Covered Entity Details

DSH100093P BAPTIST HOSPITAL (Terminated) - information as of 4/30/2025 10:53:39 PM

Main Details

Name

BAPTIST HOSPITAL

Subdivision Name

BH AI Non-Surg SM HWC

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100093P

Medicare Provider Number

100093

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/10/2020

Participating Start Date

4/1/2020

Participating Approval Date

1/28/2020

Last Recertification Date

9/5/2023

Termination Date
Termination Reason

10/1/2024
Business decision by the Covered Entity

Contacts

Authorizing Official

Baptist Health Care
Andrew L. Terry, Vice President Revenue Management
(850) 469-7643

Primary Contact

BHC
Frederick Seelmann, Executive Director of Pharmacy
(850) 469-7567

Addresses

Street Address

125 Baptist Way
Pensacola, FL 32503

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Is the service changing and/or are there additional services being added?	09/25/2023

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
AL	HOS0093P	1700979465
FL	10074900	1700979465
AK	1665931	1700979465
AZ	83838	1700979465
AR	121575105	1700979465
CO	23088842	1700979465
CT	HOS0093P	1700979465
GA	000150433AA	1700979465
IL	590657322-002	1700979465
IN	300013901	1700979465
IA	553842	1700979465
KY	1291723	1700979465
LA	1733091	1700979465
MD	217105800	1700979465
MI	HOS0093P	1700979465
MS	97779	1700979465
NJ	250252	1700979465
NC	HOS0093P	1700979465
OH	142769	1700979465
OK	200060650B	1700979465
OR	500773264	1700979465
PA	100777553-0008	1700979465
SC	10172A-inpatient,10867B-outpatient	1700979465
TN	100093	1700979465
VT	100093	1700979465
VA	1700979465	1700979465
WI	1700979465	1700979465

