Covered Entity Details

DSH070025CF HARTFORD HOSPITAL (Active) - information as of 5/2/2025 10:31:13 PM

Main Details

Name

HARTFORD HOSPITAL

Subdivision Name

HH MED ONC CI AVON 101024009 - 055.01

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070025CF

Medicare Provider Number

070025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/10/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/14/2019

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Hartford Healthcare
Sean Michael Curtin, Vice President, Finance, Hartford Region
(860) 545-0585

Primary Contact

Hartford Hospital
Eric Arlia, Director of Pharmacy
(860) 972-4165

Addresses

Street Address

80 Fisher Dr.
Avon, CT 06001

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CT	4041869,4025151,008057222	1770696643,1790183515,1902834880

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
DSH070025A	Child	DSH	HARTFORD HOSPITAL	Rehab West Hartford	445 South Main St	West Hartford	CT	Terminated
DSH070025AA	Child	DSH	HARTFORD HOSPITAL	Institute of Living - OPD Adult Psych Clinic	200 Retreat Street	Hartford	CT	Active
DSH070025AB	Child	DSH	HARTFORD HOSPITAL	HH IOL DBT MH PHP 101067031 - 90.05	200 Retreat Street	Hartford	CT	Active
DSH070025AC	Child	DSH	HARTFORD HOSPITAL	Institute of Living - Psychological Testing	200 Retreat Street	Hartford	CT	Terminated
DSH070025AD	Child	DSH	HARTFORD HOSPITAL	HH IOL OPD Institute Psych Group 101067049 - 90.05	200 Retreat Street	Hartford	CT	Active
DSH070025AE	Child	DSH	HARTFORD HOSPITAL	HH IOL SCHIZRHB MH OP 101067045 - 90.05	200 Retreat Street	Hartford	CT	Terminated
DSH070025AF	Child	DSH	HARTFORD HOSPITAL	Institute of Living - Electro Convulsive Therapy	200 Retreat Street	Hartford	CT	Active
DSH070025AG	Child	DSH	HARTFORD HOSPITAL	Institute of Living - PHP Young Adult Therapy	200 Retreat Street	Hartford	CT	Active
DSH070025AH	Child	DSH	HARTFORD HOSPITAL	Institute of Living - TOPS Extended Day Program	200 Retreat Street	Hartford	CT	Active
DSH070025AJ	Child	DSH	HARTFORD HOSPITAL	Institute of Living - OPD Child Adolescent Psych Clinic	200 Retreat Street	Hartford	CT	Active
DSH070025AK	Child	DSH	HARTFORD HOSPITAL	HH IOL CHL ADO DAY PHP 101039009 - 90.05	200 Retreat Street	Hartford	CT	Active
DSH070025AL	Child	DSH	HARTFORD HOSPITAL	HH IOL PROF PRG MH PHP 101067025 - 90.05	200 Retreat Street	Hartford	CT	Active
DSH070025AM	Child	DSH	HARTFORD HOSPITAL	HH IOL ADUL DAY MH PHP 101067020 - 90.05	200 Retreat Street	Hartford	CT	Active
DSH070025AN	Child	DSH	HARTFORD HOSPITAL	HH IOL EATING D MH PHP 101067016 - 90.05	200 Retreat Street	Hartford	CT	Terminated
DSH070025AP	Child	DSH	HARTFORD HOSPITAL	HH MED ONC CI HTFD 101025008 - 55.00	85 Retreat Ave	Hartford	CT	Active
DSH070025AQ	Child	DSH	HARTFORD HOSPITAL	Helen & Harry Gray Cancer Center - Medical Physics	85 Retreat Ave	Hartford	CT	Terminated
