Covered Entity Details

DSH330103E OLEAN GENERAL HOSPITAL (Active) - information as of 5/20/2025 12:49:03 AM

Main Details

Name

OLEAN GENERAL HOSPITAL

Subdivision Name

Smethport Health Center - General Medical

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330103E

Medicare Provider Number

330103

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2019

Participating Start Date

10/1/2019

Participating Approval Date

8/15/2019

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Olean General Hospital
Scott Jay Bonderoff, COO
(716) 375-6104

Primary Contact

Olean General Hospital
Victoria Nosowicz, Pharmacy Informatics & 340B Manager
(716) 375-6268

Addresses

Street Address

406 Franklin Street
Smethport, PA 16749

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
PA	1007755030028,1007755030022,1007755030023,1007755030024,1007755030025,1007755030029,1007755030038,1007507650041	1245502905,1427195445,1578569885,1801133210,1871630897
NY	00354632,03001796,03406377,03406388,02760709,03001778,03001787,03003156,03927699,04070032	1033499017,1225083074,1649296781,1700825262,1740333681,1699715904

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
DSH330103A	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Nuclear Medicine	116 Interstate Parkway	Bradford	PA	Active
DSH330103AA	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Ultrasound	116 Interstate Parkway	Bradford	PA	Active
DSH330103AB	Child	DSH	OLEAN GENERAL HOSPITAL	Salamanca Health Center - General Medical	4039 Route 219	Salamanca	NY	Active
DSH330103AC	Child	DSH	OLEAN GENERAL HOSPITAL	Holiday Park - Internal Medicine/Family	2666 West State Street	Olean	NY	Terminated
DSH330103AD	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Radiology	116 Interstate Parkway	Bradford	PA	Active
DSH330103AE	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Ambulatory Care 3N	116 Interstate Parkway	Bradford	PA	Active
DSH330103AF	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Urology	116 Interstate Parkway	Bradford	PA	Active
DSH330103AG	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - EEG	116 Interstate Parkway	Bradford	PA	Terminated
DSH330103AH	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - EKG	116 Interstate Parkway	Bradford	PA	Active
DSH330103B	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Bradford Family Practice	116 Interstate Parkway	Bradford	PA	Active
DSH330103C	Child	DSH	OLEAN GENERAL HOSPITAL	Outpatient Surgery Center - Surgery	500 Main Street	Olean	NY	Active
DSH330103D	Child	DSH	OLEAN GENERAL HOSPITAL	Urology Clinic - Urology	500 Main Street	Olean	NY	Terminated
DSH330103E	Child	DSH	OLEAN GENERAL HOSPITAL	Smethport Health Center - General Medical	406 Franklin Street	Smethport	PA	Active
DSH330103F	Child	DSH	OLEAN GENERAL HOSPITAL	Cancer Center - Oncology	528 North Barry Street	Olean	NY	Active
DSH330103G	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Pain Management	116 Interstate Parkway	Bradford	PA	Active
DSH330103H	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Psych Ambulatory	116 Interstate Parkway	Bradford	PA	Terminated
DSH330103J	Child	DSH	OLEAN GENERAL HOSPITAL	Mt. Jewett Health Center - General Medical	122 West Main Street	Mt. Jewett	PA	Terminated
DSH330103K	Child	DSH	OLEAN GENERAL HOSPITAL	Dialysis Clinic - Dialysis	623 Main Street	Olean	NY	Active
DSH330103L	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - ER	116 Interstate Parkway	Bradford	PA	Active
DSH330103M	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Respiratory Therapy	116 Interstate Parkway	Bradford	PA	Active
DSH330103N	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - CT	116 Interstate Parkway	Bradford	PA	Active
DSH330103P	Child	DSH	OLEAN GENERAL HOSPITAL	Delevan Health Center - Family Practice	38 North Main Street	Delevan	NY	Active
DSH330103Q	Child	DSH	OLEAN GENERAL HOSPITAL	Holiday Park - Pediatrics	2666 West State Street	Olean	NY	ToBeTerminated
DSH330103R	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Obstetrics Clinic	116 Interstate Parkway	Bradford	PA	Terminated
DSH330103S	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - MRI	116 Interstate Parkway	Bradford	PA	Active
DSH330103T	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Sameday Surgery	116 Interstate Parkway	Bradford	PA	Terminated
DSH330103U	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Chemotherapy	116 Interstate Parkway	Bradford	PA	Active
DSH330103V	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Operation Room	116 Interstate Parkway	Bradford	PA	Terminated
DSH330103W	Child	DSH	OLEAN GENERAL HOSPITAL	Wound Clinic - Wound	623 Main Street	Olean	NY	Active
DSH330103X	Child	DSH	OLEAN GENERAL HOSPITAL	Holiday Park - General Surgery	2666 West State Street	Olean	NY	ToBeTerminated
DSH330103Y	Child	DSH	OLEAN GENERAL HOSPITAL	Women's Health Center - OB/GYN	159 Interstate Parkway	Bradford	PA	Terminated
DSH330103Z	Child	DSH	OLEAN GENERAL HOSPITAL	DBA: Bradford Regional Medical Center - Pediatric Clinic	116 Interstate Parkway	Bradford	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 8:20:27 AM	9/5/2024 9:09:30 AM	9/5/2024 9:09 AM
Details	Last Recertification Date	Update	Recertification	9/21/2022 2:07:58 PM	8/16/2023 8:20:27 AM	8/16/2023 8:20 AM
