Covered Entity Details

DSH320004AF GERALD CHAMPION REGIONAL MEDICAL CTR (Terminated) - information as of 6/18/2025 1:15:42 AM

Main Details

Name

GERALD CHAMPION REGIONAL MEDICAL CTR

Subdivision Name

Pediatrics of Alamogordo - Pediatrics of Alamogordo Downtown

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH320004AF

Medicare Provider Number

320004

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/14/2020

Participating Start Date

4/1/2020

Participating Approval Date

3/10/2020

Last Recertification Date

Termination Date
Termination Reason

10/1/2020
Business decision by the Covered Entity

Contacts

Authorizing Official

Otero County Hospital Association
Bashar Naser, CFO
(575) 443-7848 Ext: 5754437841

Primary Contact

Otero County Hospital Associaton
Cheri Christine Moore, Financial Analyst
(575) 443-7841

Addresses

Street Address

1212 9th Street
Suite A
Alamogordo, NM 88310-5842

Billing Address

Gerald Champion Regional Medical Center
2669 SCENIC DR
ALAMOGORDO, NM 88310-8734

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
NM	00000018
		1861450579

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
DSH320004A	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	AMBULATORY SURGERY CENTER	2351 25TH STREET	ALAMOGORDO	NM	Terminated
DSH320004AA	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Pulmonology	2559 Medical Drive	Alamogordo	NM	Active
DSH320004AB	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Urgent Care	250 East 1st Street	Alamogordo	NM	Active
DSH320004AC	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Sleep Center	2474 Indian Wells Road	Alamogordo	NM	Active
DSH320004AD	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Sleep and Behavioral Medicine Ruidoso	101 5th Street	Ruidoso	NM	Active
DSH320004AE	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Osteo Clinic	2559 Medical Drive	Alamogordo	NM	Active
DSH320004AF	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Pediatrics of Alamogordo - Pediatrics of Alamogordo Downtown	1212 9th Street	Alamogordo	NM	Terminated
DSH320004AG	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Champion Pain Management - Alamogordo	2474 Indian Wells Road	Alamogordo	NM	Terminated
DSH320004AH	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Family Medicine Ruidoso	101 5th Street	Ruidoso	NM	Active
DSH320004AJ	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Pain Management Roswell	400 North Pennsylvania Avenue	Roswell	NM	Active
DSH320004AK	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Pain Management Alamogordo	2559 Medical Drive	Alamogordo	NM	Active
DSH320004AL	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Neurology and Diagnostics	2050 North Scenic Drive	Alamogordo	NM	Active
DSH320004B	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Family Medicine Tenth Street	1401 10TH STREET	ALAMOGORDO	NM	Active
DSH320004C	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Cancer Center	2559 Medical Drive	Alamogordo	NM	Active
DSH320004D	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Endocrinology	2579 North Scenic Drive	Alamogordo	NM	Active
DSH320004E	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Family Practice of Alamogordo	1315 12th Street	Alamogordo	NM	Terminated
DSH320004F	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	General & Vascular Surgery	1212 9th Street, Suite C	Alamogordo	NM	Terminated
DSH320004G	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Internal Medicine Ninth Street	1101 9th Street	Alamogordo	NM	Active
DSH320004H	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Surgical Associates	2559 Medical Drive	Alamogordo	NM	Active
DSH320004J	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Cardiology	2559 Medical Drive	Alamogordo	NM	Active
DSH320004K	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Surgical Association of Alamo - Suite F	2559 Medical Drive	ALAMOGORDO	NM	Terminated
DSH320004L	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Women's Specialty Services	2050 NORTH SCENIC DRIVE	ALAMOGORDO	NM	Terminated
DSH320004M	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Family Medicine Medical Drive	2539 Medical Drive	ALAMOGORDO	NM	Active
DSH320004N	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Nephrology	2579 NORTH SCENIC DRIVE	ALAMOGORDO	NM	Active
DSH320004P	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Orthopedics Complex	2559 Medical Drive	ALAMOGORDO	NM	Active
DSH320004Q	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Gastroenterology	2539 Medical Drive	ALAMOGORDO	NM	Active
DSH320004R	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Women's Health	2559 Medical Drive	Alamogordo	NM	Active