DSH070025AR	Child	DSH	HARTFORD HOSPITAL	HH RADONC 101025003 - 55.00	85 Retreat Ave	Hartford	CT	Active
DSH070025AS	Child	DSH	HARTFORD HOSPITAL	Brownstone Building - OPD Dental Clinic	79 Retreat Ave	Hartford	CT	Terminated
DSH070025AT	Child	DSH	HARTFORD HOSPITAL	HH SS GEN SURGERY 101021016 - 90.06	85 Seymour St.	Hartford	CT	Terminated
DSH070025AU	Child	DSH	HARTFORD HOSPITAL	HH CARDIOLOGY CLINIC 101018002 - 69.00	79 Retreat Ave	Hartford	CT	Active
DSH070025AV	Child	DSH	HARTFORD HOSPITAL	HH CARDIOLOGY OUTPATIENT VAD 101017003 - 69.00	85 Seymour St.	Hartford	CT	Active
DSH070025AW	Child	DSH	HARTFORD HOSPITAL	HH NEUROLOGY CLINIC 101018047 - 66.01	79 Retreat Ave	Hartford	CT	Active
DSH070025AX	Child	DSH	HARTFORD HOSPITAL	HH COMM CARE CLINIC 101018046 - 90.00	132 Jefferson Street	Hartford	CT	Active
DSH070025AY	Child	DSH	HARTFORD HOSPITAL	HH ADULT PRIM CARE 101018045 - 90.00	132 Jefferson Street	Hartford	CT	Active
DSH070025AZ	Child	DSH	HARTFORD HOSPITAL	HH HEART RHYTHM SRV HT 101017005 - 69.00	85 Jefferson Street	Hartford	CT	Active
DSH070025B	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB FARM 101060002 - 66.00	406 Farmington Ave	Farmington	CT	Active
DSH070025BA	Child	DSH	HARTFORD HOSPITAL	HH CHOLESTEROL MGT CTR 101017016 - 69.00	85 Jefferson Street	Hartford	CT	Active
DSH070025BB	Child	DSH	HARTFORD HOSPITAL	Cardiac Rehab	85 Seymour St	Hartford	CT	Terminated
DSH070025BC	Child	DSH	HARTFORD HOSPITAL	HH INFUSION 101025006 - 55.00	Helen & Harry Gray Cancer Center, 85 Retreat Ave	Hartford	CT	Active
DSH070025BD	Child	DSH	HARTFORD HOSPITAL	HH MAT FETAL MED HTFD 101016159 - 90.03	85 Jefferson Street	Hartford	CT	Active
DSH070025BE	Child	DSH	HARTFORD HOSPITAL	HH CF ADULT CENTER 101018043 - 65.00	79 Retreat Ave	Hartford	CT	Active
DSH070025BF	Child	DSH	HARTFORD HOSPITAL	HH CHCD 101017003 - 90.00	85 Jefferson Street	Hartford	CT	Active
DSH070025BG	Child	DSH	HARTFORD HOSPITAL	HH ENDOCRINE CLINIC 101018008 - 90.02	79 Retreat Ave	Hartford	CT	Active
DSH070025BH	Child	DSH	HARTFORD HOSPITAL	HH GYNONC HTFD 101021003 - 90.03	85 Seymour Street	Hartford	CT	Active
DSH070025BJ	Child	DSH	HARTFORD HOSPITAL	Rehab Hartford	85 Jefferson Street	Hartford	CT	Terminated
DSH070025BK	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB HFD 101021006 - 66.00	85 Seymour Street	Hartford	CT	Active
DSH070025BL	Child	DSH	HARTFORD HOSPITAL	HH MRI 101017009 - 58.00	85 Jefferson Street	Hartford	CT	Active
DSH070025BM	Child	DSH	HARTFORD HOSPITAL	HH PULMONARY LAB 101016110 - 65.00	85 Jefferson Street	Hartford	CT	Active
DSH070025BN	Child	DSH	HARTFORD HOSPITAL	Rehab Wallingford	85 Barnes Road	Wallingford	CT	Terminated
DSH070025BP	Child	DSH	HARTFORD HOSPITAL	West Hartford Surgery Center	65 Memorial Road	West Hartford	CT	Active
DSH070025BQ	Child	DSH	HARTFORD HOSPITAL	Rehab Blueback	65 Memorial Road	West Hartford	CT	Terminated
