Covered Entity Details

DSH450424F Houston Methodist Baytown Hospital (Active) - information as of 5/25/2025 1:17:11 AM

Main Details

Name

Houston Methodist Baytown Hospital

Subdivision Name

Radiology - Breast Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450424F

Medicare Provider Number

450424

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/9/2020

Participating Start Date

4/1/2020

Participating Approval Date

2/6/2020

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Houston Methodist Baytown Hospital
Brett T Brosseau, VICE PRESIDENT / COO
(713) 441-4136

Primary Contact

Houston Methodist
Daniel Metzen, System Director of Pharmacy
(713) 441-2141

Addresses

Street Address

1677 W Baker RD Suite, STE 2301
Baytown, TX 77521-2422

Billing Address

Houston Methodist Baytown
4401 Garth Road
Baytown, TX 77521

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
TX		1891789772

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
DSH450424A	Child	DSH	Houston Methodist Baytown Hospital	HM BAYTOWN AMBULATORY SURGERY	1677 WEST BAKER ROAD	BAYTOWN	TX	Active
DSH450424B	Child	DSH	Houston Methodist Baytown Hospital	ALEXANDER CAMPUS	1700 JAMES BOWIE DRIVE	BAYTOWN	TX	Terminated
DSH450424C	Child	DSH	Houston Methodist Baytown Hospital	HOUSTON METHODIST NEAL CANCER CENTER at Baytown	4021 GARTH ROAD SUITE 105	BAYTOWN	TX	Active
DSH450424D	Child	DSH	Houston Methodist Baytown Hospital	CT - CT - OPC	1677 West Baker Road Suite #1210	Baytown	TX	Active
DSH450424E	Child	DSH	Houston Methodist Baytown Hospital	Radiology - Radiology Imaging - OPC	1677 West Baker Road Suite #1217	Baytown	TX	Active
DSH450424F	Child	DSH	Houston Methodist Baytown Hospital	Radiology - Breast Center	1677 W Baker RD Suite, STE 2301	Baytown	TX	Active
DSH450424G	Child	DSH	Houston Methodist Baytown Hospital	MRI - MRI - OPC	1677 West Baker Road Suite #1220	Baytown	TX	Active
DSH450424H	Child	DSH	Houston Methodist Baytown Hospital	HM BAYTOWN CARDIAC REHAB - CARDIAC REHAB	4401 GARTH RD	BAYTOWN	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Joseph, Adrienne E Vice President/COO Houston Methodist Baytown Hospital 2814208924	Brosseau, Brett T VICE PRESIDENT / COO Houston Methodist Baytown Hospital 7134414136	3/3/2025 6:56 AM
Addresses	Main Address	Update	Change Request	1677 West Baker Road Suite #2301 Baytown, TX 77521	1677 W Baker RD Suite, STE 2301 Baytown, TX 77521-2422	1/22/2025 12:30 PM
Details	Last Recertification Date	Update	Recertification	8/21/2023 10:44:31 AM	8/21/2024 12:31:41 PM	8/21/2024 12:31 PM
Addresses	Main Address	Update	Change Request	1677 West Baker Road Suite #2317 Baytown, TX 77521	1677 West Baker Road Suite #2301 Baytown, TX 77521	4/12/2024 7:42 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	137962006 (TX)		1/15/2024 5:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	137962013 (TX)		1/15/2024 5:41 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 9:03:33 AM	8/21/2023 10:44:31 AM	8/21/2023 10:44 AM
Contacts	Authorizing Official	Update	Change Request	Chalupa, Becky P Vice President / Chief Nursing Officer Houston Methodist San Jacinto 2814208602	Joseph, Adrienne E Vice President/COO Houston Methodist Baytown Hospital 2814208924	5/8/2023 7:07 AM
Addresses	Main Address	Update	Change Request	1677 West Baker Road Baytown, TX 77521	1677 West Baker Road Suite #2317 Baytown, TX 77521	1/19/2023 9:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/17/2022 9:39 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137962013	10/17/2022 9:39 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	10/17/2022 9:39 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 6:39:38 PM	8/30/2022 9:03:33 AM	8/30/2022 9:03 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 8:44:18 AM	8/24/2021 6:39:38 PM	8/24/2021 6:39 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1891789772 ( )		9/8/2020 8:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891789772	9/8/2020 8:44 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/8/2020 8:44 AM
Details	Last Recertification Date	Update	Recertification		9/8/2020 8:44:18 AM	9/8/2020 8:44 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Chalupa, Becky P Vice President / Chief Nursing Officer Houston Methodist San Jacinto 2814208602	2/6/2020 9:42 AM
Details	340B ID	Update	New Registration		DSH450424F	2/6/2020 9:42 AM
Details	Entity Name	Update	New Registration	SAN JACINTO METHODIST HOSPITAL	Houston Methodist Baytown Hospital	2/6/2020 9:42 AM
Details	Entity Subname	Update	New Registration	Radiology	Radiology - Breast Center	2/6/2020 9:42 AM
Dates	Participating Approval Date	Update	New Registration		2/6/2020 9:42:27 AM	2/6/2020 9:42 AM
Details	State	Update	New Registration	Pending	Approved	2/6/2020 9:42 AM
Dates	Signed By Date	Update	New Registration		1/13/2020 9:13:42 AM	2/6/2020 9:42 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	2/6/2020 9:42 AM
Addresses	Main Address	Insert	New Registration		1677 West Baker Road Baytown, TX 77521	1/9/2020 2:08 PM
Addresses	Billing Address	Insert	New Registration		Houston Methodist Baytown 4401 Garth Road Baytown, TX 77521	1/9/2020 2:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/9/2020 2:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		137962006	1/9/2020 2:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/9/2020 2:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891789772	1/9/2020 2:08 PM
Contacts	Authorizing Official	Insert	New Registration		Chalupa, Becky P Vice President / Chief Nursing Officer Houston Methodist San Jacinto 2814208602	1/9/2020 2:08 PM
Contacts	Primary Contact	Insert	New Registration		Metzen, Daniel System Director of Pharmacy Houston Methodist 7134412141	1/9/2020 2:08 PM
Details	Last Recertification Date	Insert	New Registration			1/9/2020 2:08 PM
Details	Grant Number	Insert	New Registration			1/9/2020 2:08 PM
Details	340B ID	Insert	New Registration			1/9/2020 2:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/9/2020 2:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/9/2020 2:08 PM
Details	Medicare Provider Number	Insert	New Registration		450424	1/9/2020 2:08 PM
Details	Entity Name	Insert	New Registration		SAN JACINTO METHODIST HOSPITAL	1/9/2020 2:08 PM
Details	Program Code	Insert	New Registration		DSH	1/9/2020 2:08 PM
Details	Entity Subname	Insert	New Registration		Radiology	1/9/2020 2:08 PM
Dates	Participating Approval Date	Insert	New Registration			1/9/2020 2:08 PM
Details	State	Insert	New Registration		Pending	1/9/2020 2:08 PM
Dates	Registration Date	Insert	New Registration		1/9/2020 2:08:42 PM	1/9/2020 2:08 PM
Dates	Signed By Date	Insert	New Registration			1/9/2020 2:08 PM
Dates	Start Date	Insert	New Registration			1/9/2020 2:08 PM
Terminations	Termination Comments	Insert	New Registration			1/9/2020 2:08 PM
Terminations	Termination Date	Insert	New Registration			1/9/2020 2:08 PM
Terminations	Termination Effective Date	Insert	New Registration			1/9/2020 2:08 PM
Terminations	Termination Reason	Insert	New Registration			1/9/2020 2:08 PM