Covered Entity Details

PED053301-41 CHILDRENS HOSP & RES CNTR OAKLAND (Active) - information as of 6/19/2025 11:51:23 PM

Main Details

Name

CHILDRENS HOSP & RES CNTR OAKLAND

Subdivision Name

UCSF Benioff Childrens Hospital Walnut Creek - Plastic Surgery/Satellite

Type

Children's Hospital

Rural

340B ID

PED053301-41

Medicare Provider Number

053301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/3/2019

Participating Start Date

10/1/2019

Participating Approval Date

9/4/2019

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

UCSF Medical Center & Benioff Children's Hospital
James Wentz, SVP & CFO
(415) 514-6118

Primary Contact

UCSF Health
Kayla Hubbard, 340B Program Coordinator
(808) 339-5697

Addresses

Street Address

2401 Shadelands Dr.
Walnut Creek, CA 94598-2412

Billing Address

UCSF Benioff Childrens Hospital Oakland
747 52nd Street
Oakland, CA 94609

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
CA	HSP40611F,HSC00611F,ZZR00611F	1003961251

Shipping Addresses

Shipping Address 1

UCSF Benioff Childrens Hospital Oakland
747 52nd Street
Oakland, CA 94609

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
PED053301-01	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Urology Satellite	2401 Shadelands Dr.	Walnut Creek	CA	Active
PED053301-02	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Nephrology Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-03	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - ENT Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-04	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Gastroentrology Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-05	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Cardiology Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-06	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Orthopedic Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-07	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Endocrinology Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-08	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Neurology Satellite	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-09	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Orthopedics	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-10	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Gastroenterology	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-100	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Sports Medicine	2401 SHADELANDS DR 110	WALNUT CREEK	CA	Active
PED053301-101	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Fluoroscopy	2401 SHADELANDS DR STE 180C	WALNUT CREEK	CA	Active
PED053301-102	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Audiology	744 52ND ST	OAKLAND	CA	Active
PED053301-103	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital OPC - Diagnostic Imaging	744 52ND ST	OAKLAND	CA	Active
PED053301-104	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - Genetics	744 52ND ST	Oakland	CA	Active
PED053301-105	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - Sports Medicine	744 52ND ST	Oakland	CA	Active
PED053301-106	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - Physical Therapy	744 52ND ST	Oakland	CA	Active
PED053301-107	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - RETT	744 52ND ST	Oakland	CA	Active
PED053301-108	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Walnut Creek - Cardiology	2401 Shadelands Dr., Ste. 180C	Walnut Creek	CA	Active
PED053301-109	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC- Neurology	744 52ND ST	Oakland	CA	Active
PED053301-11	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - ENT	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-110	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - Speech Therapy	744 52ND ST	Oakland	CA	Active
PED053301-111	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	CHILDRENS HOSP & RES CNTR OAKLAND - UCSF Benioff Childrens Hospital Oakland OPC - Occupational Therapy	744 52ND ST	Oakland	CA	Active
PED053301-12	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Endocrinology	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-13	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - General Surgery	2303 Camino Ramon Bldg D	San Ramon	CA	Active
PED053301-14	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Pedi-Pulmonary	2303 Camino Ramon Bldg D	San Ramon	CA	Terminated
PED053301-15	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Dermatology Med Genetics	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-16	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Gastroenterology Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-17	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - ENT Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-18	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Dermatology	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-19	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Pulmonary	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-20	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Neurology/Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-21	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Psychiatry	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-22	