DSH070025BR	Child	DSH	HARTFORD HOSPITAL	HH BJI RHEUMATOLOGY 101021009 - 90.08	31 Seymour St.	Hartford	CT	Active
DSH070025BS	Child	DSH	HARTFORD HOSPITAL	WHS Urogynecology	85 Jefferson Street	Hartford	CT	Terminated
DSH070025BT	Child	DSH	HARTFORD HOSPITAL	HH GI ENDOSCOPY 101017012 - 050.01	85 Jefferson Street	Hartford	CT	Active
DSH070025BU	Child	DSH	HARTFORD HOSPITAL	HH VASCULAR LABORATORY 101017011 - 65.02	85 Jefferson Street	Hartford	CT	Active
DSH070025BV	Child	DSH	HARTFORD HOSPITAL	HH PULMONARY REHAB 101016111 - 65.00	85 Jefferson Street	Hartford	CT	Active
DSH070025BW	Child	DSH	HARTFORD HOSPITAL	Cardiac Rehab Glastonbury	305 Western Blvd	Glastonbury	CT	Terminated
DSH070025BX	Child	DSH	HARTFORD HOSPITAL	West Hartford Surgery Center - Blue Back Square	65 Memorial Road	West Hartford	CT	Active
DSH070025BY	Child	DSH	HARTFORD HOSPITAL	HH Eye Surgery Center	505 Willard Ave	Newington	CT	Terminated
DSH070025BZ	Child	DSH	HARTFORD HOSPITAL	HH NEURSCN MOB 101021030 - 60.01	85 Seymour Street	Hartford	CT	Active
DSH070025C	Child	DSH	HARTFORD HOSPITAL	Rehab Bishops Corner	334 North Main Street	West Hartford	CT	Terminated
DSH070025CA	Child	DSH	HARTFORD HOSPITAL	Outpatient Dialysis	85 Jefferson Street	Hartford	CT	Terminated
DSH070025CB	Child	DSH	HARTFORD HOSPITAL	HH TRANSPLANT 101021023 - 107.00	85 Seymour Street	Hartford	CT	Active
DSH070025CC	Child	DSH	HARTFORD HOSPITAL	HH AWLC UROGYN BLBK 101022015 - 90.03	65 MEMORIAL RD	WEST HARTFORD	CT	Active
DSH070025CD	Child	DSH	HARTFORD HOSPITAL	HH MED ONC CI JB HTFD 101021038 - 55.00	85 Jefferson Street	HARTFORD	CT	Active
DSH070025CE	Child	DSH	HARTFORD HOSPITAL	HH INFUSION AVON 101024008 - 055.01	80 FISHER DRIVE	AVON	CT	Active
DSH070025CF	Child	DSH	HARTFORD HOSPITAL	HH MED ONC CI AVON 101024009 - 055.01	80 Fisher Dr.	Avon	CT	Active
DSH070025CG	Child	DSH	HARTFORD HOSPITAL	HH INFUSION MANCH 100119002 - 055.02	376 Tolland Turnpike	Manchester	CT	Active
DSH070025CH	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB VERN 101081006 - 66.00	35 Talcotville Rd	Vernon	CT	Active
DSH070025CJ	Child	DSH	HARTFORD HOSPITAL	HH ENT CLINIC 101018009 - 90.00	79 Retreat Ave	Hartford	CT	Active
DSH070025CK	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB 815 101021032 - 66.01	85 Seymour St	Hartford	CT	Active
DSH070025CL	Child	DSH	HARTFORD HOSPITAL	HH UROLOGY CLINIC 101018018 - 90.00	79 Retreat Ave	Hartford	CT	Active
DSH070025CM	Child	DSH	HARTFORD HOSPITAL	HH PULMONOLOGY CLINIC 101018015 - 90.00	79 Retreat Ave	Hartford	CT	Active
DSH070025CN	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB BJI 101016216 - 66.00	32 Seymour St	Hartford	CT	Active
DSH070025CP	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED & REHAB GLAST 101020003 - 66.00	330 Western Blvd	Glastonbury	CT	Active