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
DSH100093AA	Child	DSH	BAPTIST HOSPITAL	BH AI PMR BMPA 102 - BH AI PMR BMPA 102	5100 North 12th Avenue	Pensacola	FL	Active
DSH100093AB	Child	DSH	BAPTIST HOSPITAL	BH AI PMR HWC 4A	125 Baptist Way	Pensacola	FL	Active
DSH100093AC	Child	DSH	BAPTIST HOSPITAL	BH AI PMR SM AI 208 - BH AI PMR SM AI 208	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093AD	Child	DSH	BAPTIST HOSPITAL	BH Card Con BMP9 103 - BH Card Con BMP9 103	9400 University Parkway	Pensacola	FL	Active
DSH100093AE	Child	DSH	BAPTIST HOSPITAL	BH Card Con BMPA 202 - BH Card Con BMPA 202	5100 North 12th Avenue	Pensacola	FL	Active
DSH100093AF	Child	DSH	BAPTIST HOSPITAL	BH Card Con BMPN 101 - BH Card Con BMPN 101	8880 Navarre Parkway	Navarre	FL	Active
DSH100093AG	Child	DSH	BAPTIST HOSPITAL	BH Card Con HWC 3	125 Baptist Way	Pensacola	FL	Active
DSH100093AH	Child	DSH	BAPTIST HOSPITAL	BH Card Con GB 102 - BH Card Con GB 102	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093AJ	Child	DSH	BAPTIST HOSPITAL	BH Card Con HRC HWC 3	125 Baptist Way	Pensacola	FL	Terminated
DSH100093AK	Child	DSH	BAPTIST HOSPITAL	BH Card Con Milton 200 - BH Card Con Milton 200	5907 Berryhill Road	Milton	FL	Active
DSH100093AL	Child	DSH	BAPTIST HOSPITAL	BH Convenient Care Southtowne - BH Convenient Care Southtowne	190 East Intendencia Street	Pensacola	FL	Active
DSH100093AM	Child	DSH	BAPTIST HOSPITAL	BH Endocrinology HWC 5B	125 Baptist Way	Pensacola	FL	Active
DSH100093AN	Child	DSH	BAPTIST HOSPITAL	BH ENT BMP9 200 - BH ENT BMP9 200	9400 University Parkway	Pensacola	FL	Active
DSH100093AP	Child	DSH	BAPTIST HOSPITAL	BH General Surgery Westside - BH General Surgery Westside	6715 Highway 98 West	Pensacola	FL	Active
DSH100093AQ	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery Milton 200 - BH Neurosurgery Milton 200	5907 Berryhill Road	Milton	FL	Active
DSH100093AR	Child	DSH	BAPTIST HOSPITAL	BH OBGYN HWC 5A	125 Baptist Way	Pensacola	FL	Active
DSH100093AS	Child	DSH	BAPTIST HOSPITAL	BH Wellness BMPN 206 - BH Wellness BMPN 206	8880 Navarre Parkway	Navarre	FL	Terminated
DSH100093AT	Child	DSH	BAPTIST HOSPITAL	BH Radiation Onc HWC 1E	125 Baptist Way	Pensacola	FL	Active
DSH100093AU	Child	DSH	BAPTIST HOSPITAL	BH General Surgery BMPN 101 - BH General Surgery BMPN 101	8880 Navarre Parkway	Navarre	FL	Active
DSH100093AV	Child	DSH	BAPTIST HOSPITAL	BH Gastroenterology HWC 4C	125 Baptist Way	Pensacola	FL	Active
DSH100093AW	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine GB 100 - BH Family Medicine GB 100	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Terminated
DSH100093AX	Child	DSH	BAPTIST HOSPITAL	BH Primary Care East Hill	3417 North 12th Avenue	Pensacola	FL	Active
DSH100093AY	Child	DSH	BAPTIST HOSPITAL	BH General Surgery Pace-Hwy 90 - BH General Surgery Pace-Hwy 90	4498 US Highway 90	Pace	FL	Active
DSH100093AZ	Child	DSH	BAPTIST HOSPITAL	BH Urology Milton 200 - BH Urology Milton 200	5907 Berryhill Road	Milton	FL	Terminated
DSH100093B	Child	DSH	BAPTIST HOSPITAL	Baptist Hospital Outpatient Infusion at Ciano Cancer Center	1114 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093BA	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine BMP9 409 - BH Family Medicine BMP9 409	9400 University Parkway	Pensacola	FL	Active
DSH100093BB	Child	DSH	BAPTIST HOSPITAL	BH General Surgery GB 203 - BH General Surgery GB 203	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093BC	Child	DSH	BAPTIST HOSPITAL	BH Urology HWC 4B	125 Baptist Way	Pensacola	FL	Active
DSH100093BD	Child	DSH	BAPTIST HOSPITAL	BH ENT HWC 5C	125 Baptist Way	Pensacola	FL	Active
DSH100093BE	Child	DSH	BAPTIST HOSPITAL	BH Primary Care BMP9 210 - BH Primary Care BMP9 210	9400 University Parkway	Pensacola	FL	Active
DSH100093BF	Child	DSH	BAPTIST HOSPITAL	BH Hematology Onc BMP9 408 - BH Hematology Onc BMP9 408	9400 University Parkway	Pensacola	FL	Active
DSH100093BG	Child	DSH	BAPTIST HOSPITAL	BH Urology GB 200 - BH Urology GB 200	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093BH	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine Tiger Point - BH Family Medicine Tiger Point	1337 Country Club Rd	Gulf Breeze	FL	Terminated
