Covered Entity Details

DSH450054GN SCOTT AND WHITE MEMORIAL HOSPITAL (Active) - information as of 4/29/2025 11:51:09 PM

Main Details

Name

SCOTT AND WHITE MEMORIAL HOSPITAL

Subdivision Name

Baylor Scott & White Clinic - Belton/Radiology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450054GN

Medicare Provider Number

450054

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/2/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/7/2020

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Baylor Scott & White Medical Center - Temple
Gregory Haralson, President
(254) 724-6583

Primary Contact

Baylor Scott & White Medical Center - Temple
Christy Evans, Mgr Pharmacy
(254) 724-2081

Addresses

Street Address

1505 N MAIN ST
BELTON, TX 76513-1907

Billing Address

SCOTT AND WHITE MEMORIAL HOSPITAL
2401 S 31st St
Temple, TX 76508

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	1372492-08,1372492-06	1477516466,1720102528

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
DSH450054AA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Cameron/Pulmonology	101 LAFFERTY AVENUE	CAMERON	TX	Terminated
DSH450054AB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple Westfield	7556 HONEYSUCKLE	TEMPLE	TX	Active
DSH450054AD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Harker Heights Morgan Street/Optometry	326 MORGAN ST	HARKER HEIGHTS	TX	Active
DSH450054AE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE HARKER HEIGHTS EYE	201 East Central Texas Expressway	HARKER HEIGHTS	TX	Terminated
DSH450054AH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE HARKER HEIGHTS EYE	201 East Central Texas Expressway	HARKER HEIGHTS	TX	Terminated
DSH450054AJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Wound Care	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054AM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE WACO MACARTHUR PEDIATRIC CLINIC	2201 MACARTHUR DRIVE	WACO	TX	Terminated
DSH450054AN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	MCLANE CHILDREN'S HOSPITAL-SCOTT & WHITE	1901 SW HK DODGEN LOOP	Temple	TX	Terminated
DSH450054AP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Clinic - Belton	1009 ARBOR PARK DR	BELTON	TX	Active
DSH450054AQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE BELTON SOUTH CLINIC	1001 ARBOR PARK DRIVE	BELTON	TX	Terminated
DSH450054AR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Clinic - Temple West	6684 W ADAMS AVE	TEMPLE	TX	Active
DSH450054AS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Physical Medicine & Rehabilitation	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054AT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Roney Bone & Joint Institute/Joint Clinic	2401 SOUTH 31ST STREET	TEMPLE	TX	Terminated
DSH450054AU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Roney Bone & Joint Institute/Hand Clinic	2401 SOUTH 31ST STREET	TEMPLE	TX	Terminated
DSH450054AV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Roney Bone & Joint Institute/Foot and Ankle Clinic	2401 SOUTH 31ST STREET	TEMPLE	TX	Terminated
DSH450054AW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Spine Center	2401 S 31ST ST	TEMPLE	TX	Terminated
DSH450054AX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Roney Bone & Joint Institute/Sports Medicine Clinic	2401 SOUTH 31ST STREET	TEMPLE	TX	Terminated
DSH450054AY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Orthopedics	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054AZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Roney Bone & Joint Institute/Medical Orthopedics	2401 SOUTH 31ST STREET	TEMPLE	TX	Terminated
DSH450054BA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE PEDIATRIC DENTISTRY	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054BB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Pediatric Orthopedics	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054BC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Child Psychiatry	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Adolescent Medicine	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Cancer and Blood Disorders Center	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Infectious Disease	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Pulmonology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Nephrology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Endocrinology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSh450054BK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Cardiology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Gastroenterology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/General Pediatrics	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Neurology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/General Surgery	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054BQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Waco Spine Center at Hillcrest	50 Hillcrest Medical Blvd.	Waco	TX	Terminated
DSH450054BR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Neurosciences Clinic - Waco/Physical Medicine & Rehabilitation	50 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054BS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Cameron/Podiatry	101 Lafferty Avenue	Cameron	TX	Terminated
DSH450054BT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Cameron/Family Medicine	101 LAFFERTY AVE	CAMERON	TX	Active
DSH450054BU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Center for Diagnostic Medicine - Temple/Infusion Center	1605 S 31ST ST	TEMPLE	TX	Active
DSH450054BV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Center for Diagnostic Medicine - Temple/Rheumatology	1605 S 31ST ST	TEMPLE	TX	Active
DSH450054BW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Center for Diagnostic Medicine - Temple/Endocrinology	1605 S 31ST ST	TEMPLE	TX	Active
DSH450054BX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Center for Diagnostic Medicine - Temple/Allergy and Immunology	1605 S 31ST ST	TEMPLE	TX	Active
DSH450054BY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Medical Specialties Clinic - Waco Hillcrest/Pulmonary Medicine	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054BZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Podiatry	7700 FISH POND RD	WACO	TX	Active
DSH450054C	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Belton	1505 N MAIN ST	BELTON	TX	Active
DSH450054CA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Ophthalmology	7700 FISH POND RD	WACO	TX	Active
DSH450054CB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Nephrology	7700 FISH POND RD	WACO	TX	Terminated
DSH450054CC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Family Medicine	7700 FISH POND RD	WACO	TX	Active
DSH450054CD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott and White Waco Allergy	7700 Fishpond Road	Waco	TX	Terminated
DSH450054CE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Gastroenterology	7700 FISH POND RD	WACO	TX	Active
DSH450054CF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Dermatology	7700 FISH POND RD	WACO	TX	Active
DSH450054CG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Gatesville/Family Medicine	319 HIGHWAY 36 BYP S	GATESVILLE	TX	Active
DSH450054CH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott and White Gatesville Anti-Coagulation Service	227 Memorial Drive	Gatesville	TX	Terminated