DSH320004S	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Champion Primary Group	1212 9th Street	Alamogordo	NM	Terminated
DSH320004T	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Occupational Health	2559 Medical Drive	Alamogordo	NM	Active
DSH320004U	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Behavioral Medicine Alamogordo	2351 25th Street	Alamogordo	NM	Active
DSH320004V	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Internal Medicine	2559 Medical Drive	Alamogordo	NM	Active
DSH320004W	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Pediatrics	2559 Medical Drive	Alamogordo	NM	Active
DSH320004X	Child	DSH	GERALD CHAMPION REGIONAL MEDICAL CTR	Champion Health and Wellness Clinic	1212 9th Street	Alamogordo	NM	Terminated
DSH320004Y	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Neurology	2539 Medical Drive	Alamogordo	NM	Active
DSH320004Z	Child	DSH	CHRISTUS Southern New Mexico	CHRISTUS Southern New Mexico Family Medicine	2351 25th Street Drive	Alamogordo	NM	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/15/2020 12:00:00 AM	9/15/2020 10:42 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/15/2020 10:42 AM
Terminations	Termination Comments	Update	Recertification		Another Pediatrics Clinic opened and will be registered in January 2021. The Business decision was to combined and then add a new Pain clinic in its place.	9/15/2020 10:42 AM
Terminations	Termination Date	Update	Recertification		10/1/2020 12:00:00 AM	9/15/2020 10:42 AM
Terminations	Termination Effective Date	Update	Recertification		7/20/2020 12:00:00 AM	9/15/2020 10:42 AM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/15/2020 10:42 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Naser, Bashar CFO Otero County Hospital Association 5754437848-5754437841	3/10/2020 9:21 PM
Details	340B ID	Update	New Registration		DSH320004AF	3/10/2020 9:21 PM
Details	Entity Subname	Update	New Registration	Pediatrics of Alamogordo	Pediatrics of Alamogordo - Pediatrics of Alamogordo Downtown	3/10/2020 9:21 PM
Dates	Participating Approval Date	Update	New Registration		3/10/2020 9:21:24 PM	3/10/2020 9:21 PM
Details	State	Update	New Registration	Pending	Approved	3/10/2020 9:21 PM
Dates	Signed By Date	Update	New Registration		1/14/2020 6:04:25 PM	3/10/2020 9:21 PM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	3/10/2020 9:21 PM
Addresses	Main Address	Insert	New Registration		1212 9th Street Suite A Alamogordo, NM 88310-5842	1/14/2020 5:27 PM
Addresses	Billing Address	Insert	New Registration		Gerald Champion Regional Medical Center 2669 SCENIC DR ALAMOGORDO, NM 88310-8734	1/14/2020 5:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/14/2020 5:27 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00000018	1/14/2020 5:27 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	1/14/2020 5:27 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1861450579	1/14/2020 5:27 PM
Contacts	Primary Contact	Insert	New Registration		Moore, Cheri Christine Financial Analyst Otero County Hospital Associaton 5754437841	1/14/2020 5:27 PM
Contacts	Authorizing Official	Insert	New Registration		Naser, Bashar CFO Otero County Hospital Association 5754437848-5754437841	1/14/2020 5:27 PM
Details	Last Recertification Date	Insert	New Registration			1/14/2020 5:27 PM
Details	Grant Number	Insert	New Registration			1/14/2020 5:27 PM
Details	340B ID	Insert	New Registration			1/14/2020 5:27 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/14/2020 5:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/14/2020 5:27 PM
Details	Medicare Provider Number	Insert	New Registration		320004	1/14/2020 5:27 PM
Details	Entity Name	Insert	New Registration		GERALD CHAMPION REGIONAL MEDICAL CTR	1/14/2020 5:27 PM
Details	Program Code	Insert	New Registration		DSH	1/14/2020 5:27 PM
Details	Entity Subname	Insert	New Registration		Pediatrics of Alamogordo	1/14/2020 5:27 PM
Dates	Participating Approval Date	Insert	New Registration			1/14/2020 5:27 PM
Details	State	Insert	New Registration		Pending	1/14/2020 5:27 PM
Dates	Registration Date	Insert	New Registration		1/14/2020 5:27:09 PM	1/14/2020 5:27 PM
Dates	Signed By Date	Insert	New Registration			1/14/2020 5:27 PM
Dates	Start Date	Insert	New Registration			1/14/2020 5:27 PM
Terminations	Termination Comments	Insert	New Registration			1/14/2020 5:27 PM
Terminations	Termination Date	Insert	New Registration			1/14/2020 5:27 PM
Terminations	Termination Effective Date	Insert	New Registration			1/14/2020 5:27 PM
Terminations	Termination Reason	Insert	New Registration			1/14/2020 5:27 PM