Covered Entity Details

DSH220163DB UMASS MEMORIAL MEDICAL CENTER (Active) - information as of 4/29/2025 2:48:33 AM

Main Details

Name

UMASS MEMORIAL MEDICAL CENTER

Subdivision Name

Memorial Campus South 2 - Observation Status

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH220163DB

Medicare Provider Number

220163

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2019

Participating Start Date

4/1/2019

Participating Approval Date

2/15/2019

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

UMass Memorial Medical Center
Alice Shakman, Vice President Operations
(774) 443-0540

Primary Contact

UMass Memorial Medical Center
Meetali Desai, 340B Compliance Specialist
(774) 443-2852

Addresses

Street Address

119 Belmont Street
Worcester, MA 01605

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
MA		1831151455,1689760092,1891864039,1831461086,1669630950
AZ		1831151455
CO		1831151455
CT		1831151455,1831461086
FL		1831151455
IL		1831151455
ME		1831151455
NC		1831151455
NY		1831151455
RI		1831151455

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
DSH220163A	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	MEMORIAL CAMPUS	119 BELMONT STREET	WORCESTER	MA	Active
DSH220163AA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-PRESURGICAL EVALUATION CLINIC	281 Lincoln st	Worcester	MA	Active
DSH220163AB	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	HAHNEMAN-SURG DAY CARE	281 Lincoln st	Worcester	MA	Active
DSH220163AC	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus- LITHOTRIPSY	119 Belmont Street	Worcester	MA	Active
DSH220163AD	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-ENDOSCOPY	119 Belmont Street	Worcester	MA	Active
DSH220163AE	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann-SACU	281 Lincoln st	Worcester	MA	Active
DSH220163AF	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-EKG	119 Belmont Street	Worcester	MA	Active
DSH220163AG	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-SURGICAL VASCULAR LAB	119 Belmont Street	Worcester	MA	Active
DSH220163AH	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-CARDIAC ULTRASOUND	119 Belmont Street	Worcester	MA	Active
DSH220163AJ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann-Outpatient Physical Therapy	281 Lincoln st	Worcester	MA	Active
DSH220163AK	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-PHYSICAL THERAPY	119 Belmont Street	Worcester	MA	Active
DSH220163AL	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Respiratory Therapy	119 Belmont Street	Worcester	MA	Active
DSH220163AM	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Radiation Oncology	119 Belmont Street	Worcester	MA	Active
DSH220163AN	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann-ANESTHESIA	281 Lincoln st	Worcester	MA	Active
DSH220163AP	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-ANESTHESIA	119 Belmont Street	Worcester	MA	Active
DSH220163AQ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-UROLOGY	33 Kendall Street	Worcester	MA	Active
DSH220163AR	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-PACU	281 Lincoln st	Worcester	MA	Active
DSH220163AS	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann-Operating Room	281 Lincoln st	Worcester	MA	Active
DSH220163AT	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-PACU	119 Belmont Street	Worcester	MA	Active
DSH220163AU	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Operating Room	119 Belmont Street	Worcester	MA	Active
DSH220163AV	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-CARDIOVASCULAR CLN A CVC	55 Lake Avenue North	Worcester	MA	Active
DSH220163AW	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-PRIMARY CARE CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163AX	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-DIABETES CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163AY	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-WOUND CENTER	55 Lake Avenue North	Worcester	MA	Active
DSH220163AZ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-GASTROENTEROLOGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163B	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	HAHNEMANN CAMPUS	281 LINCOLN STREET	WORCESTER	MA	Active
DSH220163BA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-FAMILY MEDICINE CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163BB	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-FAMILY MEDICINE CLINIC	281 Lincoln st	Worcester	MA	Active
DSH220163BC	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	TRIRIVER EXTENDED HRS	281 East Hartford Avenue	Uxbrdige	MA	Active
DSH220163BD	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River other Ancillary	281 east hartford ave	uxbridge	MA	Active
DSH220163BE	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River Family Heath Center-Internal Medicine	281 East Hartford Ave	Uxbridge	MA	Active
DSH220163BF	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-REPRODUCTIVE ENDO CLINIC (Womens Center W4)	119 Belmont Street	Worcester	MA	Active
DSH220163BG	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus-PEDIATRIC ORTHOPEDIC CTR	55 Lake Avenue North	Worcester	MA	Active
DSH220163BH	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-WOMEN SERVICES UROGYN	119 Belmont Street	Worcester	MA	Active
DSH220163BJ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-OUTPATIENT JOINT CENTER	119 Belmont Street	Wocester	MA	Active
DSH220163BK	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-CENTER FOR WOMEN and CHILDREN (Community Womens Care)	119 Belmont Street	Worcester	MA	Active
DSH220163BL	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-SPINE CENTER	119 Belmont Street	Worcester	MA	Active
DSH220163BM	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann - ANTICOAGULATION CLINIC	281 Lincoln Street	Worcester	MA	Active
DSH220163BN	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-WOMEN SERVICES MFM	119 Belmont Street	Worcester	MA	Active