DSH450054CJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Podiatry	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Urology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Otolaryngology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/General Surgery	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Specialty Clinic - Killeen Hemingway/General Pediatrics	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Orthopedics	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Obstetrics and Gynecology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Neurology	2405 S CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054CT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Gastroenterology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Cardiology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Anesthesiology/Pain Management	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054CW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Podiatry	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054CX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Nephrology & Temple Dialysis Center - Temple South Loop	2601 Thornton Lane	Temple	TX	Terminated
DSH450054CY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/General Pediatrics	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054CZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott and White Killeen Dermatology	3801 Scott and White Drive	Killeen	TX	Terminated
DSH450054D	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE KILLEEN CLINIC	3801 SCOTT AND WHITE DRIVE	KILLEEN	TX	Terminated
DSH450054DA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen/Family Medicine	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054DB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple Northside/Family Medicine	409 W Adams	Temple	TX	Terminated
DSH450054DC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Care Center Dermatology Clinic - Temple	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054DD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Center for Diagnostic Medicine - Temple/Internal Medicine	1605 S 31ST ST	TEMPLE	TX	Active
DSH450054DE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Surgery Center	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054DF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Mental Health Clinic - Temple	810 W U AVE	TEMPLE	TX	Active
DSH450054DG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Neurosciences Clinic - Waco/Neurosurgery	50 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054DH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Endocrinology	7700 FISH POND RD	WACO	TX	Active
DSH450054DJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Emergency Department	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Trauma Network	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Belton South	1001 ARBOR PARK DR	BELTON	TX	Active
DSH450054DM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center/NICU Follow-up	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center / Peri-op Materials Management	1901 SW HK Dodgen Loop	Temple	TX	Terminated
DSH450054DP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - EEG	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Speech Pathology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054DS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Pathology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Diagnostic Radiology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Interventional Radiology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Ultrasound	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Day Surgery Center	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - PACU	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054DY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Anesthesia	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054DZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Child Development	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054E	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE KILLEEN OB/GYN CLINIC	3106 S. WS YOUNG	KILLEEN	TX	Terminated
DSH450054EA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Ear, Nose & Throat	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054EB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Podiatry	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054EC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Urology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054ED	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen/Nephrology	2405 S Clear Creek Rd	KILLEEN	TX	Active
DSH450054EE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Cardiology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054EF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	McLane Children's Scott & White Clinic - Killeen Hemingway/Endocrinology	2405 S. Clear Creek Road	Killeen	TX	Terminated
DSH450054EG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Gastroenterology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054EH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Hematology/Oncology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054EJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Pulmonology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054EK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White OB/GYN Clinic - Waco Hillcrest	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054EL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Clinic - Waco Hillcrest/General Pediatrics	120 HILLCREST MEDICAL BLVD	Waco	TX	Active
DSH450054EM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Hematology/Oncology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054EN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Endocrinology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054EP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - EKG	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054EQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White OB/GYN Clinic - Belton South	1001 Arbor Park Drive	Belton	TX	Terminated
DSH450054ER	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Nephrology	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054ES	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Ophthalmology	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054ET	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Optometry	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054EW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Pain Management	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054EY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Sleep Institute - Temple	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054EZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Dialysis	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054F	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Dialysis Center - Killeen West	2201 S W S YOUNG DR	KILLEEN	TX	Active
DSH450054FA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Operating Room	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Nuclear Medicine	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - CT	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Blood Services	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054FE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Occupational Therapy	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Physical Therapy	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - MRI	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	McLane Children's Scott & White Clinic - Killeen Hemingway/Neonatology	2405 S. Clear Creek Road	Killeen	TX	Terminated