DSH100093BJ	Child	DSH	BAPTIST HOSPITAL	BH Primary Care Live Oak - BH Primary Care Live Oak	2896 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093BK	Child	DSH	BAPTIST HOSPITAL	BH OBGYN GB 101 - BH OBGYN GB 101	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Terminated
DSH100093BL	Child	DSH	BAPTIST HOSPITAL	BH Rheumatology HWC 4A	125 Baptist Way	Pensacola	FL	Active
DSH100093BM	Child	DSH	BAPTIST HOSPITAL	BH Gastroenterology BMPN 101 - BH Gastroenterology BMPN 101	8880 Navarre Parkway	Navarre	FL	Active
DSH100093BN	Child	DSH	BAPTIST HOSPITAL	BH Radiation Onc GB Ciano - BH Radiation Onc GB Ciano	1114 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093BP	Child	DSH	BAPTIST HOSPITAL	BH Wellness BMT 533 - BH Wellness BMT 533	1717 North E Street	Pensacola	FL	Terminated
DSH100093BQ	Child	DSH	BAPTIST HOSPITAL	BH OBGYN BMPP - BH OBGYN BMPP	3874 Highway 90	Pace	FL	Active
DSH100093BR	Child	DSH	BAPTIST HOSPITAL	BH Hematology Onc BMPA 201 - BH Hematology Onc BMPA 201	5100 North 12th Avenue	Pensacola	FL	Terminated
DSH100093BS	Child	DSH	BAPTIST HOSPITAL	BH Primary Care BMPN 206 - BH Primary Care BMPN 206	8880 Navarre Parkway	Navarre	FL	Active
DSH100093BT	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery BMPN 101 - BH Neurosurgery BMPN 101	8880 Navarre Parkway	Navarre	FL	Terminated
DSH100093BU	Child	DSH	BAPTIST HOSPITAL	BH Gastroenterology BMP9 200 - BH Gastroenterology BMP9 200	9400 University Parkway	Pensacola	FL	Active
DSH100093BV	Child	DSH	BAPTIST HOSPITAL	BH Wellness Westside - BH Wellness Westside	6715 Highway 98 West	Pensacola	FL	Terminated
DSH100093BW	Child	DSH	BAPTIST HOSPITAL	BH Gastroenterology BMPP 202 - BH Gastroenterology BMPP 202	3874 Highway 90	Pace	FL	Active
DSH100093BX	Child	DSH	BAPTIST HOSPITAL	BH General Surgery BMP9 200 - BH General Surgery BMP9 200	9400 University Parkway	Pensacola	FL	Active
DSH100093BY	Child	DSH	BAPTIST HOSPITAL	BH Wellness GB 200 - BH Wellness GB 200	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Terminated
DSH100093BZ	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine WIC BMPP101 - BH Family Medicine WIC BMPP101	3874 Highway 90	Pace	FL	Active
DSH100093C	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - Cardiology	9400 University Parkway	Pensacola	FL	Active
DSH100093CA	Child	DSH	BAPTIST HOSPITAL	BH Primary Care BMPA 201 - BH Primary Care BMPA 201	5100 North 12th Avenue	Pensacola	FL	Active
DSH100093CB	Child	DSH	BAPTIST HOSPITAL	BH Primary Care GB	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CC	Child	DSH	BAPTIST HOSPITAL	BH General Surgery HWC 5C	125 Baptist Way	Pensacola	FL	Active
DSH100093CD	Child	DSH	BAPTIST HOSPITAL	BH Urology BMPN 101 - BH Urology BMPN 101	8880 Navarre Parkway	Navarre	FL	Terminated
DSH100093CE	Child	DSH	BAPTIST HOSPITAL	BH Hematology Onc HWC 1C	125 Baptist Way	Pensacola	FL	Active
DSH100093CF	Child	DSH	BAPTIST HOSPITAL	BH General Surgery BMPP 202 - BH General Surgery BMPP 202	3874 Highway 90	Pace	FL	Terminated
DSH100093CG	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine WIC BMPN - BH Family Medicine WIC BMPN	8880 Navarre Parkway, Suite 106	Navarre	FL	Active
DSH100093CH	Child	DSH	BAPTIST HOSPITAL	BH Primary Care Perdido - BH Primary Care Perdido	12601 Sorrento Road	Pensacola	FL	Active
DSH100093CJ	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery AI 205 - BH Neurosurgery AI 205	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CK	Child	DSH	BAPTIST HOSPITAL	BH General Surgery BMPA 203 - BH General Surgery BMPA 203	5100 North 12th Avenue	Pensacola	FL	Terminated
DSH100093CL	Child	DSH	BAPTIST HOSPITAL	BH Urology BMPA 201 - BH Urology BMPA 201	5100 North 12th Avenue	Pensacola	FL	Terminated
DSH100093CM	Child	DSH	BAPTIST HOSPITAL	BH Wellness BMP9 200 - BH Wellness BMP9 200	9400 University Parkway	Pensacola	FL	Terminated
