Covered Entity Details

DSH100034E MOUNT SINAI MEDICAL CENTER (Active) - information as of 4/25/2025 6:29:49 PM

Main Details

Name

MOUNT SINAI MEDICAL CENTER

Subdivision Name

Mount Sinai Medical Center - Outpatient Behavioral Health Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100034E

Medicare Provider Number

100034

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/15/2019

Participating Start Date

1/1/2020

Participating Approval Date

12/1/2019

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Mount Sinai Medical Center
ANGEL PALLIN, SVP OF OPERATIONS
(305) 674-2520

Primary Contact

Mount Sinai Medical Center
ANA CAROLINA CALDERA, DIRECTOR OF PHARMACY
(305) 674-2855

Addresses

Street Address

4302 Alton Road
Suite 500
Miami Beach, FL 33140

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
FL	010046300	1912964768

Shipping Addresses

Shipping Address 1

MOUNT SINAI MEDICAL CENTER
4300 ALTON ROAD
MIAMI BEACH, FL 33140

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
DSH100034A	Child	DSH	MOUNT SINAI MEDICAL CENTER	COMPREHENSIVE CANCER CENTER	4306 ALTON ROAD	MIAMI BEACH	FL	Active
DSH100034B	Child	DSH	MOUNT SINAI MEDICAL CENTER	COMPREHENSIVE CANCER AT AVENTURA	2845 AVENTURA BLVD	AVENTURA	FL	Active
DSH100034C	Child	DSH	MOUNT SINAI MEDICAL CENTER	MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC.	2845 AVENTURA BLVD	AVENTURA	FL	Active
DSH100034D	Child	DSH	MOUNT SINAI MEDICAL CENTER	Mount Sinai Medical Center - Hialeah Emergency Dept.	6050 W 20TH AVE	HIALEAH	FL	Active
DSH100034E	Child	DSH	MOUNT SINAI MEDICAL CENTER	Mount Sinai Medical Center - Outpatient Behavioral Health Center	4302 Alton Road	Miami Beach	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	100463 (FL)		9/3/2024 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2024 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		010046300	9/3/2024 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/3/2024 10:20 AM
Details	Last Recertification Date	Update	Recertification	9/5/2023 8:54:41 AM	9/3/2024 10:20:11 AM	9/3/2024 10:20 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 5:36:40 PM	9/5/2023 8:54:41 AM	9/5/2023 8:54 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	MOU003RN (AL)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	315772 (AZ)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912964768 (CA)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000166797 (CO)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	822523928A (GA)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912964768 (IA)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	590624424001 (IL)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1291087 (KY)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	43248200 (MN)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912964768 (NC)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	350481 (OH)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	16118740001 (PA)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	10472B (SC)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100034 (VT)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912964768 (WI)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	350454 (NY)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	008002667 (CT)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	008014269 (CT)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300031438 (IN)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1912964768 (ME)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	80036571 (NM)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100507524 (NV)		9/12/2022 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	071769601 (TX)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (AL)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (AZ)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (CA)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (CO)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (GA)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (IA)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (IL)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (KY)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (MN)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (NC)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (OH)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (PA)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (SC)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (VT)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (WI)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (NY)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (CT)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (IN)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (ME)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (NM)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (NV)		9/12/2022 5:36 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 (TX)		9/12/2022 5:36 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 2:46:01 PM	9/12/2022 5:36:40 PM	9/12/2022 5:36 PM