DSH450054FJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pain Clinic - Waco/Pain Management	50 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054FK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Dialysis Center - Round Rock	2120 N MAYS ST	ROUND ROCK	TX	Active
DSH450054FL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Neurosciences Clinic - Waco/Neurology	50 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054FM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Child Abuse	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Nephrology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054FP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple Professional Plaza II/OBGYN	1713 SW H K DODGEN LOOP	Temple	TX	Active
DSH450054FQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Cancer Center - Killeen/Radiation Oncology	2207 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054FR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Ultrasound	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054FS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's & Baylor Scott & White Clinic - Killeen/Adolescent Medicine	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054FT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Echo Lab	2405 S CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054FU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Radiology	7700 FISH POND RD	WACO	TX	Active
DSH450054FV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Pulmonology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054FW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Plastic Surgery	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054FX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/PFT Lab	2405 S CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054FY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Cancer Center - Killeen/Hematology/Oncology	2207 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054FZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Echo Lab	7700 FISH POND RD	WACO	TX	ToBeTerminated
DSH450054G	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Santa Fe/Family Medicine	1402 W AVENUE H	TEMPLE	TX	Active
DSH450054GA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/GI Procedure Suite	7700 FISH POND RD	WACO	TX	Terminated
DSH450054GB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone & Joint Institute/Radiology	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054GC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Pediatric Surgery	120 HILLCREST MEDICAL BLVD	Waco	TX	Active
DSH450054GD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Cancer Center - Killeen/Chemo Infusion	2207 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054GE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Cardiology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054GF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Procedural Nursing	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Pediatric Convenient Care	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center/Pediatric Orthopedics	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054GJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Belton South/Radiology	1001 ARBOR PARK DR	BELTON	TX	Active
DSH450054GK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Adolescent Medicine	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054GL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Santa Fe/Radiology	1402 W AVENUE H	TEMPLE	TX	Active
DSH450054GM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Santa Fe/Mental Health	1402 W AVENUE H	TEMPLE	TX	Active
DSH450054GN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Belton/Radiology	1505 N MAIN ST	BELTON	TX	Active
DSH450054GP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Forensic Nurses	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Neurosurgery	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Medical Infusion	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Radiology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Active
DSH450054GT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Mental Health Clinic - Temple/Alcohol Rehab	810 W U AVE	TEMPLE	TX	Active
DSH450054GU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Surgical Specialties	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054GV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Diagnostic Radiology	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054GW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Radiology	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054GX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Mental Health Clinic - Harker Heights	326 MORGAN ST	HARKER HEIGHTS	TX	Terminated
DSH450054GY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Salado/Radiology	3525 FM 2484	SALADO	TX	Active
DSH450054GZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen/Radiology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054H	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE NORTHSIDE CLINIC	409 W ADAMS	TEMPLE	TX	Terminated
DSH450054HA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Cancer Center- Killeen/Anticoagulation Clinic	2207 S CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054HB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple Northside - Radiology	409 W Adams Ave	Temple	TX	Terminated
DSH450054HC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen West/Radiology	4501 S CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054HD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Hewitt/Radiology	510 N HEWITT DR	HEWITT	TX	Active
DSH450054HE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Bellmead - Radiology	556 N Loop 340	Bellmead	TX	Terminated
DSH450054HF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Harker Heights - Radiology	907 Mountain Lion Cir	Harker Heights	TX	Terminated
DSH450054HG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Convenient Care	7700 FISH POND RD	WACO	TX	Terminated
DSH450054HH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Mental Health	7700 FISH POND RD	WACO	TX	Active
DSH450054HJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Waco/Anticoagulation	7700 FISH POND RD	WACO	TX	Active
DSH450054HK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Westfield/Radiology	7556 HONEYSUCKLE	TEMPLE	TX	Active
DSH450054HL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Cameron/Radiology	101 LAFFERTY AVE	CAMERON	TX	Active
DSH450054HM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Waco/Cardiology	50 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054HN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen/Endocrinology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054HP	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Nephrology Injection	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054HQ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Harker Heights/Obstetrics and Gynecology	907 MOUNTAIN LION CIR	HARKER HEIGHTS	TX	Active
