Covered Entity Details

DSH190064AW OUR LADY OF THE LAKE (Active) - information as of 5/26/2025 12:58:28 AM

Main Details

Name

OUR LADY OF THE LAKE

Subdivision Name

OLOL STE - SLEEP LAB - SLEEP LAB

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190064AW

Medicare Provider Number

190064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/24/2019

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

FMOLHS
Jennifer Clowers, Chief Financial Officer
(225) 765-8550

Primary Contact

OUR LADY OF THE LAKE REGIONAL MED CTR
Thomas Greene, Senior Director of Pharmacy, Baton Rouge Market
(225) 765-8786

Addresses

Street Address

1125 W Highway 30
Gonzales, LA 70737-5004

Billing Address

FMOLHS Accounts Payable
P.O. Box 83880
Baton Rouge, LA 70884

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
LA	1720160,2202375,2205641,2207041	1740847771,1831605062,1215365341,1366436123

Shipping Addresses

Shipping Address 1

Our Lady of the Lake St Elizabeth
1125 W Highway 30
Gonzales, LA 70737-5004

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
DSH190064AA	Child	DSH	OUR LADY OF THE LAKE	OLOL Voice Center	4950 Essen Lane	Baton Rouge	LA	Active
DSH190064AB	Child	DSH	OUR LADY OF THE LAKE	OLOL Head and Neck Center	4950 Essen Lane	Baton Rouge	LA	Active
DSH190064AC	Child	DSH	OUR LADY OF THE LAKE	OLOL Hearing and Balance Center	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064AD	Child	DSH	OUR LADY OF THE LAKE	Lake Imaging Center	7135 Perkins Rd	Baton Rouge	LA	Active
DSH190064AE	Child	DSH	OUR LADY OF THE LAKE	Pediatric Physical Medicine Clinic	8415 Goodwood Blvd	Baton Rouge	LA	Active
DSH190064AF	Child	DSH	OUR LADY OF THE LAKE	OLOL Sleep Center	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064AG	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Livingston	5000 O'Donavan Blvd	Walker	LA	Active
DSH190064AH	Child	DSH	OUR LADY OF THE LAKE	LSU Health Imaging PSC / Imaging	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064AJ	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	Lake Main Campus-Advanced Imaging	4950 ESSEN LANE	BATON ROUGE	LA	Terminated
DSH190064AK	Child	DSH	OUR LADY OF THE LAKE	OUR LADY OF THE LAKE RHEUM SERVICES - Rheumatology	7777 HENNESSEY BLVD	BATON ROUGE	LA	Active
DSH190064AL	Child	DSH	OUR LADY OF THE LAKE	OUR LADY OF THE LAKE WOUND AND HYPE - Wound Care	7301 HENNESSY BLVD	BATON ROUGE	LA	Active
DSH190064AM	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Urology Surgery	7777 Hennessy	Baton Rouge	LA	Active
DSH190064AN	Child	DSH	OUR LADY OF THE LAKE	North ER - Emergency - Emergency Services	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064AP	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	OUR LADY OF THE LAKE INFUSION CENTE - Oncology	500 RUE DE LA VIE	BATON ROUGE	LA	Terminated
DSH190064AQ	Child	DSH	OUR LADY OF THE LAKE	LSU - Midcity Urgent Care - Urgent Care	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064AR	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - NEUROLOGY - NEUROLOGY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AS	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SURGERY - ASC - SURGERY	1014 Saint Clair Blvd	Gonzales	LA	Active
DSH190064AT	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - EMERGENCY ROOM - EMERGENCY SERVICES	1125 W Highway 30	Gonzales	LA	Active
DSH190064AU	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SURGERY - MAIN - SURGERY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AV	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - PHYSICAL MEDICINE - PHYSICAL MEDICINE	1125 W Highway 30	Gonzales	LA	Active
DSH190064AW	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SLEEP LAB - SLEEP LAB	1125 W Highway 30	Gonzales	LA	Active
DSH190064AX	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - RADIOLOGY - IMAGING	1125 W Highway 30	Gonzales	LA	Active
DSH190064AY	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - RESPIRATORY CARE - RESPIRATORY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AZ	Child	DSH	OUR LADY OF THE LAKE	Observation -OLOL STE - ICU - INTENSIVE CARE	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064B	Child	DSH	OUR LADY OF THE LAKE	Family Practice Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064BA	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - WOUND CARE - WOUND CARE	1125 W Highway 30	Gonzales	LA	Active
DSH190064BB	Child	DSH	OUR LADY OF THE LAKE	Observation - OLOL STE - MEDICINE - MEDICINE	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BC	Child	DSH	OUR LADY OF THE LAKE	Observation - OLOL STE - TELEMETRY - TELEMETRY	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BD	Child	DSH	OUR LADY OF THE LAKE	Observation-OLOL STE - SURGERY UNIT - SURGERY	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BE	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - ENDOSCOPY - ENDOSCOPY	1125 W Highway 30	Gonzales	LA	Active
DSH190064BF	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Emergency Department - Emergency Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BG	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Hematology/Oncology - Hematology & Oncology	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BH	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Physical Therapy - Physical Medicine	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BJ	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - OR MAIN - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BK	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Surgical - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BL	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	Lake Children's Hospital - Dialysis - Dialysis	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BM	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Wound Care - Wound Care	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BN	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Radiology - Imaging Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BP	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - PACU - Recovery Room	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BQ	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Preop - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BR	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEPHROLOGY - Pediatric Nephrology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BS	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S PULMONARY - Pediatric Pulmonary	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BT	