DSH220163BP	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-GYN ONCOLOGY CLINIC	33 Kendall Street	Worcester	MA	Active
DSH220163BQ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-WOMEN SERVICES REI	33 Kendall Street	Worcester	MA	Active
DSH220163BR	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-RHEUMATOLOGY CLINIC	119 Belmont Street	Worcester	MA	Active
DSH220163BS	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-SPINE PROCEDURE ROOM	119 Belmont Street	Worcester	MA	Active
DSH220163BT	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-PLASTIC/COSMETIC CLINIC	281 Lincoln st	Worcester	MA	Active
DSH220163BU	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-SPORTS MEDICINE	281 Lincoln St	Worcester	MA	Active
DSH220163BV	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-HAND/UPPER EXTREMITY CLN	281 Lincoln st	Worcester	MA	Active
DSH220163BX	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Gastroenterology Clinic	119 Belmont Street	Worcester	MA	Active
DSH220163BY	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-DERM Procedure Centre	281 Lincoln St	Worcester,	MA	Active
DSH220163BZ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-Opthalmology	281 Lincoln Street	Worcester	MA	Active
DSH220163C	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	BARRE HEALTH CENTER	151 WORCESTER RD	BARRE	MA	Active
DSH220163CA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - HEMOPHILIA CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CB	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Psych Services Program (Ambulatory Psych)	26 Queens street	Worcester	MA	Terminated
DSH220163CC	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial - TB CLINIC	119 Belmont St.	Worcester	MA	Active
DSH220163CD	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - SURGERY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CE	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - OTOLARYN/AUDIO CLINIC (Otolaryngology)	55 Lake Avenue North	Worcester	MA	Active
DSH220163CF	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - LUNG/ALLERGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CG	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - PEDIATRIC ENDOCRIN DIABET	55 Lake Avenue North	Worcester	MA	Active
DSH220163CH	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - NEUROLOGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CJ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - ONCOLOGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CK	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - GASTROENTEROLOGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CL	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - MULTIPLE SCLEROSIS CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CM	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - BREAST CANCER (Breast Ctr Sug/onc)	55 Lake Avenue North	Worcester	MA	Active
DSH220163CN	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - ORTHOPEDICS	55 Lake Avenue North	Worcester	MA	Active
DSH220163CP	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann - PSYCH SERVICES CLINIC (Ambulatory Psych)	281 Lincoln Street	Worcester	MA	Terminated
DSH220163CQ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - WEIGHT CENTER	55 Lake Avenue North	Worcester	MA	Active
DSH220163CR	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - TRANSPLANT CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CS	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University- ENDOCRINOLOGY CLINIC	55 Lake Avenue North	Worcester	MA	Active
DSH220163CT	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Marlborough Cancer Center	157 Union Street	Marlborough	MA	Active
DSH220163CU	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tobacco Treatment Program	55 Lake Avenue North	Worcester	MA	Active
DSH220163CV	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Pediatrics Clinic	55 Lake Avenue North	Worcester	MA	Active
DSH220163CW	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Diabetes Education	55 Lake Avenue North	Worcester	MA	Active
DSH220163CX	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Marlborough - Oncology Infusion Suite MH - Oncology	157 Union Street	Marlborough	MA	Active
DSH220163CY	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus Surgery Admin - Memorial SACU	119 Belmont Strret	Worcester	MA	Active
DSH220163CZ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus Renal Dialysis - Dialysis	119 Belmont Street	Worcester	MA	Active
DSH220163D	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	PLUMLEY VILLAGE HEALTH SERVICES	116 BELMONT STREET	WORCESTER	MA	Terminated
DSH220163DA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus South 5 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DB	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus South 2 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DC	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus West 1 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DD	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus West 3 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DE	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus ICU - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DF	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus South 3 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DG	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus South 6 - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DH	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus Newborn ICU - Observation Status	119 Belmont Street	Worcester	MA	Active
DSH220163DJ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River - Pediatrics	281 East Hartford Ave	Uxbridge	MA	Active
DSH220163DK	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV ENDO	55 Lake Ave North	Worcester	MA	Active
DSH220163DL	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Plastic Surgery	55 Lake Ave North	Worcester	MA	Active
DSH220163DM	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River - Urgent Care	281 East Hartford Ave	Uxbridge	MA	Active