DSH450054HR	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Temple/Rheumatology	1901 SW H K DODGEN LOOP	TEMPLE	TX	Terminated
DSH450054HS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Nephrology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054HT	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Podiatry	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054HU	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Temple South Loop/Home Dialysis	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054HV	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Endocrinology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054HW	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Spine Orthopaedics	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054HX	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Anesthesiology	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054HY	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Roney Bone and Joint Institute/Physical Therapy	2401 S 31ST ST	TEMPLE	TX	Active
DSH450054HZ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Gastroenterology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054I	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE CENTER FOR DIAGNOSTIC MEDICINE	1605 S. 31ST ST.	TEMPLE	TX	Terminated
DSH450054J	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Dialysis Center - Killeen	3701 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054JA	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Specialty Clinic - Waco Hillcrest/Neurology	120 HILLCREST MEDICAL BLVD	WACO	TX	Active
DSH450054JB	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Pavilion - Temple/Radiology	1815 S 31ST ST	TEMPLE	TX	Active
DSH450054JC	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Neurology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054JD	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's at Baylor Scott & White Clinic - Killeen/Convenient Care	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054JE	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen/Mental Health	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054JF	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Mental Health Clinic - Temple/Psychiatry Fast Access	810 W U AVE	TEMPLE	TX	Active
DSH450054JG	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	BAYLOR SCOTT & WHITE SPECIALTY CLIN - Dermatology	907 MOUNTAIN LION CIR	HARKER HEIGHTS	TX	Active
DSH450054JH	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	BAYLOR SCOTT & WHITE CLINIC-TEMPLE - South Loop/Pediatric Dialysis	2601 THORNTON LN	TEMPLE	TX	Active
DSH450054JJ	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	BAYLOR SCOTT & WHITE CLINIC-KILLEEN - Rheumatology	3801 SCOTT AND WHITE DR	KILLEEN	TX	Active
DSH450054JK	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White McLane Children's Medical Center - Lab	1901 SW HK DODGEN LOOP	Temple	TX	Active
DSH450054JL	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	BAYLOR SCOTT & WHITE MENTAL HEALTH CLINIC-TEMPLE - Treatment Resistant Depression	810 W U AVE	TEMPLE	TX	Active
DSH450054JM	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Cosmetic Surgery Center - Temple	2401 S 31st ST	TEMPLE	TX	Active
DSH450054JN	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	BAYLOR SCOTT & WHITE CLINIC-KILLEEN - Allergy	3801 SCOTT AND WHITE DR	Killeen	TX	Active
DSH450054K	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	SCOTT AND WHITE PAVILION CTR	1815 S 31ST	TEMPLE	TX	Terminated
DSH450054L	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Killeen West	4501 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054M	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Cancer Center - Killeen	2207 South Clear Creek Road	KILLEEN	TX	Terminated
DSH450054N	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	HILLCREST PAIN AND SPINE	50 HILLCREST MEDICAL CENTER BLVD,	WACO	TX	Terminated
DSH450054P	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	MCLANE CHILDREN'S PEDI AND OB/GYN AT HILLCREST	120 HILLCREST BAPTIST MEDICAL CENTER BLVD	WACO	TX	Terminated
DSH450054Q	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	KILLEEN METROPLEX	2405 S. CLEAR CREEK RD	KILLEEN	TX	Terminated
DSH450054R	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Salado	3525 FM 2484	SALADO	TX	Active
DSH450054RS	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Specialty Clinic - Killeen Hemingway/Pulmonary	2405 S CLEAR CREEK RD	KILLEEN	TX	Active
DSH450054S	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	TEMPLE TOWNE CENTER	2112 LOOP 363	TEMPLE	TX	Terminated
DSH450054T	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	GATESVILLE	319 South Hwy 36 Bypass	Gatesville	TX	Terminated
DSH450054U	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Harker Heights	907 MOUNTAIN LION CIRCLE	HARKER HEIGHTS	TX	Terminated
DSH450054V	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Moody	498 AVE E	MOODY	TX	Terminated
DSH450054W	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Hewitt	510 N HEWITT DR	HEWITT	TX	Active
DSH450054X	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	WACO	7700 FISHPOND ROAD	WACO	TX	Terminated
DSH450054Y	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Scott & White Nephrology & Dialysis Center - Round Rock	2120 N. MAYS	ROUND ROCK	TX	Terminated
DSH450054Z	Child	DSH	SCOTT AND WHITE MEMORIAL HOSPITAL	Baylor Scott & White Clinic - Bellmead	556 N. LOOP 340	BELLMEAD	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	1372492-07 (TX)		8/28/2024 7:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/28/2024 7:03 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1372492-06	8/28/2024 7:03 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/28/2024 7:03 PM
Details	Last Recertification Date	Update	Recertification	8/20/2023 4:16:35 PM	8/28/2024 7:03:48 PM	8/28/2024 7:03 PM
Contacts	Primary Contact	Update	Profile Change Request	Evans, Christy Elaine Pharmacist Specialist Baylor Scott & White Medical Center - Temple 2547242081	Evans, Christy Mgr Pharmacy Baylor Scott & White Medical Center - Temple 2547242081	3/18/2024 5:12 PM
Contacts	Authorizing Official	Update	Change Request	Snell, Scott Altus Vice President Baylor Scott & White Medical Center - Temple 2547245292	Haralson, Gregory President Baylor Scott & White Medical Center - Temple 2547246583	1/22/2024 11:26 