Covered Entity Details

DSH160033AM GENESIS MEDICAL CENTER - DAVENPORT (Terminated) - information as of 5/26/2025 12:47:13 AM

Main Details

Name

GENESIS MEDICAL CENTER - DAVENPORT

Subdivision Name

PT and Sports Med - Bettendorf - PT and Sports Med - Bettendorf

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH160033AM

Medicare Provider Number

160033

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/10/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/31/2019

Last Recertification Date

8/29/2022

Termination Date
Termination Reason

4/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Genesis Health System
Jordan Voigt, GMC Davenport President
(563) 421-2792

Primary Contact

Genesis Health System
Kevin Cassatt, Director of Pharmacy
(563) 421-6212

Addresses

Street Address

4850 Competition Dr
TBK Sports Complex
Bettendorf, IA 52722

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
IL	421418847401	1972542264
IA	0600338	1972542264

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
DSH160033A	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Emergency Care Center	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033AA	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / ULTRASOUND	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AB	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / RADIOLOGY	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AC	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / PACU	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AD	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / OP CARE CENTER	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AE	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / ENDOSCOPY	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AF	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / OP PSYCH	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AG	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / DAY REHAB PROGRAM	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AH	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GIC-53rd st-GenRad - Radiology	1970 East 53rd Street	Davenport	IA	Active
DSH160033AJ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GIC-DG-GenRad - Radiology	2140 East 53rd Ave	Bettendorf	IA	Active
DSH160033AK	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Surgery - Cardiac Surgery	1236 East Rusholme St	Davenport	IA	Active
DSH160033AL	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Neurosurgery - Neurosurgery	1230 East Rusholme St	Davenport	IA	Active
DSH160033AM	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	PT and Sports Med - Bettendorf - PT and Sports Med - Bettendorf	4850 Competition Dr	Bettendorf	IA	Terminated
DSH160033AN	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy - Davenport 3rd - Physical Therapy - Davenport 3rd	1820 West 3rd St	Davenport	IA	Terminated
DSH160033AP	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Diagnostics - Cardiac Diagnostics	1236 E Rusholme	Davenport	IA	Active
DSH160033AQ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy - Clinton - Physical Therapy - Clinton	1663 G Lincoln Way	Clinton	IA	Terminated
DSH160033AR	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Adult Psychiatric Unit - Psychiatric	1401 West Central Park	Davenport	IA	Active
DSH160033AS	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Adolescent Psych Unit - Psychiatric	1401 West Central Park Ave	Davenport	IA	Active
DSH160033AT	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Genesis Vascular Specialist - GHG Davenport Vascular Specialists	1230 East Rusholme St.	Davenport	IA	Active
DSH160033AU	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS PT AT HEADACHE CLINIC - Genesis Davenport Headache Clinic PT	1230 E RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AV	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS DAVENPORT HEADACHE CLINIC - Headache Clinic	1230 E. RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AW	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cancer Genetics Clinic - Cancer Genetics Clinic	1228 East Rusholme St.	Davenport	IA	Active
DSH160033AX	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GHG DAVENPORT EAST GASTROENTEROLOGY - Genesis Gastroenterology	1236 E RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AY	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS MEDICAL CENTER - ED BETT. - Bettendorf ED	2140 53RD AVE	BETTENDORF	IA	Active
DSH160033AZ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	MercyOne Genesis Neurology Care - Genesis Memory Disorder Clinic	1351 West Central Park Ave	Davenport	IA	Active
DSH160033B	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Neurodiagnostics	1401 W Central Park Ave	Davenport	IA	Active
DSH160033BA	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS PLASTIC SURGERY - Genesis Plastic Surgery 53rd	4334 E 53RD ST	DAVENPORT	IA	Active
DSH160033C	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Rehab	1236 E Rusholme St	Davenport	IA	Active
DSH160033D	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Occupational Therapy	1228 E Rusholme St	Davenport	IA	Terminated
DSH160033E	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Occupational Therapy	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033F	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Respiratory Care	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033G	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GMC / Davenport Laboratory	1401 W Central Park Ave	Davenport	IA	Active
DSH160033H	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / MRI	1401 W Central Park Ave	Davenport	IA	Active
DSH160033J	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / CT Scan	1401 W Central Park Ave	Davenport	IA	Active
DSH160033K	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Nuclear Medicine	1236 East Rusholme	Davenport	IA	Active
DSH160033L	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Wound & Hyperbaric Institute	1351 West Central Park	Davenport	IA	Active
