| Details | Last Recertification Date | Update | Recertification | | 8/20/2024 9:41:03 AM | 8/20/2024 9:41 AM |
| Details | State | Update | | Approved | Active | 4/1/2024 12:01 AM |
| Addresses | Billing Address | Insert | Reinstatement | | Munson Healthcare Grayling Hospital
PO Box 669
Traverse City, MI 49685-0669 | 2/6/2024 9:32 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Reinstatement | | False | 2/6/2024 9:32 AM |
| Medicaid Billing | Medicaid: Number | Insert | Reinstatement | | 1083010953 | 2/6/2024 9:32 AM |
| Medicaid Billing | Medicaid: State | Insert | Reinstatement | | MI | 2/6/2024 9:32 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1083010953 | 2/6/2024 9:32 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | MI | 2/6/2024 9:32 AM |
| Contacts | Authorizing Official | Update | Reinstatement | Maitland, Alicia
CFO
Munson Healthcare
2319357840 | LaRaia, Kathleen M
Vice President
Munson Healthcare
2313928410 | 2/6/2024 9:32 AM |
| Contacts | Signed By | Update | Reinstatement | Hepler, Mark
CFO
Munson Healthcare
2319356702 | LaRaia, Kathleen M
Vice President
Munson Healthcare
2313928410 | 2/6/2024 9:32 AM |
| Details | Last Recertification Date | Update | Reinstatement | 8/19/2021 10:27:08 AM | | 2/6/2024 9:32 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 4/1/2022 12:00:00 AM | | 2/6/2024 9:32 AM |
| Details | Entity Name | Update | Reinstatement | Munson Healthcare Grayling Hospital | MUNSON HEALTHCARE GRAYLING HOSPITAL | 2/6/2024 9:32 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 8/14/2019 10:11:06 AM | 2/6/2024 9:32:08 AM | 2/6/2024 9:32 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 2/6/2024 9:32 AM |
| Dates | Registration Date | Update | Reinstatement | 7/9/2019 12:55:40 PM | 1/12/2024 10:23:37 AM | 2/6/2024 9:32 AM |
| Dates | Signed By Date | Update | Reinstatement | 7/10/2019 10:20:51 AM | 1/12/2024 3:38:18 PM | 2/6/2024 9:32 AM |
| Dates | Start Date | Update | Reinstatement | 10/1/2019 12:00:00 AM | 4/1/2024 12:00:00 AM | 2/6/2024 9:32 AM |
| Terminations | Termination Date | Update | Reinstatement | 4/1/2022 12:00:00 AM | | 2/6/2024 9:32 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 4/1/2022 12:00:00 AM | | 2/6/2024 9:32 AM |
| Terminations | Termination Reason | Update | Reinstatement | Change of covered entity type | | 2/6/2024 9:32 AM |
| Details | Comments Public | Insert | Reinstatement | | Participating Start Date 10/1/2019, Termination date 4/1/2022, Reinstatement 4/1/2024 | 2/5/2024 12:32 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Niemi, Sam Patrick
Manager Reimbursement
Munson Healthcare
2319357761 | Niemi, Sam Patrick
System Director Reimbursement
Munson Healthcare
2319357761 | 5/2/2022 12:31 PM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2022 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 2/22/2022 8:18 AM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 2/22/2022 8:18 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 2/22/2022 8:18 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 2/22/2022 8:18 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 2/22/2022 8:18 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2020 12:13:06 PM | 8/19/2021 10:27:08 AM | 8/19/2021 10:27 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Hepler, Mark
CFO
Munson Healthcare
2319356702 | Maitland, Alicia
CFO
Munson Healthcare
2319357840 | 6/23/2021 9:47 AM |
| Contacts | Primary Contact | Update | Change Request | Leach, Steve
Regional Director, Reimbursement
Munson Healthcare
2319357797 | Niemi, Sam Patrick
Manager Reimbursement
Munson Healthcare
2319357761 | 10/13/2020 11:57 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/26/2020 12:13:06 PM | 8/26/2020 12:13 PM |
| Details | State | Update | | Approved | Active | 10/1/2019 12:04 AM |
| Contacts | Signed By | Insert | New Registration | | Hepler, Mark
CFO
Munson Healthcare
2319356702 | 8/14/2019 10:11 AM |
| Details | 340B ID | Update | New Registration | | SCH230058-10 | 8/14/2019 10:11 AM |
| Details | Entity Name | Update | New Registration | MUNSON HEALTHCARE GRAYLING HOSPITAL | Munson Healthcare Grayling Hospital | 8/14/2019 10:11 AM |
| Details | Entity Subname | Update | New Registration | Grayling Community Health Center | Grayling Community Health Center - Walk In Clinic | 8/14/2019 10:11 AM |
| Dates | Participating Approval Date | Update | New Registration | | 8/14/2019 10:11:06 AM | 8/14/2019 10:11 AM |
| Details | State | Update | New Registration | Pending | Approved | 8/14/2019 10:11 AM |
| Dates | Signed By Date | Update | New Registration | | 7/10/2019 10:20:51 AM | 8/14/2019 10:11 AM |
| Dates | Start Date | Update | New Registration | | 10/1/2019 12:00:00 AM | 8/14/2019 10:11 AM |
| Addresses | Main Address | Insert | New Registration | |
1250 E. Michigan Avenue
Grayling
Grayling, MI 49738 | 7/9/2019 12:55 PM |
| Addresses | Billing Address | Insert | New Registration | | Munson Healthcare Grayling Hospital
PO Box 669
Traverse City, MI 49685-0669 | 7/9/2019 12:55 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Hepler, Mark
CFO
Munson Healthcare
2319356702 | 7/9/2019 12:55 PM |
| Contacts | Primary Contact | Insert | New Registration | | Leach, Steve
Regional Director, Reimbursement
Munson Healthcare
2319357797 | 7/9/2019 12:55 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Details | Grant Number | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Details | 340B ID | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 230058 | 7/9/2019 12:55 PM |
| Details | Entity Name | Insert | New Registration | | MUNSON HEALTHCARE GRAYLING HOSPITAL | 7/9/2019 12:55 PM |
| Details | Program Code | Insert | New Registration | | SCH | 7/9/2019 12:55 PM |
| Details | Entity Subname | Insert | New Registration | | Grayling Community Health Center | 7/9/2019 12:55 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Details | State | Insert | New Registration | | Pending | 7/9/2019 12:55 PM |
| Dates | Registration Date | Insert | New Registration | | 7/9/2019 12:55:40 PM | 7/9/2019 12:55 PM |
| Dates | Signed By Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Dates | Start Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Terminations | Termination Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 7/9/2019 12:55 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 7/9/2019 12:55 PM |