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Plastic Surgery	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-23	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Rheumatology Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-24	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Neurology Headache	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-25	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Nephrology	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-26	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Hematology Oncology Satellite	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-27	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Psychiatry/Satellite	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-28	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Endocrinology Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-29	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Rheumatology	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-30	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - ENT	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-31	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Endocrinology	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-32	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - General Surgery Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-33	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Pedi-Pulmonary Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-34	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Neurosurgery/Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-35	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Hematology Oncology Infusion Center	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-36	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Orthopedics	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-37	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Orthopedic/Satellite	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-38	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Gastroenterology	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-39	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Urology	2401 Shadelands Dr.	Walnut Creek	CA	Terminated
PED053301-40	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Nephrology/Satellite	2401 Shadelands Dr.	Walnut Creek	CA	Active
PED053301-41	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Plastic Surgery/Satellite	2401 Shadelands Dr.	Walnut Creek	CA	Active
PED053301-42	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Claremont Ave - Ophthalmology	5275 Claremont Ave	Oakland	CA	Active
PED053301-43	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - General Surgery	744 52nd St	Oakland	CA	Active
PED053301-44	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Plastic Surgery	744 52nd St	Oakland	CA	Active
PED053301-45	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - General Surgery PACU	744 52nd St	Oakland	CA	Terminated
PED053301-46	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Tuberculosis Sclerosis	744 52nd St	Oakland	CA	Terminated
PED053301-47	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Endocrinology	744 52nd Street	Oakland	CA	Active
PED053301-48	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Synagis Clinic	744 52nd Street	Oakland	CA	Active
PED053301-49	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Rheumatology	744 52nd Street	Oakland	CA	Active
PED053301-50	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Preop	744 52nd Street	Oakland	CA	Terminated
PED053301-51	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Neurosurgery	744 52nd Street	Oakland	CA	Active
PED053301-52	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Gastroenterology	744 52nd Street	Oakland	CA	Active
PED053301-53	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Cardiology/Pulmonary Clinic	744 52nd Street	Oakland	CA	Active
PED053301-54	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Orthopedics	744 52nd Street	Oakland	CA	Active
PED053301-55	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Plastic Surgery/Ortho	744 52nd Street	Oakland	CA	Terminated
PED053301-56	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Oncology GI	747 52nd Street	Oakland	CA	Terminated
PED053301-57	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Mental Health - Psychiatry	770 53rd St	Oakland	CA	Active
PED053301-58	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Mental Health - Psychological Services	770 53rd St	Oakland	CA	Terminated
PED053301-59	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Pedi-Pulmonary	744 52nd Street	Oakland	CA	Active
PED053301-60	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - IntraOp	744 52nd Street	Oakland	CA	Terminated
PED053301-61	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Day Hospital	744 52nd Street	Oakland	CA	Active
PED053301-62	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Neuro Oncology	744 52nd Street	Oakland	CA	Active
PED053301-63	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Dermatology/Med Genetics	744 52nd Street	Oakland	CA	Terminated
PED053301-64	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland Brentwood - Neurology Satellite	1181 Central Blvd	Brentwood	CA	Active
