Covered Entity Details

DSH220086BB BETH ISRAEL DEACONESS MEDICAL CENTER (Terminated) - information as of 4/29/2025 11:49:46 PM

Main Details

Name

BETH ISRAEL DEACONESS MEDICAL CENTER

Subdivision Name

MEDICAL CARE CENTER OF LEXINGTON - DERMATOLOGY CLINIC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH220086BB

Medicare Provider Number

220086

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/12/2018

Participating Start Date

1/1/2019

Participating Approval Date

10/23/2018

Last Recertification Date

9/9/2021

Termination Date
Termination Reason

10/1/2022
Site closure

Contacts

Authorizing Official

Beth Israel Deaconess Medical Center
Marsha Lynn Maurer, Senior Vice President, Chief Nursing Officer
(617) 667-1747

Primary Contact

Beth Israel Lahey Health
Shawn J Wood, Director of System 340B Oversight
(781) 352-6685

Addresses

Street Address

482 BEDFORD STREET
LEXINGTON, MA 02420

Billing Address

Beth Israel Deaconess Medical Center
330 Brookline Ave.
Boston, MA 02215

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	110000014C,110000014D	1548202641

Shipping Addresses

Shipping Address 1

Beth Israel Deaconess Medical Center
330 Brookline Ave.
Boston, MA 02215

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
DSH220086A	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER	230 BOWDOIN ST.	DORCHESTER	MA	Terminated
DSH220086AA	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - INFECTIOUS DISEASE CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086AB	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - CARDIAC SURGERY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086AC	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - ORTHOPEDICS CLINIC	482 Bedford St.	LEXINGTON	MA	Active
DSH220086AD	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - PHYSICAL THERAPY SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AE	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - OCCUPATIONAL THERAPY SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AF	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - PHYSICAL THERAPY	230 BOWDOIN STREET	DORCHESTER	MA	Active
DSH220086AG	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - OB/GYN CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AH	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - OPTOMETRY SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AJ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - PODIATRY CLINIC	230 BOWDOIN STREET	DORCHESTER	MA	Terminated
DSH220086AK	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - RADIOLOGY SERVICES	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AL	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - PHYSICAL THERAPY	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AM	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - ADULT MEDICINE CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AN	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - URGENT CARE - CHELSEA	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AP	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	One Bookline Place - GERONTOLOGY CLINIC	One Brookline Place	Brookline	MA	Active
DSH220086AQ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - LAB SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Terminated
DSH220086AR	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - LABORATORY SERVICES	1000 BROADWAY STREET	CHELSEA	MA	Terminated
DSH220086AS	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - OPTOMETRY CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AT	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - PFT CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AU	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - NEUROSURGERY CLINIC	110 FRANCIS STREET	Boston	MA	Active
DSH220086AV	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - MEDICINE SPECIALTY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AW	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - ADULT SPECIALTY CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086AX	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - ENDOSCOPY SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AY	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - ALLERGY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086AZ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - TRANSPLANT CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086B	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH	1000 BROADWAY	CHELSEA	MA	Terminated
DSH220086BA	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - GENERAL SURGERY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086BB	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - DERMATOLOGY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Terminated
DSH220086BC	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - NEUROLOGY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BD	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - PODIATRY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BE	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - MEDICINE	230 BOWDOIN ST	DORCHESTER	MA	Active
DSH220086BF	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - DERMATOLOGY CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086BG	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - MEDICINE ALLERGY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086BH	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - OTOLARYNGOLOGY CLINIC	110 FRANCIS STREET	BOSTON	MA	Terminated
DSH220086BJ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - VASCULAR LAB	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086BK	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - OB/GYN CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BL	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - PFT CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BM	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CLINIC - PSYCHIATRY CLINIC	230 BOWDOIN STREET	DORCHESTER	MA	Active