Contacts	Authorizing Official	Update	AO Change Request	DiBacco, David J COO Olean General Hospital 7163756104	Bonderoff, Scott Jay COO Olean General Hospital 7163756104	11/15/2022 7:14 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 3:42:07 PM	9/21/2022 2:07:58 PM	9/21/2022 2:07 PM
Contacts	Authorizing Official	Update	AO Change Request	Braun Jr., Richard G. SVP Finance and CFO Bradford Regional Medical Center 7163756190	DiBacco, David J COO Olean General Hospital 7163756104	7/8/2022 6:51 AM
Details	Last Recertification Date	Update	Recertification	9/14/2020 6:09:56 AM	8/23/2021 3:42:07 PM	8/23/2021 3:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		02760709	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001778	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001787	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03003156	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03927699	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04070032	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007507650041	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/28/2021 7:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1699715904	6/28/2021 7:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/28/2021 7:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030022	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030023	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030024	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030025	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030029	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007755030038	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00354632	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		03001796	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		03406377	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		03406388	9/14/2020 6:09 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1801133210 ( )		9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245502905	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1427195445	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1578569885	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1801133210	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871630897	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1033499017	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1225083074	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649296781	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700825262	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1740333681	9/14/2020 6:09 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 6:09 AM
Details	Last Recertification Date	Update	Recertification		9/14/2020 6:09:56 AM	9/14/2020 6:09 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Braun Jr., Richard G. SVP Finance and CFO Bradford Regional Medical Center 7163756190	8/15/2019 1:28 PM
Details	340B ID	Update	New Registration		DSH330103E	8/15/2019 1:28 PM
Details	Entity Subname	Update	New Registration	Smethport Health Center	Smethport Health Center - General Medical	8/15/2019 1:28 PM
Dates	Participating Approval Date	Update	New Registration		8/15/2019 1:28:14 PM	8/15/2019 1:28 PM
Details	State	Update	New Registration	Pending	Approved	8/15/2019 1:28 PM
Dates	Signed By Date	Update	New Registration		7/11/2019 9:00:21 PM	8/15/2019 1:28 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	8/15/2019 1:28 PM
Addresses	Main Address	Insert	New Registration		406 Franklin Street Smethport, PA 16749	7/11/2019 12:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2019 12:31 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007755030028	7/11/2019 12:31 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	7/11/2019 12:31 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801133210	7/11/2019 12:31 PM
Contacts	Authorizing Official	Insert	New Registration		Braun Jr., Richard G. SVP Finance and CFO Bradford Regional Medical Center 7163756190	7/11/2019 12:31 PM
Contacts	Primary Contact	Insert	New Registration		Nosowicz, Victoria Pharmacy Informatics & 340B Manager Olean General Hospital 7163756268	7/11/2019 12:31 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2019 12:31 PM
Details	Grant Number	Insert	New Registration			7/11/2019 12:31 PM
Details	340B ID	Insert	New Registration			7/11/2019 12:31 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2019 12:31 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2019 12:31 PM
Details	Medicare Provider Number	Insert	New Registration		330103	7/11/2019 12:31 PM
Details	Entity Name	Insert	New Registration		OLEAN GENERAL HOSPITAL	7/11/2019 12:31 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2019 12:31 PM
Details	Entity Subname	Insert	New Registration		Smethport Health Center	7/11/2019 12:31 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2019 12:31 PM
Details	State	Insert	New Registration		Pending	7/11/2019 12:31 PM
Dates	Registration Date	Insert	New Registration		7/11/2019 12:31:29 PM	7/11/2019 12:31 PM
Dates	Signed By Date	Insert	New Registration			7/11/2019 12:31 PM
Dates	Start Date	Insert	New Registration			7/11/2019 12:31 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2019 12:31 PM
Terminations	Termination Date	Insert	New Registration			7/11/2019 12:31 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2019 12:31 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2019 12:31 PM