DSH070025CQ	Child	DSH	HARTFORD HOSPITAL	HH GI Clinic 101018010 - 90.00	79 Retreat Ave	Hartford	CT	Active
DSH070025CR	Child	DSH	HARTFORD HOSPITAL	Oncology-Infusion _Manchester 55.02 HH GYNONC MANCH 101119004	376 Tolland Turnpike	Manchester	CT	Active
DSH070025CS	Child	DSH	HARTFORD HOSPITAL	Oncology-Infusion _Manchester 55.02 HH MED ONC CI MANCH 101119001	376 Tolland Turnpike	Manchester	CT	Active
DSH070025CT	Child	DSH	HARTFORD HOSPITAL	Radiology Therapeutic 55.00 HH INFUSION JB	85 JEFFERSON STREEET	Hartford	CT	Active
DSH070025CU	Child	DSH	HARTFORD HOSPITAL	HH DIABETES LC HTFD - Endocrinology	85 Seymour St	Hartford	CT	Active
DSH070025CV	Child	DSH	HARTFORD HOSPITAL	Clinic 90.00 HH SS OPHTHALMOLOGY 101021025	79 Retreat Ave	hartford	CT	Active
DSH070025CW	Child	DSH	HARTFORD HOSPITAL	EMG/Physiatry 66.01 HH NEUROLOGY SPORTS32 101016219	32 Seymour St	Hartford	CT	Terminated
DSH070025CX	Child	DSH	HARTFORD HOSPITAL	EMG/Physiatry 66.01 HH NEUROLOGY SPORTS31 101016220	31 Seymour St	Hartford	CT	Terminated
DSH070025CY	Child	DSH	HARTFORD HOSPITAL	Cardiology-EKG 69.00 HH HEART RHYTHM SRV WH 101022003 - Cardiology	65 Memorial Road	West Hartford	CT	Active
DSH070025CZ	Child	DSH	HARTFORD HOSPITAL	Physical Therapy 66.00 HH PHYS MED REHAB BLBK 101022020 - Physical Therapy	65 Memorial Road	West Hartford	CT	Active
DSH070025D	Child	DSH	HARTFORD HOSPITAL	HH AWLC UROGYN GLAST 101013004 - 90.03	330 Western Blvd	Glastonbury	CT	Active
DSH070025DA	Child	DSH	HARTFORD HOSPITAL	Hepatology Clinic 090.07 HH HEPATOLOGY WINDHAM 101083001 - Hepatology	112 Mansfield Avenue	Willimantic	CT	Active
DSH070025DB	Child	DSH	HARTFORD HOSPITAL	BJI CLINIC 90.08 HH BJI RHEUM INFUSION 101021037 - BJI Clinic	31 Seymour St.	Hartford	CT	Active
DSH070025DC	Child	DSH	HARTFORD HOSPITAL	PSYCH CLINICS 90.05 HH IOL ESKETAMINE CTR 101067062 - Psych Clinic	200 Retreat Street, Burlingame Building	Hartford	CT	Active
DSH070025DD	Child	DSH	HARTFORD HOSPITAL	PSYCH CLINICS 90.05 HH IOL INST PSY PERI 101067054 - Psych Clinic	200 Retreat St, West Grad Building	hartford	CT	Active
DSH070025DE	Child	DSH	HARTFORD HOSPITAL	PSYCH CLINICS 90.05 HH IOL SA MATCH - Psych Clinic	200 Retreat Street Thompson Building	Hartford	CT	Active
DSH070025DF	Child	DSH	HARTFORD HOSPITAL	Physical Therapy 066.00 HH PHYS MED NEURONC 101016865 - Physical Therapy	85 Seymour Street	Hartford	CT	Active
DSH070025DG	Child	DSH	HARTFORD HOSPITAL	PHP Schizophrenia Rehab 90.05 HH IOL SRP PHP 101067045 - Psych Clinic	200 Retreat St	Hartford	CT	Active
DSH070025DH	Child	DSH	HARTFORD HOSPITAL	HH NEURO ONC HTFD85 - Neuro Oncology	85 Retreat Avenue	Hartford	CT	Active
DSH070025DJ	Child	DSH	HARTFORD HOSPITAL	HH NEURO STROKE MOB - Neurology-Stroke	85 Seymour Street	Hartford	CT	Active
DSH070025DK	Child	DSH	HARTFORD HOSPITAL	HH SS BREAST CLINIC - Breast Clinic	79 Retreat Avenue	Hartford	CT	Active