DSH100093CN	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine Westside - BH Family Medicine Westside	6715 Highway 98 West	Pensacola	FL	Active
DSH100093CP	Child	DSH	BAPTIST HOSPITAL	BH Family Medicine BMPP 201 - BH Family Medicine BMPP 201	3874 Highway 90	Pace	FL	Active
DSH100093CQ	Child	DSH	BAPTIST HOSPITAL	BH Urology BMP9 408 - BH Urology BMP9 408	9400 University Parkway	Pensacola	FL	Active
DSH100093CR	Child	DSH	BAPTIST HOSPITAL	BH Primary Care GB B - BH Primary Care GB B	1200 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CS	Child	DSH	BAPTIST HOSPITAL	BH Gastroenterology GB 101 - BH Gastroenterology GB 101	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CT	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery HWC 4C	125 Baptist Way	Pensacola	FL	Active
DSH100093CU	Child	DSH	BAPTIST HOSPITAL	BH Hematology Onc GB Ciano - BH Hematology Onc GB Ciano	1114 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CV	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery BMPA 201 - BH Neurosurgery BMPA 201	5100 North 12th Avenue	Pensacola	FL	Terminated
DSH100093CW	Child	DSH	BAPTIST HOSPITAL	Navarre FSED - Navarre FSED	8888 Navarre Pkwy	Pensacola	FL	Active
DSH100093CX	Child	DSH	BAPTIST HOSPITAL	BH Card Con Perdido - BH Card Con Perdido	12601 Sorrento Road	Pensacola	FL	Active
DSH100093CY	Child	DSH	BAPTIST HOSPITAL	BH ENT GB 100B - BH ENT GB 100B	1118 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093CZ	Child	DSH	BAPTIST HOSPITAL	Pharmacotherapy Clinic	125 Baptist Way	Pensacola	FL	Active
DSH100093D	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - Radiology	9400 University Parkway	Pensacola	FL	Active
DSH100093DA	Child	DSH	BAPTIST HOSPITAL	BH Neurosurgery BMP9 200 - BH Neurosurgery BMP9 200	9400 University Parkway	Pensacola	FL	Active
DSH100093DB	Child	DSH	BAPTIST HOSPITAL	BH AI PMR GB 203 - BH AI PMR GB 203	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Terminated
DSH100093DC	Child	DSH	BAPTIST HOSPITAL	BH AI PMR BMPP 202 - BH AI PMR BMPP 202	3874 US-90	Pace	FL	Terminated
DSH100093DD	Child	DSH	BAPTIST HOSPITAL	BH Primary Care Pine Forest - BH Primary Care Pine Forest	2115 W 9 Mile Road	Pensacola	FL	Active
DSH100093DE	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM Westside - BH AI Ortho SM Westside	12601 Sorrento Road	Pensacola	FL	Terminated
DSH100093DF	Child	DSH	BAPTIST HOSPITAL	BH Card Con BMP9 306 - BH Card Con BMP9 306	9400 University Parkway	Pensacola	FL	Active
DSH100093DG	Child	DSH	BAPTIST HOSPITAL	BH Card Con BMPP 202 - BH Card Con BMPP 202	3874 Highway 90	Pace	FL	Active
DSH100093DH	Child	DSH	BAPTIST HOSPITAL	BH Radiology - Navarre - BH Radiology - Navarre	8888 Navarre Parkway	Navarre	FL	Active
DSH100093DJ	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM BMP9 200 - BH AI Ortho SM BMP9 200	9400 University Parkway	Pensacola	FL	Active
DSH100093DK	Child	DSH	BAPTIST HOSPITAL	BH Primary Care HWC - BH Primary Care HWC	125 Baptist Way	Pensacola	FL	Active
DSH100093DL	Child	DSH	BAPTIST HOSPITAL	9 Mile FSED - 9 Mile FSED	9400 University Parkway	Pensacola	FL	Active
DSH100093DM	Child	DSH	BAPTIST HOSPITAL	BH AIPMR AI 206 - BH AIPMR AI 206	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093DN	Child	DSH	BAPTIST HOSPITAL	Wound Care Center - Wound Care Center	121 Baptist Way	Pensacola	FL	Approved
DSH100093E	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - Women Services - Womens Services	9400 University Parkway	Pensacola	FL	Active
DSH100093F	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - Ultrasound - Ultrasound	9400 University Parkway	Pensacola	FL	Active
DSH100093G	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - CT - CT	9400 University Parkway	Pensacola	FL	Active
DSH100093H	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - Nuclear Medicine - Nuclear Medicine	9400 University Parkway	Pensacola	FL	Active
DSH100093J	Child	DSH	BAPTIST HOSPITAL	Baptist Medical Park - MRI - MRI	9400 University Parkway	Pensacola	FL	Active
DSH100093K	Child	DSH	BAPTIST HOSPITAL	BH AI Non-Surg SM AI 204 - BH AI Non-Surg SM AI 204	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Terminated