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (AK)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (AZ)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (AR)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (CA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (CT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (FL)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (GA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (IL)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (IN)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (KY)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (LA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NM)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NY)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (OH)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (OK)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (PA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (TN)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (VT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (WA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (WI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (CO)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (HI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (ID)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (IA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MS)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NV)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NC)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (OR)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (SC)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (UT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (VA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (WY)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (AK)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (AZ)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (AR)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (CA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (CO)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (CT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (FL)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (GA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (HI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (ID)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (IL)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (IN)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (IA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (KY)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (LA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MS)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NV)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NY)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NM)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NC)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (OH)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (OK)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (OR)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (PA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (SC)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (TN)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (UT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (VT)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (VA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (WA)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (WI)		12/22/2023 1:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (WY)		12/22/2023 1:11 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	244018 (AZ)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	229670105 (AR)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003211405A (GA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	741166904002 (IL)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300037858 (IN)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	7100539640 (KY)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1733962 (LA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	110154147A (MA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	46130829 (NM)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	244220 (OH)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100701070C (OK)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0017785520003 (PA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	Q055242 (TN)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	6701939 (VT)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2150692 (WA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100088292 (WI)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	00096862 (MS)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003231338A (GA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	021659200 (FL)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	122961 (SC)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100088292 (WY)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1729631 (AK)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (CA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (CT)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (ID)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (IA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (MI)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (MT)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (NV)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (NC)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (OR)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (UT)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (VA)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9000158553 (CO)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	05180290 (NY)		12/4/2023 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (AL)		9/8/2023 12:31 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477516466 (CO)		9/8/2023 12:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/8/2023 12:31 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000158553	9/8/2023 12:31 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	9/8/2023 12:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/8/2023 12:31 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05180290	9/8/2023 12:31 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	9/8/2023 12:31 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (AL)		9/8/2023 12:31 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MO)		9/8/2023 12:31 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (AL)		9/8/2023 12:31 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MO)		9/8/2023 12:31 PM
Contacts	Authorizing Official	Update	Change Request	Motakef, Shahin CEO Baylor Scott & White Medical Center - Temple 2547246583	Snell, Scott Altus Vice President Baylor Scott & White Medical Center - Temple 2547245292	9/7/2023 6:36 AM
Addresses	Billing Address	Insert	Recertification		SCOTT AND WHITE MEMORIAL HOSPITAL 2401 S 31st St Temple, TX 76508	8/20/2023 4:16 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 5:28:55 PM	8/20/2023 4:16:35 PM	8/20/2023 4:16 PM
Contacts	Primary Contact	Update	Group Change Request	Rosatti, Rosie 340B Pharmacist Baylor Scott & White Medical Center - Temple 2547242081	Evans, Christy Elaine Pharmacist Specialist Baylor Scott & White Medical Center - Temple 2547242081	8/10/2023 2:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AL	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1729631	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AK	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CT	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		ID	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IA	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MI	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MT	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NV	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NC	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OR	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		UT	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1477516466	3/16/2023 7:37 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		VA	