DSH070025DL	Child	DSH	HARTFORD HOSPITAL	HH GERIATRIC CLINIC - Geriatrics	79 Retreat Avenue	Hartford	CT	Active
DSH070025DM	Child	DSH	HARTFORD HOSPITAL	HH TRAUMA CLINIC - Trauma	79 Retreat Avenue	Hartford	CT	Active
DSH070025DN	Child	DSH	HARTFORD HOSPITAL	HH ADDICTION MED - Addiction Medicine	79 Retreat Avenue	Hartford	CT	Active
DSH070025DP	Child	DSH	HARTFORD HOSPITAL	HH NEUROMUSCULAR MOB - Neuromuscular	85 Seymour Street	Hartford	CT	Active
DSH070025DQ	Child	DSH	HARTFORD HOSPITAL	HH WHSC GI CENTER - GI CLINIC	65 MEMORIAL RD	WEST HARTFORD	CT	Active
DSH070025DR	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED REHAB HARTFORD79 - REHAB	79 RETREAT AVENUE	HARTFORD	CT	Active
DSH070025DS	Child	DSH	HARTFORD HOSPITAL	HH MOVEMENT DISORDER SPAN HTFD - MOVEMENT DISORDER	85 SEYMOUR STREET	HARTFORD	CT	Active
DSH070025DT	Child	DSH	HARTFORD HOSPITAL	HH ARRHYTHMIA WEST HARTFORD - ARRHYTHMIA	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025DU	Child	DSH	HARTFORD HOSPITAL	HH ARRHYTHMIA HTFD - ARRHYTHMIA	85 JEFFERSON STREET	HARTFORD	CT	Active
DSH070025DV	Child	DSH	HARTFORD HOSPITAL	HH NEURODIAGNOSTIC MOB - NEUROLOGY	85 SEYMOUR STREET	HARTFORD	CT	Active
DSH070025DW	Child	DSH	HARTFORD HOSPITAL	HH ENDO NEOPLASIA - ENDOCRINOLOGY	79 RETREAT AVENUE	HARTFORD	CT	Active
DSH070025DX	Child	DSH	HARTFORD HOSPITAL	HH ENDO BONE - ENDOCRINOLOGY	79 RETREAT AVENUE	HARTFORD	CT	Active
DSH070025DY	Child	DSH	HARTFORD HOSPITAL	HH ENDO THYROID - ENDOCRINE	79 RETREAT AVENUE	HARTFORD	CT	Active
DSH070025DZ	Child	DSH	HARTFORD HOSPITAL	HH TRANSITIONAL CARE - TRANSITIONAL CARE	79 RETREAT AVENUE	HARTFORD	CT	Active
DSH070025E	Child	DSH	HARTFORD HOSPITAL	Rehab Glastonbury	330 Western Blvd	Glastonbury	CT	Terminated
DSH070025EA	Child	DSH	HARTFORD HOSPITAL	HH HEADACHE CTR BLBK - HEADACHE CENTER	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025EB	Child	DSH	HARTFORD HOSPITAL	HH COMMUNITY CARE PSYCH - PSYCHIATRY	132 JEFFERSON STREET	HARTFORD	CT	Active
DSH070025EC	Child	DSH	HARTFORD HOSPITAL	HH BEHAVIORAL HEALTH HARTFORD 132 - BEHAVIORAL HEALTH	132 JEFFERSON STREET	HARTFORD	CT	Active
DSH070025ED	Child	DSH	HARTFORD HOSPITAL	HH INFECTIOUS DISEASE - INFECTIOUS DISEASE	132 JEFFERSON STREET	HARTFORD	CT	Active
DSH070025EE	Child	DSH	HARTFORD HOSPITAL	HH AWLC FAC PRACT BLBK - WOMENS HEALTH	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025EF	Child	DSH	HARTFORD HOSPITAL	HH AWLC GYNONC BLBK - WOMENS HEALTH	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025EG	Child	DSH	HARTFORD HOSPITAL	HH BEH HLTH WMNS WH65 - BEHAVIORAL HEALTH	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025EH	Child	DSH	HARTFORD HOSPITAL	HH EPILEPSY HTFD 85 - EPILEPSY	85 SEYMOUR STREET	HARTFORD	CT	Active
DSH070025EJ	Child	DSH	HARTFORD HOSPITAL	HH PAIN PSYCH CTR WH - PSYCH	65 MEMORIAL ROAD	WEST HARTFORD	CT	Active