DSH220163DN	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Marlborough - Radiation Oncology	157 Union Street	Marlborough	MA	Active
DSH220163DP	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Nephrology	55 Lake Ave North	Worcester	MA	Active
DSH220163DQ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus - Neurodiagnostics	119 Belmont St	Worcester	MA	Active
DSH220163DR	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial - Gen OBGYN	119 Belmont St	Worcester	MA	Active
DSH220163DS	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann - Audiology	281 Lincoln Street	Worcester	MA	Active
DSH220163DT	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Vascular Lab	55 Lake Avenue North	Worcester	MA	Active
DSH220163DU	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Dermatology	55 Lake Ave North	Worcester	MA	Active
DSH220163DV	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Nuclear Medicine	55 Lake Avenue North	Worcester	MA	Active
DSH220163DW	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV ENDO PREPOST	55 Lake Ave North	Worcester	MA	Active
DSH220163DX	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial - Phlebotomy	119 Belmont St	Worcester	MA	Active
DSH220163DY	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River - Imaging Services	281 East Hartford Ave	Uxbridge	MA	Active
DSH220163DZ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV PULM/ENDO FLUORO	55 Lake Ave North	Worcester	MA	Active
DSH220163EA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Surgery Clinic	55 Lake Ave North	Worcester	MA	Active
DSH220163EB	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Interventional Radiology	55 Lake Ave North	Worcester	MA	Active
DSH220163EC	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Pedi Duchenne	55 Lake Avenue North	Worcester	MA	Terminated
DSH220163ED	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Neurosurgery	55 Lake Ave North	Worcester	MA	Active
DSH220163EE	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus - Cardiac Ultrasound	55 Lake Avenue North	Worcester	MA	Active
DSH220163EF	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Campus - Infusion Center - Infusion Clinic	55 Lake Avenue North	Worcester	MA	Active
DSH220163EG	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Radiation Oncology	55 Lake Ave North	Worcester	MA	Active
DSH220163EH	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - Radiology Diagnostics	55 Lake Ave North	Worcester	MA	Active
DSH220163EJ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University - UNV Primary Care Dermatology	55 Lake Ave North	Worcester	MA	Active
DSH220163EK	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River Cardiology - Cardiology	281 East Hartford Avenue	Uxbridge	MA	Active
DSH220163EL	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	University Opthalmology - Opthalmology	55 Lake Ave North	Worcester	MA	Active
DSH220163EM	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus - Cardiology	119 Belmont Street	Worcester	MA	Active
DSH220163EN	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River Orthopedics - Orthopedics	281 East Hartford Avenue	Uxbridge	MA	Active
DSH220163EP	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial - IVF Center	33 Kendall Street	Worcester	MA	Active
DSH220163EQ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann - ADDICTION SERVICES MOBILE CARE	281 Lincoln Street	Worcester	MA	Active
DSH220163ER	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann - Monoclonal Antibody Therapy	281 Lincoln Street	Worcester	MA	Active
DSH220163ES	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	TRI-RIVER FAMILY HEALTH CENTER - Diabetes	281 E HARTFORD AVE	UXBRIDGE	MA	Active
DSH220163ET	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	MEMORIAL CAMPUS - Primary Care	119 BELMONT ST	WORCESTER	MA	Active
DSH220163EU	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	TRI-RIVER FAMILY HEALTH CENTER - Pedi Gastro	281 E HARTFORD AVE	UXBRIDGE	MA	Active
DSH220163EV	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	MEMORIAL CAMPUS - Care Mobile	119 BELMONT ST	WORCESTER	MA	Active
DSH220163EW	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	TRI-RIVER FAMILY HEALTH CENTER - Sports Medicine	281 E HARTFORD AVE	UXBRIDGE	MA	Active
DSH220163EX	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	MEMORIAL CAMPUS - Delivery	119 BELMONT ST	WORCESTER	MA	Active
DSH220163EY	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	MEMORIAL CAMPUS - Endocrinology	119 BELMONT ST	WORCESTER	MA	Active
DSH220163EZ	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	HAHNEMANN CAMPUS - Cardiology	281 LINCOLN ST	WORCESTER	MA	Active
DSH220163F	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	ENDOSCOPY CENTER	21 EASTERN AVENUE	WORCESTER	MA	Active
DSH220163FA	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River Rheumatology - Rheumatology	281 East Hartford Ave	Uxbridge	MA	Active
DSH220163H	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahnemann Family Health Clinic	279 Lincoln Street	Worcester	MA	Active
DSH220163J	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Tri River Family Health Center	281 Hartford Ave E	Uxbridge	MA	Active
DSH220163M	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	OCCUPATIONAL THERAPY	119 Belmont Street	Worcester	MA	Active
DSH220163P	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Nuclear Medicine	119 Belmont Street	Worcester	MA	Active
DSH220163Q	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-CATSCAN	119 Belmont Street	Worcester	MA	Active
DSH220163R	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Radiology	119 Belmont Street	Worcester	MA	Active
DSH220163S	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Radiology-ULTRASOUND GYN	33 Kendall Street	Worcester	MA	Active
DSH220163T	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-ULTRASOUND	119 Belmont Street	Worcester	MA	Active