Addresses	Shipping Address	Insert	Recertification		MOUNT SINAI MEDICAL CENTER 4300 ALTON ROAD MIAMI BEACH, FL 33140	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		008002667	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		008014269	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300031438	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		80036571	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100507524	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NV	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		071769601	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/7/2021 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/7/2021 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/7/2021 2:46 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 12:16:53 PM	9/7/2021 2:46:01 PM	9/7/2021 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		MOU003RN	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		315772	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000166797	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		822523928A	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		590624424001	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1291087	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		43248200	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		350481	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		16118740001	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10472B	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100034	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		350454	9/9/2020 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1912964768 ( )		9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/9/2020 12:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912964768	9/9/2020 12:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/9/2020 12:16 PM
Details	Last Recertification Date	Update	Recertification		9/9/2020 12:16:53 PM	9/9/2020 12:16 PM
Details	Entity Subname	Update	Recertification	Outpatient Behavioral Health Center - Outpatient Behavioral Health Center	Mount Sinai Medical Center - Outpatient Behavioral Health Center	9/9/2020 12:16 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Addresses	Main Address	Insert	New Registration		4302 Alton Road Suite 500 Miami Beach, FL 33140	12/1/2019 7:41 PM
Contacts	Signed By	Insert	New Registration		PALLIN, ANGEL SVP OF OPERATIONS Mount Sinai Medical Center 3056742520	12/1/2019 7:41 PM
Details	340B ID	Update	New Registration		DSH100034E	12/1/2019 7:41 PM
Details	Entity Name	Update	New Registration	MT. SINAI MEDICAL CENTER	MOUNT SINAI MEDICAL CENTER	12/1/2019 7:41 PM
Details	Entity Subname	Update	New Registration	Outpatient Behavioral Health Center	Outpatient Behavioral Health Center - Outpatient Behavioral Health Center	12/1/2019 7:41 PM
Dates	Participating Approval Date	Update	New Registration		12/1/2019 7:41:57 PM	12/1/2019 7:41 PM
Details	State	Update	New Registration	Pending	Approved	12/1/2019 7:41 PM
Dates	Signed By Date	Update	New Registration		10/21/2019 10:55:51 AM	12/1/2019 7:41 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	12/1/2019 7:41 PM
Addresses	Main Address	Insert	New Registration		4302 Alton Road Suite 500 Miami, FL 33140	10/15/2019 4:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2019 4:31 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100463	10/15/2019 4:31 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/15/2019 4:31 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1912964768	10/15/2019 4:31 PM
Contacts	Primary Contact	Insert	New Registration		CALDERA, ANA CAROLINA DIRECTOR OF PHARMACY Mount Sinai Medical Center 3056742855	10/15/2019 4:31 PM
Contacts	Authorizing Official	Insert	New Registration		PALLIN, ANGEL SVP OF OPERATIONS Mount Sinai Medical Center 3056742520	10/15/2019 4:31 PM
Details	Last Recertification Date	Insert	New Registration			10/15/2019 4:31 PM
Details	Grant Number	Insert	New Registration			10/15/2019 4:31 PM
Details	340B ID	Insert	New Registration			10/15/2019 4:31 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/15/2019 4:31 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/15/2019 4:31 PM
Details	Medicare Provider Number	Insert	New Registration		100034	10/15/2019 4:31 PM
Details	Entity Name	Insert	New Registration		MT. SINAI MEDICAL CENTER	10/15/2019 4:31 PM
Details	Program Code	Insert	New Registration		DSH	10/15/2019 4:31 PM
Details	Entity Subname	Insert	New Registration		Outpatient Behavioral Health Center	10/15/2019 4:31 PM
Dates	Participating Approval Date	Insert	New Registration			10/15/2019 4:31 PM
Details	State	Insert	New Registration		Pending	10/15/2019 4:31 PM
Dates	Registration Date	Insert	New Registration		10/15/2019 4:31:29 PM	10/15/2019 4:31 PM
Dates	Signed By Date	Insert	New Registration			10/15/2019 4:31 PM
Dates	Start Date	Insert	New Registration			10/15/2019 4:31 PM
Terminations	Termination Comments	Insert	New Registration			10/15/2019 4:31 PM
Terminations	Termination Date	Insert	New Registration			10/15/2019 4:31 PM
Terminations	Termination Effective Date	Insert	New Registration			10/15/2019 4:31 PM
Terminations	Termination Reason	Insert	New Registration			10/15/2019 4:31 PM