DSH070025EK	Child	DSH	HARTFORD HOSPITAL	HH LDL APHERESIS - CHOLESTEROL MANAGEMENT	85 JEFFERSON STREET	HARTFORD	CT	Active
DSH070025EL	Child	DSH	HARTFORD HOSPITAL	HH IOL SRP OP - PSYCH- SCHIZOPHRENIA REHAB	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025EM	Child	DSH	HARTFORD HOSPITAL	HH GYN SPECIALTIES BLBK - GYNECOLOGY	65 MEMORIAL RD	WEST HARTFORD	CT	Approved
DSH070025EN	Child	DSH	HARTFORD HOSPITAL	HH IOL PROF PROGRAM IOP - PSYCH	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025EP	Child	DSH	HARTFORD HOSPITAL	HH NEURO ONC HTFD SYMR - NEURO ONCOLOGY	85 SEYMOUR STREET	HARTFORD	CT	Approved
DSH070025EQ	Child	DSH	HARTFORD HOSPITAL	HH IOL AUT CHAD OP - PSYCH- AUTISM	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025ER	Child	DSH	HARTFORD HOSPITAL	HH NEURO ONC JB HTFD - NEURO ONC	85 JEFFERSON STREET	HARTFORD	CT	Approved
DSH070025ES	Child	DSH	HARTFORD HOSPITAL	HH IOL SA MATCH IOP - SUBSTACE ABUSE PSYCH	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025ET	Child	DSH	HARTFORD HOSPITAL	HH GYN ONC BLBK - GYNECOLOGY ONCOLOGY	65 MEMORIAL ROAD	WEST HARTFORD	CT	Approved
DSH070025EU	Child	DSH	HARTFORD HOSPITAL	HH IOL INST PSY ADU OP - PSYCH - ADULT	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025EV	Child	DSH	HARTFORD HOSPITAL	HH IOL OLDER ADULT OP - PSYCH	200 RETREAT AVE	HARTFORD	CT	Approved
DSH070025F	Child	DSH	HARTFORD HOSPITAL	Rehab Manchester	252 North Main St	Manchester	CT	Terminated
DSH070025G	Child	DSH	HARTFORD HOSPITAL	Rehab Granby	18 East Granby Rd	Granby	CT	Terminated
DSH070025H	Child	DSH	HARTFORD HOSPITAL	HH PHYS MED & REHAB SW 101010004 - 66.00	1559 Sullivan Avenue	South Windsor	CT	Active
DSH070025J	Child	DSH	HARTFORD HOSPITAL	Sleep Lab Wethersfield	1260 Silas Deane Hwy	Wethersfield	CT	Terminated
DSH070025K	Child	DSH	HARTFORD HOSPITAL	HH NEUROSCN WETH 101039008 - 70.00	1260 Silas Deane Hwy	Wethersfield	CT	Terminated
DSH070025L	Child	DSH	HARTFORD HOSPITAL	Womens Ambulatory Health Services	111 Park Street	Hartford	CT	Active
DSH070025M	Child	DSH	HARTFORD HOSPITAL	Nuclear Cardiology Farmington	11 South Road	Farmington	CT	Terminated
DSH070025N	Child	DSH	HARTFORD HOSPITAL	Meriden Rehab	1064 East Main St	Meriden	CT	Terminated
DSH070025P	Child	DSH	HARTFORD HOSPITAL	Windsor Rehab	1060 Day Hill Rd	Windsor	CT	Terminated
DSH070025Q	Child	DSH	HARTFORD HOSPITAL	Wethersfield Rehab	1260 SILAS DEANE HWY	WETHERSFIELD	CT	Terminated
DSH070025R	Child	DSH	HARTFORD HOSPITAL	Avon Cardiac Rehab	100 SIMSBURY ROAD	AVON	CT	Terminated
DSH070025S	Child	DSH	HARTFORD HOSPITAL	Avon Rehab	100 SIMSBURY ROAD	AVON	CT	Terminated
DSH070025T	Child	DSH	HARTFORD HOSPITAL	Enfield Rehab	100 HAZARD AVENUE	ENFIELD	CT	Terminated
DSH070025U	Child	DSH	HARTFORD HOSPITAL	HH RADONC AVON 101024002 - 55.01	80 Fisher Road	Avon	CT	Active
DSH070025V	Child	DSH	HARTFORD HOSPITAL	Avon Cancer Center Medical Physics	80 Fisher Road	Avon	CT	Terminated