DSH220086BN	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - PLASTIC SURGERY CLINIC	110 FRANCIS STREET	BOSTON	MA	Terminated
DSH220086BP	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - LIVER CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086BQ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - SURGERY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BR	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - BREAST IMAGING CENTER	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BS	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - RHEUMATOLOGY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086BT	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - INFUSION CENTER	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BU	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - ULTRASOUND SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086BV	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - PEDIATRIC CLINIC	230 BOWDOIN STREET	DORCHESTER	MA	Active
DSH220086BW	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - VOICE,SPEECH,SWALLOW	1 Deaconess Rd	Boston	MA	Active
DSH220086BX	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - HOLTER LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086BY	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RADIOLOGY MRI	1 Deaconess Rd	Boston	MA	Active
DSH220086BZ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - CDAC Outpatient	1 Deaconess Rd	Boston	MA	Active
DSH220086C	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON	482 BEDFORD STREET	LEXINGTON	MA	Terminated
DSH220086CA	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Thoracic Clinic	1 Deaconess Rd	Boston	MA	Active
DSH220086CB	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - ANESTHESIA	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CC	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - EXERCISE LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086CD	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RAD NEUROINTERV	1 Deaconess Rd	Boston	MA	Active
DSH220086CE	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - West Specialty Clinic WSC	1 Deaconess Rd	Boston	MA	Active
DSH220086CF	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Radiology Nursing	1 Deaconess Rd	Boston	MA	Active
DSH220086CG	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - PACU/SDS-West	1 Deaconess Rd	Boston	MA	Active
DSH220086CH	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RAD ANGIOGRAPHY	1 Deaconess Rd	Boston	MA	Active
DSH220086CJ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RADIOLOGY CAT SCAN	1 Deaconess Rd	Boston	MA	Active
DSH220086CK	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Pancreas Multidisciplinary Clinic	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CL	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - EEG LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086CM	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - CARDIAC CATH LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086CN	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - VENOUS ACCESS TEAM	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CP	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Psych Clinic	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CQ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Emergency Unit	1 Deaconess Rd	Boston	MA	Active
DSH220086CR	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Gerontology Clinic	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CS	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - PODIATRY-West	1 Deaconess Rd	Boston	MA	Active
DSH220086CT	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - ELECTROPHYSIOLOGY UNIT	1 Deaconess Rd	Boston	MA	Active
DSH220086CU	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RADIOLOGY GENERAL DIAGNOSTICS	1 Deaconess Rd	Boston	MA	Active
DSH220086CV	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Wound/Ostomy Clinic	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CW	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - WEST PROCEDURAL CENTER	1 Deaconess Rd	Boston	MA	Active
DSH220086CX	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - BLOOD BANK	1 Deaconess Rd	Boston	MA	Terminated
DSH220086CY	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Nephrology Clinic	1 Deaconess Rd	Boston	MA	Active
DSH220086CZ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - RADIOLOGY ULTRASOUND	1 Deaconess Rd	Boston	MA	Active
DSH220086D	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	West Campus	ONE DEACONESS ROAD	BOSTON	MA	Terminated
DSH220086DA	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - ECHO LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086DB	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Radiology Nuclear Medicine	1 Deaconess Rd	Boston	MA	Terminated
DSH220086DC	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - AUTONOMIC LAB	1 Deaconess Rd	Boston	MA	Active
DSH220086DD	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - OR-West	1 Deaconess Rd	Boston	MA	Active
DSH220086DE	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - REHAB (PT/OT)	1 Deaconess Rd	Boston	MA	Active
DSH220086DF	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - ECT SB	1 Deaconess Rd	Boston	MA	Active
DSH220086DG	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	GASTROENTEROLOGY - WEST - GI Clinic	110 Francis St	Boston	MA	Active
DSH220086DH	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	DEVICES CLINIC - Device Remote	One Deaconess Road	Boston	MA	Active
DSH220086DJ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Surgical Associates LMOB NP - Surgical Associates LMOB NP	110 Francis St	Boston	MA	Active
