVICES FLORENCE	68 CAVALIER BOULEVARD	FLORENCE	KY	Active
DSH360003EJ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OB GYN - GENERALIST - HOSP BASED CLINIC - MIDTOWN	3590 LUCILLE DRIVE	CINCINNATI	OH	Active
DSH360003EK	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - NEUROLOGY - ONCOLOGY - NEURO-ONCOLOGY HOSPITAL BASED CLINIC BCC	3151 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003EL	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - SURGERY -ONCOLOGY HOSPITAL BASED BREAST SURGERY - BCC	3151 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003EM	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OB GYN -ONCOLOGY GYNECOLOGICAL ONC HOSPITAL BASED CLINIC BCC	3151 BELLEVUE AVENUE FLOOR 3	CINCINNATI	OH	Active
DSH360003EN	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - INTERNAL MEDICINE -HEMATOLOGY ONCOLOGY BREAST HEM-ONC HOSPITAL BASED CLINIC BCC	3151 BELLEVUE AVENUE FLOOR 3	CINCINNATI	OH	Active
DSH360003EP	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OB GYN - GENERALIST NORTH - HOSPITAL BASED CLINIC - MOB SOUTH	7675 WELLNESS WAY	WEST CHESTER	OH	Active
DSH360003EQ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PSYCHIATRY - ELECTROCONVULSIVE THERAPY	3200 BURNET AVENUE FLOOR 1	CINCINNATI	OH	Active
DSH360003ER	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PHARMACIST - INJECTABLE SERVICE- WEST CHESTER	7690 DISCOVERY DRIVE	WEST CHESTER	OH	Active
DSH360003ES	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PHARMACIST - INJECTABLE SERVICE HOXWORTH	3130 HIGHLAND AVENUE, FLOOR 2	CINCINNATI	OH	Active
DSH360003ET	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PHARMACIST - INJECTABLE SERVICE HOLMES	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003EU	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - UROLOGY HOSPITAL BASED CLINIC - WCN	7690 DISCOVERY DRIVE	WEST CHESTER	OH	Active
DSH360003EV	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - IMMUNOLOGY - HOSPITAL BASED CLINIC - RHEUM - WCH	7690 DISCOVERY DRIVE	WEST CHESTER	OH	Active
DSH360003EW	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - IMMUNOLOGY - HOSPITAL BASED CLINIC - RHEUM - MIDTOWN	3590 LUCILLE DRIVE	CINCINNATI	OH	Active
DSH360003EX	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - IMMUNOLOGY - HOSPITAL BASED CLINIC - RHEUM - INFUSION - WCH	7690 DISCOVERY DRIVE	WEST CHESTER	OH	Active
DSH360003EY	Child	DSH	University of Cincinnati Medical Center LLC	INTRAVENOUS THERAPY - IMMUNOLOGY - HOSPITAL BASED CLINIC - RHEUM - INFUSION - MIDTOWN	3590 LUCILLE DRIVE	CINCINNATI	OH	Active
DSH360003EZ	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - PRIMARY CARE NETWORK-FREEMAN CENTER	3120 Burnet Ave	Cincinnati	OH	Active
DSH360003F	Child	DSH	University of Cincinnati Medical Center LLC	HOSP BASED RHEUMATOLOGY CLINIC	3130 HIGHLAND	CINCINNATI	OH	Terminated
DSH360003FA	Child	DSH	University of Cincinnati Medical Center LLC	CLINIC - OB GYN - GENERALIST NORTH - HOSPITAL BASED CLINIC - MOB SOUTH - UCH OB UROGYN WCS	7675 WELLNESS WAY	WEST CHESTER	OH	Approved
DSH360003G	Child	DSH	University of Cincinnati Medical Center LLC	VARSITY VILLAGE IMAGING CTR-HB	2650 VARSITY VILLAGE DR	CINCINNATI	OH	Terminated
DSH360003H	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE- CARDIOLOGY CLINIC	222 Piedmont Ave	CINCINNATI	OH	Active
DSH360003J	Child	DSH	University of Cincinnati Medical Center LLC	NEUROLOGY CLINIC - UCGNI	3113 BELLEVUE AVENUE	CINCINNATI	OH	Active
DSH360003K	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE-DIGESTIVE DISEASES-GASTRO CLINIC	222 PIEDMONT AVE	CINCINNATI	OH	Active
DSH360003L	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE- PULMONARY CLINIC	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003M	Child	DSH	University of Cincinnati Medical Center LLC	INTERNAL MEDICINE- PULMONARY HOSP BASED SLEEP CLINIC	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003N	Child	DSH	University of Cincinnati Medical Center LLC	HOSP BASED NEPHROLOGY CLINIC	222 PIEDMONT AVE	CINCINNATI	OH	Terminated
DSH360003P	Child	DSH	University of Cincinnati Medical Center LLC	OB/GYN PERINATOLOGY SERVICES	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003Q	Child	DSH	University of Cincinnati Medical Center LLC	ORAL & MAXILLOFACIAL SURGERY CLINIC	200 ALBERT SABIN WAY	CINCINNATI	OH	Active
DSH360003R	Child	DSH	University of Cincinnati Medical Center LLC	DERMATOLOGY CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003S	Child	DSH	University of Cincinnati Medical Center LLC	OB/GYN CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003T	Child	DSH	University of Cincinnati Medical Center LLC	UNIVERSITY SPECIALTIES CENTER	234 Goodman ST.	CINCINNATI	OH	Terminated
DSH360003U	Child	DSH	University of Cincinnati Medical Center LLC	OPHTHALMOLOGY CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003V	Child	DSH	University of Cincinnati Medical Center LLC	SURGERY CLINIC	222 PIEDMONT AVE	CINCINNATI	OH	Terminated
DSH360003W	Child	DSH	University of Cincinnati Medical Center LLC	GENERAL MEDICINE CLINIC	3130 HIGHLAND AVE	CINCINNATI	OH	Active
DSH360003X	Child	DSH	University of Cincinnati Medical Center LLC	UROLOGY CLINIC	222 Piedmont	CINCINNATI	OH	Active
DSH360003Y	Child	DSH	University of Cincinnati Medical Center LLC	DENTAL CENTER	3231 HARVEY AVE	CINCINNATI	OH	Terminated