DSH070025W	Child	DSH	HARTFORD HOSPITAL	HH SAME DAY ADMISSION 101016114 - 50.00	85 Jefferson Street	Hartford	CT	Active
DSH070025X	Child	DSH	HARTFORD HOSPITAL	Sleep Lab Bloomfield	533 Cottage Grove Rd	Bloomfield	CT	Terminated
DSH070025Y	Child	DSH	HARTFORD HOSPITAL	Duncaster Geriatric Services	40 Loeffler Dr.	Bloomfield	CT	Terminated
DSH070025Z	Child	DSH	HARTFORD HOSPITAL	HH BJI ORTHO 101021010 - 90.00	31 Seymour St.	Hartford	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	Curtin, Sean Michael Vice President, Finance, Hartford Region Hartford Healthcare 8605450585	12/26/2024 7:46 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 11:28:08 AM	9/3/2024 10:12:02 AM	9/3/2024 10:12 AM
Contacts	Authorizing Official	Update	AO Change Request	Fichandler, David Senior Director, Clinical Operations Hartford Hospital 8609722450	Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	1/11/2024 7:24 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 8:07:14 AM	8/30/2023 11:28:08 AM	8/30/2023 11:28 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 1:24:51 PM	8/25/2022 8:07:14 AM	8/25/2022 8:07 AM
Contacts	Authorizing Official	Update	AO Change Request	Drouin, Julie M VP of Finance Hartford Hospital 8605450585	Fichandler, David Senior Director, Clinical Operations Hartford Hospital 8609722450	3/30/2022 1:37 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 11:10:32 AM	8/30/2021 1:24:51 PM	8/30/2021 1:24 PM
Contacts	Authorizing Official	Update	Change Request	Boisvert, Gerald Vice President, Finance Operations Hartford Hospital 8605450585	Drouin, Julie M VP of Finance Hartford Hospital 8605450585	9/23/2020 8:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1770696643	9/14/2020 11:10 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/14/2020 11:10 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790183515	9/14/2020 11:10 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/14/2020 11:10 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1902834880	9/14/2020 11:10 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/14/2020 11:10 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1902834880 ( )		9/14/2020 11:10 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1770696643 ( )		9/14/2020 11:10 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1790183515 ( )		9/14/2020 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 1:04:34 PM	9/14/2020 11:10:32 AM	9/14/2020 11:10 AM
Details	Entity Subname	Update	Recertification	HH Medical Oncology - Avon - Oncology	HH MED ONC CI AVON 101024009 - 055.01	9/14/2020 11:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	8057222	008057222	9/24/2019 10:21 AM