PED053301-65	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Infectious Disease	744 52nd Street	Oakland	CA	Active
PED053301-66	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - General Hematology	744 52nd Street	Oakland	CA	Active
PED053301-67	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Ped CLI Research	744 52nd Street	Oakland	CA	Terminated
PED053301-68	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - ENT	744 52nd Street	Oakland	CA	Active
PED053301-69	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland Marin - Cardiology Satellite	1100 Larkspur Landing Cir STE 150	Larkspur	CA	Terminated
PED053301-70	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Oncology	744 52nd Street	Oakland	CA	Active
PED053301-71	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Thalassemia	744 52nd Street	Oakland	CA	Active
PED053301-72	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland Brentwood - Gastroenterology	1181 Central Blvd	Brentwood	CA	Terminated
PED053301-73	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - BMT Psych	744 52nd Street	Oakland	CA	Terminated
PED053301-74	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Bone Marrow Transplant	744 52nd Street	Oakland	CA	Active
PED053301-75	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Dermatology	744 52nd Street	Oakland	CA	Active
PED053301-76	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Nephrology	744 52nd Street	Oakland	CA	Active
PED053301-77	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Urology	744 52nd Street	Oakland	CA	Active
PED053301-78	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland Brentwood - Gastroenterology Satellite	1181 Central Blvd	Brentwood	CA	Active
PED053301-79	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Hemophilia	744 52nd Street	Oakland	CA	Active
PED053301-80	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Pulmonary Function	744 52nd Street	Oakland	CA	Active
PED053301-81	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Peds Sickle Cell	744 52nd Street	Oakland	CA	Active
PED053301-82	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - CDC Neonatal F/U	744 52nd Street	Oakland	CA	Active
PED053301-83	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland Brentwood - General Surgery	1181 Central Blvd	Brentwood	CA	Active
PED053301-84	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Children's Hospital Oakland - OPC - Pedi Rehab	744 52nd Street	Oakland	CA	Active
PED053301-85	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Ultrasound - Ultrasound	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-86	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Audiology - Audiology	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-87	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - MRI - MRI	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-88	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Diagnostic Imaging - Diagnostic Imaging	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-89	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Preop - Preop	2401 Shadelands Dr	Walnut Creek	CA	Terminated
PED053301-90	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Perioperative - BCHO OPC Perioperative	744 52nd Street	Oakland	CA	Active
PED053301-91	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Perioperative - Walnut Creek Perioperative Services	2401 Shadelands Dr	Walnut Creek	CA	Active
PED053301-92	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Walnut Creek - Preanesthesia	2401 SHADELANDS DR 180	WALNUT CREEK	CA	Active
PED053301-93	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Allergy	744 52ND ST	Oakland	CA	Active
PED053301-94	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland - Behavior Health and Psychiatry	5275 CLAREMONT AVE	OAKLAND	CA	Active
PED053301-95	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Oakland OPC - Craniofacial	744 52ND ST	OAKLAND	CA	Active
PED053301-96	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital Brentwood - High Risk Infant	1181 Central Boulevard, Suite B	Brentwood	CA	Active
PED053301-97	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Sports Medicine	2303 CAMINO RAMON	SAN RAMON	CA	Active
PED053301-98	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital San Ramon - Speech Therapy SP Lang	2303 CAMINO RAMON	SAN RAMON	CA	Active
PED053301-99	Child	PED	CHILDRENS HOSP & RES CNTR OAKLAND	UCSF Benioff Childrens Hospital OPC - Adult Sickle Cell	744 52ND ST	OAKLAND	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Wang, Ted VP & Chief Financial Officer Children's Hospital & Research Center At Oakland 5104428030	Wentz, James SVP & CFO UCSF Medical Center & Benioff Children's Hospital 4155146118	12/17/2024 8:08 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 5:40:14 AM	8/12/2024 11:40:51 AM	8/12/2024 11:40 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1588833347 (CA)		7/1/2024 7:55 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1346530227 (CA)		7/1/2024 7:55 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1982994869 (CA)		7/1/2024 7:55 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 6:14:34 PM	8/15/2023 5:40:14 AM	8/15/2023 5:40 AM