DSH220163U	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-ANGIOGRAPHY	119 Belmont Street	Worcester	MA	Active
DSH220163V	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Hahneman-HAHNEMANN MAMMOGRAPHY	281 Lincoln st	Worcester	MA	Active
DSH220163W	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	HAHNEMANN-Radiology	281 Lincoln st	Worcester	MA	Active
DSH220163X	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-ORTHOPEDICS (PLASTER ROOM) CLINIC	119 Belmont Street	Worcester	MA	Active
DSH220163Y	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Outpatient North	119 Belmont Street	Worcester	MA	Active
DSH220163Z	Child	DSH	UMASS MEMORIAL MEDICAL CENTER	Memorial Campus-Emergency Room	119 Belmont Street	Worcester	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 10:00:15 AM	8/13/2024 9:40:05 AM	8/13/2024 9:40 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 12:00:51 PM	8/17/2023 10:00:15 AM	8/17/2023 10:00 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 1:25:47 PM	9/6/2022 12:00:51 PM	9/6/2022 12:00 PM
Details	Last Recertification Date	Update	Recertification	9/1/2020 3:43:48 PM	8/17/2021 1:25:47 PM	8/17/2021 1:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1831151455 (VT)		4/6/2021 4:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831461086	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/1/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151455	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	9/1/2020 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		MA	9/1/2020 3:43 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:00:24 PM	9/1/2020 3:43:48 PM	9/1/2020 3:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3086060 (NH)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	OP20165 (RI)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	15429000 (ME)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220163 (VT)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1689760092 (VT)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03113637 (NY)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03113628 (NY)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124 (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003107267 (CT)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	UMA0163N (AL)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	911182 (AZ)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (CA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	96873779 (CO)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (DE)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	090638700 (FL)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000953829X (GA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	806194900 (ID)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	043358564002 (IL)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200814600A (IN)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (IA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200675680A (KS)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (ME)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1689760092 (ME)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	337219700 (MD)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (MI)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	044920200 (MN)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100508057 (NV)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	6113508 (NJ)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (NC)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0300721 (OH)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500683133 (OR)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1011835340001 (PA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11752B (SC)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220163 (TN)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0103998743 (VA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2009655 (WA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124K (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124F (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124J (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124P (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124S (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124U (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124Y (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124X (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124V (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124W (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124A (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124N (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124O (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124T (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124Z (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110093140B (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110093140A (MA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	8047967 (CT)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0102580 (WA)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151455 (NY)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2200163 (NC)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110022124O (CT)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	756785502 (MD)		1/9/2020 8:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	220163 (NC)		1/9/2020 8:20 AM