DSH220086DK	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BIDMC INFUSION SERVICES AT LAHEY HO - BIDMC Infusion Services at LHMC-Burlington	41 MALL RD	BURLINGTON	MA	Active
DSH220086DL	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BIDMC INFUSION SERVICES AT LAHEY PE - BIDMC Infusion Services at LHMC-Peabody	1 ESSEX CENTER DR	PEABODY	MA	Active
DSH220086DM	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Medical Center - Prophylactic MAB Clinic	1 Deaconess Rd	Boston	MA	Terminated
DSH220086DN	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess Healthcare - Chestnut Hill - Optometry	200 Boylston Street	Newton	MA	Active
DSH220086DP	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Klarman - BIDMC Pre-OP - West	111 Francis St.	Boston	MA	Active
DSH220086DQ	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Klarman - Cardiac Intermediate Care	111 Francis St.	Boston	MA	Active
DSH220086DR	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Klarman - Cardiothoracic surgery	111 Francis St.	Boston	MA	Active
DSH220086DS	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	The Cancer Center at Beth Israel Deaconess Medical Center - Physical Therapy	148 Chestnut St.	Needham	MA	Active
DSH220086DT	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Klarman - Cardiac medicine	111 Francis St.	Boston	MA	Active
DSH220086DU	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Joslin - Diabetes	1 Joslin Pl	Boston	MA	Active
DSH220086DV	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Feldberg - Intravenous therapy	330 Brookline Ave.	Boston	MA	Active
DSH220086DW	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BIDMC West Campus - Crisis Stabilization Unit	One Deaconess Road	Boston	MA	Active
DSH220086DX	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BIDMC Winchester HemOnc	620 Washington Street	Winchester	MA	Active
DSH220086DY	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BETH ISRAEL DEACONESS MEDICAL CENTE - HEMONC INFUSION	330 BROOKLINE AVE	BOSTON	MA	Active
DSH220086E	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	ARNOLD PAIN MANAGEMENT CENTER	ONE BROOKLINE PLACE	BROOKLINE	MA	Active
DSH220086F	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Lab Services at Chestnut Hill	200 Boylston Street	Newton	MA	Terminated
DSH220086G	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	The Cancer Center at Beth Israel Deaconess Medical Center - Needham / Hem/Onc - BID Cancer Center Needham	148 Chestnut St	Needham	MA	Active
DSH220086H	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Urgent Care	200 Boylston Street	Newton	MA	Active
DSH220086J	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Outpatient Rehab at Chestnut Hill	200 Boylston Street	Newton	MA	Active
DSH220086K	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Radiology at Chestnut Hill Square	200 Boylston Street	Newton	MA	Active
DSH220086L	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Med/Surg Specialty	200 Boylston Street	Newton	MA	Active
DSH220086M	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Ob / Gyn Clinic	200 Boylston Street	Newton	MA	Active
DSH220086N	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	Beth Israel Deaconess HealthCare - Chestnut Hill / Sports Medicine	200 Boylston Street	Newton	MA	Active
DSH220086P	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	The Cancer Center at Beth Israel Deaconess Medical Center - Needham / Lab Services At Cancer Center - Needham	148 Chestnut St	Needham	MA	Terminated
DSH220086Q	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	The Cancer Center at Beth Israel Deaconess Medical Center - Needham / Radiation Oncology	148 Chestnut St	Needham	MA	Active
DSH220086R	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	The Cancer Center at Beth Israel Deaconess Medical Center - Needham / Med/Surg Specialty	148 Chestnut St	Needham	MA	Active
DSH220086S	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - RADIOLOGY SERVICES	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086T	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - GI OFFICE	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086U	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER NORTH - PODIATRY CLINIC	1000 BROADWAY STREET	CHELSEA	MA	Active
DSH220086V	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - VASCULAR SURGERY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086W	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	LOWRY MEDICAL OFFICE - ENDOCRINOLOGY CLINIC	110 FRANCIS STREET	BOSTON	MA	Active
DSH220086X	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	MEDICAL CARE CENTER OF LEXINGTON - CARDIOLOGY CLINIC	482 BEDFORD STREET	LEXINGTON	MA	Active
DSH220086Y	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - OB/GYN CLINIC	230 BOWDOIN STREET	DORCHESTER	MA	Active
DSH220086Z	Child	DSH	BETH ISRAEL DEACONESS MEDICAL CENTER	BOWDOIN STREET HEALTH CENTER - OPTOMETRY CLINIC	230 BOWDOIN STREET	DORCHESTER	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Wood, Shawn J 340B Hospital Program Manager Beth Israel Deaconess Medical Center 6177543835	Wood, Shawn J Director of System 340B Oversight Beth Israel Lahey Health 7813526685	3/27/2023 6:20 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		7/9/2020 12:00:00 AM	9/7/2022 1:02 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/7/2022 1:02 PM
Terminations	Termination Comments	Update	Recertification		Provider/Dermatologist left with this service/child-site now closed.	9/7/2022 1:02 PM
Terminations	Termination Date	Update	Recertification		10/1/2022 12:00:00 AM	9/7/2022 1:02 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2021 12:00:00 AM	9/7/2022 1:02 PM
Terminations	Termination Reason	Update	Recertification		Site closure	9/7/2022 1:02 PM