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ORTHOPEDIC - Pediatric Orthopedic	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BU	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ADOLESCENT MEDICINE - Pediatric Adolescent Medicine	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BV	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ALLERGY&IMMUNOLOGY - Pediatric Allergy & Immunology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BW	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEUROSURGERY - Pediatric Neurosurgery	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BX	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S INFECTIOUS DISEASE - Pediatric Infectious Disease	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BY	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ENDOCRINOLOGY - Pediatric Endocrinology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BZ	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S GASTROENTEROLOGY - Pediatric Gastroenterology	8200 Constantin Blvd	Baton Rouge	LA	Active
DSH190064C	Child	DSH	OUR LADY OF THE LAKE	Early Interven HIV Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064CA	Child	DSH	OUR LADY OF THE LAKE	LSU North Baton Rouge Imaging - Imaging Services	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064CB	Child	DSH	OUR LADY OF THE LAKE	OLOL Livingston Imaging - Imaging Services	5000 O'Donovan Blvd	Walker	LA	Active
DSH190064CC	Child	DSH	OUR LADY OF THE LAKE	OLOL Livingston Cardiac Imaging - Imaging Services	5000 O'Donovan Blvd	Walker	LA	Active
DSH190064CD	Child	DSH	OUR LADY OF THE LAKE	LSU Health Baton Rouge MidCity Clinic Imaging Services	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064CE	Child	DSH	OUR LADY OF THE LAKE	OLOL Ascension Heart Vascular Ctr - Cath Lab	1125 W Highway 30	Gonzales	LA	Active
DSH190064CF	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ENT - Ear, Nose, and Throat	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064CG	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Advanced Diagnostics - Imaging	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064CH	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEUROLOGY - Pediatric Neurology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064CJ	Child	DSH	OUR LADY OF THE LAKE	St Elizabeth Infusion	2647 St Elizabeth Blvd	Gonzales	LA	Active
DSH190064CK	Child	DSH	OUR LADY OF THE LAKE	Lake Main Campus-OP Diabetes Management - Diabetes	2041 Silverside Dr	Baton Rouge	LA	Approved
DSH190064CL	Child	DSH	OUR LADY OF THE LAKE	Lake Childrens Hospital-Respiratory - Respiratory	8300 Constantin Blvd	Baton Rouge	LA	Approved
DSH190064CM	Child	DSH	OUR LADY OF THE LAKE	LSU Mid City Location-Diabetes and Nutrition - Nutrition	1401 N Foster Dr	Baton Rouge	LA	Approved
DSH190064D	Child	DSH	OUR LADY OF THE LAKE	Diab Ft & Wound Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064E	Child	DSH	OUR LADY OF THE LAKE	Dermatology Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064F	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Adult Ophthalmology	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064G	Child	DSH	OUR LADY OF THE LAKE	LSU North-Oral Surgery Clinic	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064H	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Adult Orthopedic Surgery	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064J	Child	DSH	OUR LADY OF THE LAKE	Infusion North BR Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064K	Child	DSH	OUR LADY OF THE LAKE	Oncology North BR Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064L	Child	DSH	OUR LADY OF THE LAKE	North BR Clinic Primary Care	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064M	Child	DSH	OUR LADY OF THE LAKE	LSU North-Urgent Care Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064N	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Endoscopy	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064P	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Operating Room	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064Q	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-PACU	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064R	Child	DSH	OUR LADY OF THE LAKE	Medicine OLOL MOB IV Clinic	5131 O'Donovan Drive	Baton Rouge	LA	Active
DSH190064S	Child	DSH	OUR LADY OF THE LAKE	Medicine Subspecialty OLOL MOB IV Clinic	5131 O'Donovan Drive	Baton Rouge	LA	Active
DSH190064T	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	South BR Clinic	950 E Washington	Baton Rouge	LA	Terminated
DSH190064U	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	LSU Perkins-Pre Admit	9032 Perkins Road	Baton Rouge	LA	Terminated
DSH190064V	Child	DSH	OUR LADY OF THE LAKE	Louisiana Cardiology Associates Imaging	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064W	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	Our Lady of the Lake Outpatient Infusion at Picardy	8119 Picardy Avenue	Baton Rouge	LA	Terminated
DSH190064X	Child	DSH	OUR LADY OF THE LAKE	St. Jude Baton Rouge Affiliate Clinic	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064Y	Child	DSH	OUR LADY OF THE LAKE	Lake Main Campus-Infusion	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064Z	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	Franciscan Clinic	7777 Hennessy Blvd	Baton Rouge	LA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Group Change Request		Our Lady of the Lake St Elizabeth 1125 W Highway 30 Gonzales, LA 70737-5004	4/4/2025 9:14 AM
Details	Last Recertification Date	Update	Recertification	9/2/2023 12:02:48 PM	8/15/2024 2:34:53 PM	8/15/2024 2:34 PM
Details	Entity Name	Update	Change Request	OUR LADY OF THE LAKE REGIONAL MED CTR	OUR LADY OF THE LAKE	2/5/2024 7:57 AM
Contacts	Primary Contact	Update	Profile Change Request	Greene, Thomas Director of Integrated Pharmacy Operations OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	Greene, Thomas Senior Director of Pharmacy, Baton Rouge Market OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	10/12/2023 3:42 PM
Details	Entity Name	Update	Change Request	OUR LADY OF THE LAKE HOSPITAL, INC.	OUR LADY OF THE LAKE REGIONAL MED CTR	9/11/2023 1:37 PM
Contacts	Primary Contact	Update	PC Change Request	Mellor, Britney Ross Senior Director of Pharmacy Our Lady of the Lake Regional Medical Center 2257653067	Greene, Thomas Director of Integrated Pharmacy Operations OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	9/5/2023 7:16 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 1:17:16 PM	9/2/2023 12:02:48 PM	9/2/2023 12:02 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 12:41:18 PM	8/25/2022 1:17:16 PM	8/25/2022 1:17 PM