DSH160033M	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Center for Weight Management	1230 East Rusholme Street	Davenport	IA	Active
DSH160033N	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Maplecrest / Rehab Pediatrics	2535 Maplecrest Road	Bettendorf	IA	Active
DSH160033P	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / Lombard	1414 West Lombard Street	Davenport	IA	Terminated
DSH160033Q	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Genesis / Physical Therapy & Wellness Center	4017 Devils Glen Road	Bettendorf	IA	Terminated
DSH160033R	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / LeClaire	1003 Canal Shore Drive	LeClaire	IA	Terminated
DSH160033S	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy / & Sports Medicine Clinic	1702 East 53rd Street	Davenport	IA	Terminated
DSH160033T	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / Valley Fair	2720 West Locust Street	Davenport	IA	Terminated
DSH160033U	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Infusion Center	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033V	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Radiation Therapy	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033W	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Cancer Care Institute	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033X	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	McKay / Center For Breast Health	1228 E. Rusholme Street	Davenport	IA	Active
DSH160033Y	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / DIABETES INSTITUTE	2535 MAPLECREST RD STE 13	BETTENDORF	IA	Terminated
DSH160033Z	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / PAIN AND SPINE CENTER	2535 MAPLECREST ROAD STE 12	BETTENDORF	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/31/2023 12:00:00 AM	3/29/2023 12:53 PM
Details	State	Update	Termination Request	Active	To Be Terminated	3/29/2023 12:53 PM
Terminations	Termination Date	Update	Termination Request		4/1/2023 12:00:00 AM	3/29/2023 12:53 PM
Terminations	Termination Effective Date	Update	Termination Request		3/31/2023 12:00:00 AM	3/29/2023 12:53 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	3/29/2023 12:53 PM
Details	Last Recertification Date	Update	Recertification	8/20/2021 1:34:29 PM	8/29/2022 2:42:46 PM	8/29/2022 2:42 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 3:52:35 PM	8/20/2021 1:34:29 PM	8/20/2021 1:34 PM
Contacts	Authorizing Official	Update	Change Request	Rogers, Mark CFO Genesis Health System 5634216513	Voigt, Jordan GMC Davenport President Genesis Health System 5634212792	12/3/2020 10:38 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	600338 (IA)		8/19/2020 3:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/19/2020 3:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0600338	8/19/2020 3:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	8/19/2020 3:52 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	8/19/2020 3:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972542264	8/19/2020 3:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/19/2020 3:52 PM
Details	Last Recertification Date	Update	Recertification		8/19/2020 3:52:35 PM	8/19/2020 3:52 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	421418847001	421418847401	10/31/2019 2:35 PM
Contacts	Signed By	Insert	New Registration		Rogers, Mark CFO Genesis Health System 5634216513	10/31/2019 9:15 AM
Details	340B ID	Update	New Registration		DSH160033AM	10/31/2019 9:15 AM
Details	Entity Subname	Update	New Registration	PT and Sports Med - Bettendorf	PT and Sports Med - Bettendorf - PT and Sports Med - Bettendorf	10/31/2019 9:15 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2019 9:15:48 AM	10/31/2019 9:15 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2019 9:15 AM
Dates	Signed By Date	Update	New Registration		10/11/2019 9:49:56 AM	10/31/2019 9:15 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/31/2019 9:15 AM
Medicaid Billing	Medicaid: Number	Update	New Registration	421418847401	421418847001	10/10/2019 5:02 PM
Addresses	Main Address	Insert	New Registration		4850 Competition Dr TBK Sports Complex Bettendorf, IA 52722	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600338	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		421418847401	10/10/2019 5:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/10/2019 5:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972542264	10/10/2019 5:02 PM
Contacts	Authorizing Official	Insert	New Registration		Rogers, Mark CFO Genesis Health System 5634216513	10/10/2019 5:02 PM
Contacts	Primary Contact	Insert	New Registration		Cassatt, Kevin Director of Pharmacy Genesis Health System 5634216212	10/10/2019 5:02 PM
Details	Last Recertification Date	Insert	New Registration			10/10/2019 5:02 PM
Details	Grant Number	Insert	New Registration			10/10/2019 5:02 PM
Details	340B ID	Insert	New Registration			10/10/2019 5:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2019 5:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2019 5:02 PM
Details	Medicare Provider Number	Insert	New Registration		160033	10/10/2019 5:02 PM
Details	Entity Name	Insert	New Registration		GENESIS MEDICAL CENTER - DAVENPORT	10/10/2019 5:02 PM
Details	Program Code	Insert	New Registration		DSH	10/10/2019 5:02 PM
Details	Entity Subname	Insert	New Registration		PT and Sports Med - Bettendorf	10/10/2019 5:02 PM
Dates	Participating Approval Date	Insert	New Registration			10/10/2019 5:02 PM
Details	State	Insert	New Registration		Pending	10/10/2019 5:02 PM
Dates	Registration Date	Insert	New Registration		10/10/2019 5:02:01 PM	10/10/2019 5:02 PM
Dates	Signed By Date	Insert	New Registration			10/10/2019 5:02 PM
Dates	Start Date	Insert	New Registration			10/10/2019 5:02 PM
Terminations	Termination Comments	Insert	New Registration			10/10/2019 5:02 PM
Terminations	Termination Date	Insert	New Registration			10/10/2019 5:02 PM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2019 5:02 PM
Terminations	Termination Reason	Insert	New Registration			10/10/2019 5:02 PM