Contacts	Authorizing Official	Update	AO Change Request	Phillips, Jamie Christine Chief Operating Officer UCSF Benioff Childrens Hospital Oakland 4153539116	Wang, Ted VP & Chief Financial Officer Children's Hospital & Research Center At Oakland 5104428030	9/9/2022 1:50 PM
Details	Last Recertification Date	Update	Recertification	9/2/2021 2:27:38 PM	8/29/2022 6:14:34 PM	8/29/2022 6:14 PM
Contacts	Primary Contact	Update	Profile Change Request	Hubbard, Kayla 340B Senior Analyst UCSF Health 8083395697	Hubbard, Kayla 340B Program Coordinator UCSF Health 8083395697	7/11/2022 2:00 PM
Contacts	Primary Contact	Update	Group Change Request	Fleming Jr., Patrick D. Director, Pharmacy Services UCSF Benioff Childrens Hospital Oakland 5104283851	Hubbard, Kayla 340B Senior Analyst UCSF Health 8083395697	6/23/2022 7:03 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 12:37:22 PM	9/2/2021 2:27:38 PM	9/2/2021 2:27 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1588833347 (CA)		7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		HSP40611F	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		HSC00611F	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		ZZR00611F	7/14/2021 4:52 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	7/14/2021 4:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1003961251	5/13/2021 5:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	5/13/2021 5:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346530227	5/13/2021 5:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	5/13/2021 5:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982994869	5/13/2021 5:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	5/13/2021 5:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1588833347 ( )		9/4/2020 12:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1588833347	9/4/2020 12:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/4/2020 12:37 PM
Details	Last Recertification Date	Update	Recertification		9/4/2020 12:37:22 PM	9/4/2020 12:37 PM
Contacts	Authorizing Official	Update	AO Change Request	Fries, Robert Chief Financial Officer UCSF Benioff Children's Hospitals 5104283469	Phillips, Jamie Christine Chief Operating Officer UCSF Benioff Childrens Hospital Oakland 4153539116	4/14/2020 1:44 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Fries, Robert Chief Financial Officer UCSF Benioff Children's Hospitals 5104283469	9/4/2019 2:53 PM
Details	340B ID	Update	New Registration		PED053301-41	9/4/2019 2:53 PM
Details	Entity Subname	Update	New Registration	UCSF Benioff Childrens Hospital Walnut Creek	UCSF Benioff Childrens Hospital Walnut Creek - Plastic Surgery/Satellite	9/4/2019 2:53 PM
Dates	Participating Approval Date	Update	New Registration		9/4/2019 2:53:30 PM	9/4/2019 2:53 PM
Details	State	Update	New Registration	Pending	Approved	9/4/2019 2:53 PM
Dates	Signed By Date	Update	New Registration		7/8/2019 11:01:09 AM	9/4/2019 2:53 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	9/4/2019 2:53 PM
Addresses	Main Address	Insert	New Registration		2401 Shadelands Dr. Walnut Creek, CA 94598-2412	7/3/2019 6:30 PM
Addresses	Billing Address	Insert	New Registration		UCSF Benioff Childrens Hospital Oakland 747 52nd Street Oakland, CA 94609	7/3/2019 6:30 PM
Addresses	Shipping Address	Insert	New Registration		UCSF Benioff Childrens Hospital Oakland 747 52nd Street Oakland, CA 94609	7/3/2019 6:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/3/2019 6:30 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1588833347	7/3/2019 6:30 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/3/2019 6:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1588833347	7/3/2019 6:30 PM
Contacts	Primary Contact	Insert	New Registration		Fleming Jr., Patrick D. Director, Pharmacy Services UCSF Benioff Childrens Hospital Oakland 5104283851	7/3/2019 6:30 PM
Contacts	Authorizing Official	Insert	New Registration		Fries, Robert Chief Financial Officer UCSF Benioff Children's Hospitals 5104283469	7/3/2019 6:30 PM
Details	Last Recertification Date	Insert	New Registration			7/3/2019 6:30 PM
Details	Grant Number	Insert	New Registration			7/3/2019 6:30 PM
Details	340B ID	Insert	New Registration			7/3/2019 6:30 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/3/2019 6:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/3/2019 6:30 PM
Details	Medicare Provider Number	Insert	New Registration		053301	7/3/2019 6:30 PM
Details	Entity Name	Insert	New Registration		CHILDRENS HOSP & RES CNTR OAKLAND	7/3/2019 6:30 PM
Details	Program Code	Insert	New Registration		PED	7/3/2019 6:30 PM
Details	Entity Subname	Insert	New Registration		UCSF Benioff Childrens Hospital Walnut Creek	7/3/2019 6:30 PM
Dates	Participating Approval Date	Insert	New Registration			7/3/2019 6:30 PM
Details	State	Insert	New Registration		Pending	7/3/2019 6:30 PM
Dates	Registration Date	Insert	New Registration		7/3/2019 6:30:12 PM	7/3/2019 6:30 PM
Dates	Signed By Date	Insert	New Registration			7/3/2019 6:30 PM
Dates	Start Date	Insert	New Registration			7/3/2019 6:30 PM
Terminations	Termination Comments	Insert	New Registration			7/3/2019 6:30 PM
Terminations	Termination Date	Insert	New Registration			7/3/2019 6:30 PM
Terminations	Termination Effective Date	Insert	New Registration			7/3/2019 6:30 PM
Terminations	Termination Reason	Insert	New Registration			7/3/2019 6:30 PM