DSH360003Z	Child	DSH	University of Cincinnati Medical Center LLC	BARRETT CENTER--HEMATOLOGY ONCOLOGY	3151 Bellevue Avenue	CINCINNATI	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Janson, Sue Ann 340B Medication Program Coordinator University of Cincinnati Medical Center LLC 5135841392	Janson, Sue Ann 340B Medication Program Manager University of Cincinnati Medical Center LLC 5135857008	12/4/2024 1:47 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Contacts	Authorizing Official	Update	Change Request	HINDS, RICK Executive Vice President and Chief Financial Officer University of Cincinnati Medical Center LLC 5135858720	Akers, Jeffrey VP Pharmacy Administration UC Health University of Cincinnati Medical Center 5135858005	7/29/2024 9:04 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/24/2024 12:00:00 AM	7/18/2024 7:22 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/18/2024 7:22 AM
Terminations	Termination Comments	Update	Termination Request		The physician that provided services used this location one day a week. He retired and was not replaced. Therefore this service will no longer be available at this location.	7/18/2024 7:22 AM
Terminations	Termination Date	Update	Termination Request		10/1/2024 12:00:00 AM	7/18/2024 7:22 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2024 12:00:00 AM	7/18/2024 7:22 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	7/18/2024 7:22 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1688734 (AK)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	XHSP31361 (CA)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9000168312 (CO)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	911361400 (FL)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003211412A (GA)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	311479038001 (IL)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1703150 (LA)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	110066593A (MA)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	01565764 (NY)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0019459280001 (PA)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10733b (SC)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	Q036018 (TN)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0360003 (VT)		1/10/2024 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0105171000 (WV)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (ID)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (MI)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (MN)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (NV)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (WV)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (PA)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (GA)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (NY)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (VT)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (SC)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (MA)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (AK)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (LA)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (IL)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (CO)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (FL)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (TN)		1/10/2024 2:41 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1033154026 (CA)		1/10/2024 2:41 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 2:43:10 PM	9/8/2023 1:56:59 PM	9/8/2023 1:56 PM
Addresses	Shipping Address	Insert	Group Change Request		UNIVERSITY OF CINCINNATI MEDICAL CENTER LLC 3188 BELLEVUE AVENUE CINCINNATI, OH 45219	7/14/2023 7:36 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1245394469 (OH)		11/10/2022 8:36 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891302626 (OH)		11/10/2022 8:36 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730190976 (OH)		11/10/2022 8:36 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1780259291 (OH)		11/10/2022 8:36 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1871959551 (OH)		11/10/2022 8:36 AM
Details	Last Recertification Date	Update	Recertification	8/26/2021 2:07:06 PM	9/7/2022 2:43:10 PM	9/7/2022 2:43 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1245394469 (KY)		7/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1891302626 (KY)		7/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1780259291 (KY)		7/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1871959551	7/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1245394469	7/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	7/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1891302626	7/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	7/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780259291	7/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	7/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1245394469	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1891302626	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1780259291	4/13/2022 12:30 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	4/13/2022 12:30 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780259291	3/7/2022 2:14 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	3/7/2022 2:14 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 12:00:47 PM	8/26/2021 2:07:06 PM	8/26/2021 2:07 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1245394469	7/15/2021 12:26 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/15/2021 12:26 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1891302626	7/15/2021 12:26 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/15/2021 12:26 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1730190976	7/15/2021 12:26 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/15/2021 12:26 PM