Details	Last Recertification Date	Update	Recertification		8/20/2019 12:00:24 PM	8/20/2019 12:00 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03113637 (NY)		6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124K	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124F	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124J	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124P	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124S	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124U	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124Y	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124X	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124V	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124W	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124A	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124N	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124O	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124T	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124Z	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110093140B	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110093140A	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		8047967	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0102580	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2200163	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110022124O	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		756785502	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		220163	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	6/15/2019 8:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		UMA0163N	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		911182	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		96873779	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		090638700	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000953829X	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		806194900	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		043358564002	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200814600A	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200675680A	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1689760092	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		337219700	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		044920200	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100508057	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		6113508	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1831151455	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0300721	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500683133	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1011835340001	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11752B	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0220163	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0103998743	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2009655	5/31/2019 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	5/31/2019 10:51 AM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Shakman, Alice Vice President Operations UMass Memorial Medical Center 7744430540	2/15/2019 3:05 PM
Details	340B ID	Update	New Registration		DSH220163DB	2/15/2019 3:05 PM
Details	Entity Subname	Update	New Registration	Memorial Campus South 2	Memorial Campus South 2 - Observation Status	2/15/2019 3:05 PM
Dates	Participating Approval Date	Update	New Registration		2/15/2019 3:05:18 PM	2/15/2019 3:05 PM
Details	State	Update	New Registration	Pending	Approved	2/15/2019 3:05 PM
Dates	Signed By Date	Update	New Registration		2/1/2019 11:03:29 AM	2/15/2019 3:05 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	2/15/2019 3:05 PM
Addresses	Main Address	Insert	New Registration		119 Belmont Street Worcester, MA 01605	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03113637	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3086060	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NH	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		OP20165	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		15429000	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0220163	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1689760092	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03113637	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03113628	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110022124	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003107267	1/15/2019 3:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	1/15/2019 3:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831151455	1/15/2019 3:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1689760092	1/15/2019 3:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891864039	1/15/2019 3:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831461086	1/15/2019 3:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1669630950	1/15/2019 3:39 PM
Contacts	Primary Contact	Insert	New Registration		Desai, Meetali 340B Compliance Specialist UMass Memorial Medical Center 7744432852	1/15/2019 3:39 PM
Contacts	Authorizing Official	Insert	New Registration		Shakman, Alice Vice President Operations UMass Memorial Medical Center 7744430540	1/15/2019 3:39 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2019 3:39 PM
Details	Grant Number	Insert	New Registration			1/15/2019 3:39 PM
Details	340B ID	Insert	New Registration			1/15/2019 3:39 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2019 3:39 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2019 3:39 PM
Details	Medicare Provider Number	Insert	New Registration		220163	1/15/2019 3:39 PM
Details	Entity Name	Insert	New Registration		UMASS MEMORIAL MEDICAL CENTER	1/15/2019 3:39 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2019 3:39 PM
Details	Entity Subname	Insert	New Registration		Memorial Campus South 2	1/15/2019 3:39 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2019 3:39 PM
Details	State	Insert	New Registration		Pending	1/15/2019 3:39 PM
Dates	Registration Date	Insert	New Registration		1/15/2019 3:39:11 PM	1/15/2019 3:39 PM
Dates	Signed By Date	Insert	New Registration			1/15/2019 3:39 PM
Dates	Start Date	Insert	New Registration			1/15/2019 3:39 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2019 3:39 PM
Terminations	Termination Date	Insert	New Registration			1/15/2019 3:39 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2019 3:39 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2019 3:39 PM