Details	Last Recertification Date	Update	Recertification		8/20/2019 1:04:34 PM	8/20/2019 1:04 PM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Boisvert, Gerald Vice President, Finance Operations Hartford Hospital 8605450585	1/14/2019 7:59 AM
Details	340B ID	Update	New Registration		DSH070025CF	1/14/2019 7:59 AM
Details	Entity Subname	Update	New Registration	HH Medical Oncology - Avon	HH Medical Oncology - Avon - Oncology	1/14/2019 7:59 AM
Dates	Participating Approval Date	Update	New Registration		1/14/2019 7:59:00 AM	1/14/2019 7:59 AM
Details	State	Update	New Registration	Pending	Approved	1/14/2019 7:59 AM
Dates	Signed By Date	Update	New Registration		1/10/2019 3:22:57 PM	1/14/2019 7:59 AM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/14/2019 7:59 AM
Addresses	Main Address	Insert	New Registration		80 Fisher Dr. Avon, CT 06001	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4041869	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4025151	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		8057222	1/10/2019 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	1/10/2019 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1902834880	1/10/2019 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770696643	1/10/2019 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1790183515	1/10/2019 1:32 PM
Contacts	Primary Contact	Insert	New Registration		Arlia, Eric Director of Pharmacy Hartford Hospital 8609724165	1/10/2019 1:32 PM
Contacts	Authorizing Official	Insert	New Registration		Boisvert, Gerald Vice President, Finance Operations Hartford Hospital 8605450585	1/10/2019 1:32 PM
Details	Last Recertification Date	Insert	New Registration			1/10/2019 1:32 PM
Details	Grant Number	Insert	New Registration			1/10/2019 1:32 PM
Details	340B ID	Insert	New Registration			1/10/2019 1:32 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2019 1:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2019 1:32 PM
Details	Medicare Provider Number	Insert	New Registration		070025	1/10/2019 1:32 PM
Details	Entity Name	Insert	New Registration		HARTFORD HOSPITAL	1/10/2019 1:32 PM
Details	Program Code	Insert	New Registration		DSH	1/10/2019 1:32 PM
Details	Entity Subname	Insert	New Registration		HH Medical Oncology - Avon	1/10/2019 1:32 PM
Dates	Participating Approval Date	Insert	New Registration			1/10/2019 1:32 PM
Details	State	Insert	New Registration		Pending	1/10/2019 1:32 PM
Dates	Registration Date	Insert	New Registration		1/10/2019 1:32:21 PM	1/10/2019 1:32 PM
Dates	Signed By Date	Insert	New Registration			1/10/2019 1:32 PM
Dates	Start Date	Insert	New Registration			1/10/2019 1:32 PM
Terminations	Termination Comments	Insert	New Registration			1/10/2019 1:32 PM
Terminations	Termination Date	Insert	New Registration			1/10/2019 1:32 PM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2019 1:32 PM
Terminations	Termination Reason	Insert	New Registration			1/10/2019 1:32 PM