Addresses	Billing Address	Update	Change Request	UC Health 234 Goodman Street Attn: 3 EAST, AP Cincinnati, OH 45229	UC Health 3200 BURNET AVE Attn: 3 EAST, AP Cincinnati, OH 45229	1/12/2021 4:08 PM
Addresses	Billing Address	Update	Change Request	UC Health 234 Goodman Street Attn: 3 Ridgeway, AP Cincinnati, OH 45229	UC Health 234 Goodman Street Attn: 3 EAST, AP Cincinnati, OH 45229	10/15/2020 9:43 AM
Addresses	Billing Address	Update	Recertification	UC Health 3200 Burnet Ave Attn: 3 Ridgeway, AP CINCINNATI, OH 45229	UC Health 234 Goodman Street Attn: 3 Ridgeway, AP Cincinnati, OH 45229	9/10/2020 12:00 PM
Addresses	Shipping Address	Insert	Recertification		University of Cincinnati Medical Center 234 GOODMAN ST. CINCINNATI, OH 45219	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	01542752 (KY)		9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1688734	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		XHSP31361	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000168312	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		911361400	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003211412A	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		311479038001	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1703150	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110066593A	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01565764	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0019459280001	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10733b	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q036018	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0360003	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0105171000	9/10/2020 12:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033154026	9/10/2020 12:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2020 12:00 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1033154026 ( )		9/10/2020 12:00 PM
Details	Last Recertification Date	Update	Recertification	9/6/2019 10:51:27 AM	9/10/2020 12:00:47 PM	9/10/2020 12:00 PM
Contacts	Primary Contact	Update	Change Request	LOBAS, NANCY ASSISTANT DIRECTOR PHARMACY University of Cincinnati Medical Center LLC 5135848807	Janson, Sue Ann 340B Medication Program Coordinator University of Cincinnati Medical Center LLC 5135841392	7/8/2020 9:04 AM
Details	Last Recertification Date	Update	Recertification		9/6/2019 10:51:27 AM	9/6/2019 10:51 AM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		HINDS, RICK Executive Vice President and Chief Financial Officer University of Cincinnati Medical Center LLC 5135858720	10/23/2018 10:30 AM
Details	340B ID	Update	New Registration		DSH360003BK	10/23/2018 10:30 AM
Details	Entity Name	Update	New Registration	UNIVER.OF CINCINNATI MED CENTER LLC	University of Cincinnati Medical Center LLC	10/23/2018 10:30 AM
Details	Entity Subname	Update	New Registration	HOSP BASED PULMONARY CLINIC	HOSP BASED PULMONARY CLINIC - UCH SARCO ILD MAB	10/23/2018 10:30 AM
Dates	Participating Approval Date	Update	New Registration		10/23/2018 10:30:32 AM	10/23/2018 10:30 AM
Details	State	Update	New Registration	Pending	Approved	10/23/2018 10:30 AM
Dates	Signed By Date	Update	New Registration		10/11/2018 2:03:08 PM	10/23/2018 10:30 AM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	10/23/2018 10:30 AM
Addresses	Main Address	Insert	New Registration		222 PIEDMONT AVE CINCINNATI, OH 45219	10/11/2018 12:40 PM
Addresses	Billing Address	Insert	New Registration		UC Health 3200 Burnet Ave Attn: 3 Ridgeway, AP CINCINNATI, OH 45229	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		034-9331	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100369340A	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01542752	10/11/2018 12:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/11/2018 12:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1033154026	10/11/2018 12:40 PM
Contacts	Primary Contact	Insert	New Registration		LOBAS, NANCY ASSISTANT DIRECTOR PHARMACY University of Cincinnati Medical Center LLC 5135848807	10/11/2018 12:40 PM
Contacts	Authorizing Official	Insert	New Registration		HINDS, RICK Executive Vice President and Chief Financial Officer University of Cincinnati Medical Center LLC 5135858720	10/11/2018 12:40 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2018 12:40 PM
Details	Grant Number	Insert	New Registration			10/11/2018 12:40 PM
Details	340B ID	Insert	New Registration			10/11/2018 12:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2018 12:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2018 12:40 PM
Details	Medicare Provider Number	Insert	New Registration		360003	10/11/2018 12:40 PM
Details	Entity Name	Insert	New Registration		UNIVER.OF CINCINNATI MED CENTER LLC	10/11/2018 12:40 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2018 12:40 PM
Details	Entity Subname	Insert	New Registration		HOSP BASED PULMONARY CLINIC	10/11/2018 12:40 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2018 12:40 PM
Details	State	Insert	New Registration		Pending	10/11/2018 12:40 PM
Dates	Registration Date	Insert	New Registration		10/11/2018 12:40:18 PM	10/11/2018 12:40 PM
Dates	Signed By Date	Insert	New Registration			10/11/2018 12:40 PM
Dates	Start Date	Insert	New Registration			10/11/2018 12:40 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2018 12:40 PM
Terminations	Termination Date	Insert	New Registration			10/11/2018 12:40 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2018 12:40 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2018 12:40 PM