Contacts	Authorizing Official	Update	AO Change Request	Skura, Samuel Jay COO Beth Israel Deaconess Med Ctr 6176677144	Maurer, Marsha Lynn Senior Vice President, Chief Nursing Officer Beth Israel Deaconess Medical Center 6176671747	8/8/2022 10:57 AM
Contacts	Authorizing Official	Update	AO Change Request	Cullen, Michael CFO Beth Israel Deaconess Medical Center 6176677146	Skura, Samuel Jay COO Beth Israel Deaconess Med Ctr 6176677144	6/22/2022 12:30 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 8:04:01 AM	9/9/2021 1:49:55 PM	9/9/2021 1:49 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	XHSP40986 (CA)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3032430 (CT)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	042103881 (ME)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	99220086 (NH)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00350490 (NY)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	OP20086 (RI)		8/26/2020 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	99220086 (VT)		8/26/2020 8:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1548202641	8/26/2020 8:04 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/26/2020 8:04 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1548202641 ( )		8/26/2020 8:04 AM
Contacts	Primary Contact	Update	Recertification	Wood, Shawn Pharmacy 340B and Inventory Supervisor Beth Israel Deaconess Medical Center 6177543835	Wood, Shawn J 340B Hospital Program Manager Beth Israel Deaconess Medical Center 6177543835	8/26/2020 8:04 AM
Details	Last Recertification Date	Update	Recertification	9/8/2019 6:48:41 AM	8/26/2020 8:04:01 AM	8/26/2020 8:04 AM
Contacts	Authorizing Official	Update	Profile Change Request	Cullen, Mike CFO Beth Israel Deaconess Medical Center 6176320155	Cullen, Michael CFO Beth Israel Deaconess Medical Center 6176677146	8/26/2020 6:06 AM
Contacts	Signed By	Update	Profile Change Request	Cullen, Mike CFO Beth Israel Deaconess Medical Center 6176320155	Cullen, Michael CFO Beth Israel Deaconess Medical Center 6176677146	8/26/2020 6:06 AM
Addresses	Billing Address	Insert	Change Request		Beth Israel Deaconess Medical Center 330 Brookline Ave. Boston, MA 02215	3/2/2020 3:07 PM
Addresses	Shipping Address	Insert	Change Request		Beth Israel Deaconess Medical Center 330 Brookline Ave. Boston, MA 02215	3/2/2020 3:07 PM
Contacts	Primary Contact	Update	Recertification	Ogin, George Sr. Director of Financial Analysis and Regulatory Reporting Beth Israel Deaconess Medical Center 6176675089	Wood, Shawn Pharmacy 340B and Inventory Supervisor Beth Israel Deaconess Medical Center 6177543835	9/8/2019 6:48 AM
Details	Last Recertification Date	Update	Recertification		9/8/2019 6:48:41 AM	9/8/2019 6:48 AM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Cullen, Mike CFO Beth Israel Deaconess Medical Center 6176320155	10/23/2018 1:01 PM
Details	340B ID	Update	New Registration		DSH220086BB	10/23/2018 1:01 PM
Details	Entity Subname	Update	New Registration	MEDICAL CARE CENTER OF LEXINGTON	MEDICAL CARE CENTER OF LEXINGTON - DERMATOLOGY CLINIC	10/23/2018 1:01 PM
Dates	Participating Approval Date	Update	New Registration		10/23/2018 1:01:15 PM	10/23/2018 1:01 PM
Details	State	Update	New Registration	Pending	Approved	10/23/2018 1:01 PM
Dates	Signed By Date	Update	New Registration		10/15/2018 11:12:45 AM	10/23/2018 1:01 PM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	10/23/2018 1:01 PM
Addresses	Main Address	Insert	New Registration		482 BEDFORD STREET LEXINGTON, MA 02420	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110000014C	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110000014D	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		XHSP40986	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3032430	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		042103881	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		99220086	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NH	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00350490	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		OP20086	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		99220086	10/12/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	10/12/2018 3:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548202641	10/12/2018 3:32 PM
Contacts	Primary Contact	Insert	New Registration		Ogin, George Sr. Director of Financial Analysis and Regulatory Reporting Beth Israel Deaconess Medical Center 6176675089	10/12/2018 3:32 PM
Contacts	Authorizing Official	Insert	New Registration		Cullen, Mike CFO Beth Israel Deaconess Medical Center 6176320155	10/12/2018 3:32 PM
Details	Last Recertification Date	Insert	New Registration			10/12/2018 3:32 PM
Details	Grant Number	Insert	New Registration			10/12/2018 3:32 PM
Details	340B ID	Insert	New Registration			10/12/2018 3:32 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2018 3:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2018 3:32 PM
Details	Medicare Provider Number	Insert	New Registration		220086	10/12/2018 3:32 PM
Details	Entity Name	Insert	New Registration		BETH ISRAEL DEACONESS MEDICAL CENTER	10/12/2018 3:32 PM
Details	Program Code	Insert	New Registration		DSH	10/12/2018 3:32 PM
Details	Entity Subname	Insert	New Registration		MEDICAL CARE CENTER OF LEXINGTON	10/12/2018 3:32 PM
Dates	Participating Approval Date	Insert	New Registration			10/12/2018 3:32 PM
Details	State	Insert	New Registration		Pending	10/12/2018 3:32 PM
Dates	Registration Date	Insert	New Registration		10/12/2018 3:32:33 PM	10/12/2018 3:32 PM
Dates	Signed By Date	Insert	New Registration			10/12/2018 3:32 PM
Dates	Start Date	Insert	New Registration			10/12/2018 3:32 PM
Terminations	Termination Comments	Insert	New Registration			10/12/2018 3:32 PM
Terminations	Termination Date	Insert	New Registration			10/12/2018 3:32 PM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2018 3:32 PM
Terminations	Termination Reason	Insert	New Registration			10/12/2018 3:32 PM