| Medicaid Billing | Medicaid: Number | Delete | Change Request | 1265811251 (NV) | | 9/5/2024 2:02 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 250001030 (NV) | | 9/5/2024 2:02 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1548780554 (NV) | | 9/5/2024 2:02 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1265811251 (NV) | | 9/5/2024 2:02 PM |
| Addresses | Billing Address | Update | Change Request | Banner Health
PO Box 2977
Phoenix, AZ 85062 | Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062 | 8/28/2024 5:05 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2023 6:00:38 PM | 8/20/2024 1:21:49 PM | 8/20/2024 1:21 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Toigo, Alison S.
Pharmacy Senior Manager
Banner Churchill Community Hospital
7758677123 | Toigo, Alison S.
Associate Director of Pharmacy
Banner Churchill Community Hospital
7758677123 | 7/23/2024 4:12 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 1548780554 (NV) | | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1265811251 | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NV | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 250001030 | 10/16/2023 11:07 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NV | 10/16/2023 11:07 AM |
| Contacts | Authorizing Official | Update | Change Request | Schultz, Lorena
CFO
Banner Health
9708101573 | King, Matthew K
Senior Finance Director
Banner Payson Medical Center
8016829661 | 10/12/2023 4:23 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 11:49:14 AM | 8/31/2023 6:00:38 PM | 8/31/2023 6:00 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Schultz, Lorena
CFO
Banner Churchill Community Hospital
5302522239 | Schultz, Lorena
CFO
Banner Health
9708101573 | 8/15/2023 9:56 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1265811251 | 3/15/2023 1:13 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | NV | 3/15/2023 1:13 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 291313 (NV) | | 12/12/2022 5:38 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 12/12/2022 5:38 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1548780554 | 12/12/2022 5:38 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NV | 12/12/2022 5:38 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2021 5:13:22 PM | 8/30/2022 11:49:14 AM | 8/30/2022 11:49 AM |
| Contacts | Authorizing Official | Update | Change Request | Fraker, Steven
Chief Financial Officer
Banner Churchill Community Hospital
7758677002 | Schultz, Lorena
CFO
Banner Churchill Community Hospital
5302522239 | 6/9/2022 12:31 PM |
| Addresses | Shipping Address | Delete | Change Request | Banner Health- AZRX
7300 W. Detroit St.
Chandler, AZ 85226 | | 10/4/2021 2:03 PM |
| Details | Entity Subname | Update | Change Request | BANNER CHURCHILL COMMUNITY HOSPITAL - Fernley FP RHC - Clinic | BANNER CHURCHILL COMMUNITY HOSPITAL - Fernley HC PCP RHC - Clinic | 10/4/2021 2:03 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2020 12:24:42 PM | 9/3/2021 5:13:22 PM | 9/3/2021 5:13 PM |
| Addresses | Billing Address | Insert | Change Request | | Banner Health
PO Box 2977
Phoenix, AZ 85062 | 7/12/2021 6:40 AM |
| Details | Entity Subname | Update | Change Request | BANNER CHURCHILL COMMUNITY HOSPITAL - Fernley Multi-Specialty Clinic | BANNER CHURCHILL COMMUNITY HOSPITAL - Fernley FP RHC - Clinic | 7/12/2021 6:40 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1548780554 ( ) | | 9/11/2020 12:24 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1548780554 | 9/11/2020 12:24 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NV | 9/11/2020 12:24 PM |
| Details | Last Recertification Date | Update | Recertification | | 9/11/2020 12:24:42 PM | 9/11/2020 12:24 PM |
| Addresses | Shipping Address | Insert | Change Request | | Banner Churchill Community Hospital
1260 Nevada Pacific Blvd
Fernley, NV 89408 | 1/10/2020 7:08 AM |
| Addresses | Shipping Address | Insert | Change Request | | Banner Churchill Community Hospital
801 East Williams
Fallon, NV 89406 | 1/10/2020 7:08 AM |
| Addresses | Shipping Address | Insert | Change Request | | Banner Health- AZRX
7300 W. Detroit St.
Chandler, AZ 85226 | 1/10/2020 7:08 AM |
| Details | State | Update | | Approved | Active | 1/1/2020 12:04 AM |
| Contacts | Signed By | Insert | New Registration | | Fraker, Steven
Chief Financial Officer
Banner Churchill Community Hospital
7758677002 | 11/7/2019 3:04 PM |
| Details | 340B ID | Update | New Registration | | CAH291313-01 | 11/7/2019 3:04 PM |
| Details | Entity Name | Update | New Registration | BANNER CHURCHILL COMMUNITY HOSPITAL | Banner Churchill Community Hospital | 11/7/2019 3:04 PM |
| Details | Entity Subname | Update | New Registration | BANNER CHURCHILL COMMUNITY HOSPITAL | BANNER CHURCHILL COMMUNITY HOSPITAL - Fernley Multi-Specialty Clinic | 11/7/2019 3:04 PM |
| Dates | Participating Approval Date | Update | New Registration | | 11/7/2019 3:04:08 PM | 11/7/2019 3:04 PM |
| Details | State | Update | New Registration | Pending | Approved | 11/7/2019 3:04 PM |
| Dates | Signed By Date | Update | New Registration | | 10/11/2019 2:28:59 PM | 11/7/2019 3:04 PM |
| Dates | Start Date | Update | New Registration | | 1/1/2020 12:00:00 AM | 11/7/2019 3:04 PM |
| Addresses | Main Address | Insert | New Registration | |
1260 NEVADA PACIFIC BLVD
FERNLEY, NV 89408-9871 | 10/11/2019 1:30 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 10/11/2019 1:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 291313 | 10/11/2019 1:30 PM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | NV | 10/11/2019 1:30 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1548780554 | 10/11/2019 1:30 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Fraker, Steven
Chief Financial Officer
Banner Churchill Community Hospital
7758677002 | 10/11/2019 1:30 PM |
| Contacts | Primary Contact | Insert | New Registration | | Toigo, Alison S.
Pharmacy Senior Manager
Banner Churchill Community Hospital
7758677123 | 10/11/2019 1:30 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Details | Grant Number | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Details | 340B ID | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 291313 | 10/11/2019 1:30 PM |
| Details | Entity Name | Insert | New Registration | | BANNER CHURCHILL COMMUNITY HOSPITAL | 10/11/2019 1:30 PM |
| Details | Program Code | Insert | New Registration | | CAH | 10/11/2019 1:30 PM |
| Details | Entity Subname | Insert | New Registration | | BANNER CHURCHILL COMMUNITY HOSPITAL | 10/11/2019 1:30 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Details | State | Insert | New Registration | | Pending | 10/11/2019 1:30 PM |
| Dates | Registration Date | Insert | New Registration | | 10/11/2019 1:30:21 PM | 10/11/2019 1:30 PM |
| Dates | Signed By Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Dates | Start Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Terminations | Termination Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 10/11/2019 1:30 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 10/11/2019 1:30 PM |