DSH100093L	Child	DSH	BAPTIST HOSPITAL	BH AI Non-Surg SM BMP9 101B - BH AI Non-Surg SM BMP9 101B	9400 University Parkway	Pensacola	FL	Terminated
DSH100093M	Child	DSH	BAPTIST HOSPITAL	BH AI Non-Surg SM BMPA 102 - BH AI Non-Surg SM BMPA 102	5100 North 12th Avenue	Pensacola	FL	Active
DSH100093N	Child	DSH	BAPTIST HOSPITAL	BH AI Non-Surg SM BMPN 201 - BH AI Non-Surg SM BMPN 201	8880 Navarre Parkway	Navarre	FL	Active
DSH100093P	Child	DSH	BAPTIST HOSPITAL	BH AI Non-Surg SM HWC	125 Baptist Way	Pensacola	FL	Terminated
DSH100093Q	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM AI 203 - BH AI Ortho SM AI 203	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093R	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM AI 204 - BH AI Ortho SM AI 204	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093S	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM AI 206 - BH AI Ortho SM AI 206	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093T	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM AI 208 - BH AI Ortho SM AI 208	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093U	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM BMP9 101B - BH AI Ortho SM BMP9 101B	9400 University Parkway	Pensacola	FL	Active
DSH100093V	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho SM BMPA 102 - BH AI Ortho SM BMPA 102	5100 North 12th Avenue	Pensacola	FL	Active
DSH100093W	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho Trauma AI 205 - BH AI Ortho Trauma AI 205	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093X	Child	DSH	BAPTIST HOSPITAL	BH AI Ortho Trauma HWC 4A	125 Baptist Way	Pensacola	FL	Active
DSH100093Y	Child	DSH	BAPTIST HOSPITAL	BH AI PMR AI 210 - BH AI PMR AI 210	1040 Gulf Breeze Parkway	Gulf Breeze	FL	Active
DSH100093Z	Child	DSH	BAPTIST HOSPITAL	BH AI PMR BMP9 101B - BH AI PMR BMP9 101B	9400 University Parkway	Pensacola	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Seelmann, Frederick Director of Pharmacy BHC 8504697567	Seelmann, Frederick Executive Director of Pharmacy BHC 8504697567	2/20/2025 12:19 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/15/2023 12:00:00 AM	9/4/2024 2:47 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/4/2024 2:47 PM
Terminations	Termination Comments	Update	Recertification		Clinic Closed this in our FY24.	9/4/2024 2:47 PM
Terminations	Termination Date	Update	Recertification		10/1/2024 12:00:00 AM	9/4/2024 2:47 PM
Terminations	Termination Effective Date	Update	Recertification		10/31/2023 12:00:00 AM	9/4/2024 2:47 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/4/2024 2:47 PM
Addresses	Main Address	Update	Change Request	1717 North E Street Suite 534 Pensacola, FL 32501	125 Baptist Way Pensacola, FL 32503	9/27/2023 1:49 PM
Details	Entity Subname	Update	Change Request	BH AI Non-Surg SM BMT 534 - BH AI Non-Surg SM BMT 534	BH AI Non-Surg SM HWC	9/27/2023 1:49 PM
Details	Comments Public	Insert	Change Request		Is the service changing and/or are there additional services being added?	9/25/2023 7:24 AM
Details	Last Recertification Date	Update	Recertification	9/14/2022 3:48:14 PM	9/5/2023 4:34:58 PM	9/5/2023 4:34 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 1:58:48 PM	9/14/2022 3:48:14 PM	9/14/2022 3:48 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 11:02:04 AM	9/8/2021 1:58:48 PM	9/8/2021 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1665931	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		83838	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		121575105	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AR	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		23088842	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HOS0093P	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000150433AA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		590657322-002	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300013901	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		553842	