Contacts	Authorizing Official	Update	Change Request	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	Clowers, Jennifer Chief Financial Officer FMOLHS 2257658550	8/11/2022 3:55 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1938589 (LA)		12/15/2021 4:10 PM
Addresses	Billing Address	Update	Group Change Request	Our Lady of the Lake REG MED CTR ATTN PHARMACY PO Box 83880 Baton Rouge, LA 70884-3880	FMOLHS Accounts Payable P.O. Box 83880 Baton Rouge, LA 70884	12/8/2021 9:36 AM
Details	Last Recertification Date	Update	Recertification	9/13/2020 5:18:11 PM	8/25/2021 12:41:18 PM	8/25/2021 12:41 PM
Addresses	Billing Address	Insert	Change Request		Our Lady of the Lake REG MED CTR ATTN PHARMACY PO Box 83880 Baton Rouge, LA 70884-3880	7/7/2021 8:55 AM
Contacts	Primary Contact	Update	Change Request	Mohundro, Michael Marlan Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	Mellor, Britney Ross Senior Director of Pharmacy Our Lady of the Lake Regional Medical Center 2257653067	5/25/2021 12:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (AL)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (CA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (DE)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (ID)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (ME)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MI)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MN)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MO)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (NV)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (VA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (WI)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1005587 (AK)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	127947105 (AR)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	68957 (AZ)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95015574 (CO)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	8087863 (CT)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	8050061 (CT)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	46047631 (DC)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	96632100 (FL)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000393181X (GA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	579664 (IA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	720423651001 (IL)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300018975 (IN)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200270200A (KS)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1370287 (KY)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110128871B (MA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110128871A (MA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	616017400 (MD)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	20433 (MS)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	427737 (MT)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1900064 (NC)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10026685900 (NE)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	666823 (NJ)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	51051737 (NM)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1461150 (NY)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	440437 (OH)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200036510A (OK)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500613214 (OR)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1019706740001 (PA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10738B (SC)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	190064 (TN)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	107816401 (TX)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1010764 (UT)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	6703509 (VT)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2037942 (WA)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3810009186 (WV)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AL)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (DE)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (ID)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (ME)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MI)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MN)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MO)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NV)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (VA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WI)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AK)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AR)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AZ)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CO)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CT)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (DC)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (FL)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (GA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IL)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IN)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (KS)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (KY)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MD)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MS)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MT)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NC)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NE)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NJ)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NM)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NY)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OH)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OK)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OR)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (PA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (SC)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (TN)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (TX)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (UT)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (VT)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WA)		3/21/2021 3:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WV)		3/21/2021 3:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1938589	