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1291723	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1733091	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		217105800	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HOS0093P	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		97779	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		250252	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HOS0093P	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		142769	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200060650B	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500773264	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100777553-0008	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10172A-inpatient	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10867B-outpatient	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100093	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100093	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1700979465 ( )		9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/11/2020 11:02 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700979465	9/11/2020 11:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/11/2020 11:02 AM
Details	Last Recertification Date	Update	Recertification		9/11/2020 11:02:04 AM	9/11/2020 11:02 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Terry, Andrew L. Vice President Revenue Management Baptist Health Care 8504697643	1/28/2020 11:19 AM
Details	340B ID	Update	New Registration		DSH100093P	1/28/2020 11:19 AM
Details	Entity Subname	Update	New Registration	BH AI Non-Surg SM BMT 534	BH AI Non-Surg SM BMT 534 - BH AI Non-Surg SM BMT 534	1/28/2020 11:19 AM
Dates	Participating Approval Date	Update	New Registration		1/28/2020 11:19:03 AM	1/28/2020 11:19 AM
Details	State	Update	New Registration	Pending	Approved	1/28/2020 11:19 AM
Dates	Signed By Date	Update	New Registration		1/13/2020 12:53:38 PM	1/28/2020 11:19 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	1/28/2020 11:19 AM
Addresses	Main Address	Insert	New Registration		1717 North E Street Suite 534 Pensacola, FL 32501	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HOS0093P	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10074900	1/10/2020 11:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/10/2020 11:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700979465	1/10/2020 11:22 PM
Contacts	Authorizing Official	Insert	New Registration		Terry, Andrew L. Vice President Revenue Management Baptist Health Care 8504697643	1/10/2020 11:22 PM
Contacts	Primary Contact	Insert	New Registration		Seelmann, Frederick Director of Pharmacy BHC 8504697567	1/10/2020 11:22 PM
Details	Last Recertification Date	Insert	New Registration			1/10/2020 11:22 PM
Details	Grant Number	Insert	New Registration			1/10/2020 11:22 PM
Details	340B ID	Insert	New Registration			1/10/2020 11:22 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2020 11:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2020 11:22 PM
Details	Medicare Provider Number	Insert	New Registration		100093	1/10/2020 11:22 PM
Details	Entity Name	Insert	New Registration		BAPTIST HOSPITAL	1/10/2020 11:22 PM
Details	Program Code	Insert	New Registration		DSH	1/10/2020 11:22 PM
Details	Entity Subname	Insert	New Registration		BH AI Non-Surg SM BMT 534	1/10/2020 11:22 PM
Dates	Participating Approval Date	Insert	New Registration			1/10/2020 11:22 PM
Details	State	Insert	New Registration		Pending	1/10/2020 11:22 PM
Dates	Registration Date	Insert	New Registration		1/10/2020 11:22:17 PM	1/10/2020 11:22 PM
Dates	Signed By Date	Insert	New Registration			1/10/2020 11:22 PM
Dates	Start Date	Insert	New Registration			1/10/2020 11:22 PM
Terminations	Termination Comments	Insert	New Registration			1/10/2020 11:22 PM
Terminations	Termination Date	Insert	New Registration			1/10/2020 11:22 PM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2020 11:22 PM
Terminations	Termination Reason	Insert	New Registration			1/10/2020 11:22 PM