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2207041	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NV	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1005587	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		127947105	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AR	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		68957	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		95015574	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		8087863	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		8050061	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		46047631	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		96632100	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000393181X	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		579664	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		720423651001	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300018975	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200270200A	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KS	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1370287	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110128871B	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110128871A	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		616017400	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		20433	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		427737	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1900064	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10026685900	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NE	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		666823	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		51051737	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1461150	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		440437	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200036510A	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500613214	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1019706740001	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10738B	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		190064	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		107816401	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1010764	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		6703509	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2037942	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810009186	9/13/2020 5:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1366436123 ( )		9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1215365341 ( )		9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1831605062 ( )		9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1740847771	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831605062	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1215365341	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/13/2020 5:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/13/2020 5:18 PM
Details	Last Recertification Date	Update	Recertification	9/16/2019 4:54:40 PM	9/13/2020 5:18:11 PM	9/13/2020 5:18 PM
Contacts	Authorizing Official	Update	AO Change Request	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550-2259077045	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	4/22/2020 1:40 PM
Details	Last Recertification Date	Update	Recertification		9/16/2019 4:54:40 PM	9/16/2019 4:54 PM
Contacts	Authorizing Official	Update	New Registration	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550-2259077045	7/15/2019 5:01 PM
Contacts	Signed By	Update	New Registration	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550-2259077045	7/15/2019 5:01 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	5/24/2019 9:51 AM
Details	340B ID	Update	New Registration		DSH190064AW	5/24/2019 9:51 AM
Details	Entity Subname	Update	New Registration	OLOL STE - SLEEP LAB	OLOL STE - SLEEP LAB - SLEEP LAB	5/24/2019 9:51 AM
Dates	Participating Approval Date	Update	New Registration		5/24/2019 9:51:15 AM	5/24/2019 9:51 AM
Details	State	Update	New Registration	Pending	Approved	5/24/2019 9:51 AM
Dates	Signed By Date	Update	New Registration		4/12/2019 4:36:19 PM	5/24/2019 9:51 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	5/24/2019 9:51 AM
Addresses	Main Address	Insert	New Registration		1125 W Highway 30 Gonzales, LA 70737-5004	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1720160	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2202375	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2205641	4/12/2019 4:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/12/2019 4:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366436123	4/12/2019 4:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1215365341	4/12/2019 4:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831605062	4/12/2019 4:36 PM
Contacts	Primary Contact	Insert	New Registration		Mohundro, Michael Marlan Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	4/12/2019 4:36 PM
Contacts	Authorizing Official	Insert	New Registration		Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	4/12/2019 4:36 PM
Details	Last Recertification Date	Insert	New Registration			4/12/2019 4:36 PM
Details	Grant Number	Insert	New Registration			4/12/2019 4:36 PM
Details	340B ID	Insert	New Registration			4/12/2019 4:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2019 4:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2019 4:36 PM
Details	Medicare Provider Number	Insert	New Registration		190064	4/12/2019 4:36 PM
Details	Entity Name	Insert	New Registration		OUR LADY OF THE LAKE HOSPITAL, INC.	4/12/2019 4:36 PM
Details	Program Code	Insert	New Registration		DSH	4/12/2019 4:36 PM
Details	Entity Subname	Insert	New Registration		OLOL STE - SLEEP LAB	4/12/2019 4:36 PM
Dates	Participating Approval Date	Insert	New Registration			4/12/2019 4:36 PM
Details	State	Insert	New Registration		Pending	4/12/2019 4:36 PM
Dates	Registration Date	Insert	New Registration		4/12/2019 4:36:17 PM	4/12/2019 4:36 PM
Dates	Signed By Date	Insert	New Registration			4/12/2019 4:36 PM
Dates	Start Date	Insert	New Registration			4/12/2019 4:36 PM
Terminations	Termination Comments	Insert	New Registration			4/12/2019 4:36 PM
Terminations	Termination Date	Insert	New Registration			4/12/2019 4:36 PM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2019 4:36 PM
Terminations	Termination Reason	Insert	New Registration			4/12/2019 4:36 PM