3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (DE)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (DC)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (KS)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (ME)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MD)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (MN)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NE)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NH)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (NJ)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (ND)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (RI)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (SD)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1477516466 (WV)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (DE)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (DC)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (KS)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (ME)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MD)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (MN)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NE)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NH)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (NJ)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (ND)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (RI)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (SD)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720102528 (WV)		3/16/2023 7:37 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (TX)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (AL)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (AK)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (AZ)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (AR)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (CA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (CT)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (FL)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (GA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (IL)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (IN)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (KY)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (LA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MO)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NM)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NY)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (OH)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (OK)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (PA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (TN)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (VT)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (WA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (WI)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (CO)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (DE)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (DC)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (HI)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (ID)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (IA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (KS)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (ME)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MD)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MI)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MN)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MS)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (MT)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NE)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NV)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NH)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NJ)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (NC)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (ND)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (OR)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (RI)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (SC)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (SD)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (UT)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (VA)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (WV)		8/31/2022 5:28 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497833685 (WY)		8/31/2022 5:28 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 2:10:19 PM	8/31/2022 5:28:55 PM	8/31/2022 5:28 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (AL)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (AK)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (CA)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (CT)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	21659200 (FL)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	20200401 (GA)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	010053942 (MO)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (NM)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	05180290 (NY)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (NY)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (OK)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (TN)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	Q055242 (VT)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249208 (VT)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	137249206 (CA)		7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		00096862	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MS	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		003231338A	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		021659200	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		122961	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		SC	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		100088292	7/13/2022 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WY	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AK	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AZ	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AR	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CT	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		DC	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		HI	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		ID	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		LA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		ME	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MD	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MO	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MT	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NV	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NH	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NJ	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NM	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OK	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		SD	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TN	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		UT	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VT	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WA	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	7/13/2022 7:20 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720102528	7/13/2022 7:20 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WY	7/13/2022 7:20 AM
Addresses	Main Address	Update	Recertification	1505 N Main St Belton, TX 76513	1505 N MAIN ST BELTON, TX 76513-1907	9/7/2021 2:10 PM
Details	Last Recertification Date	Update	Recertification	8/29/2020 11:56:53 AM	9/7/2021 2:10:19 PM	9/7/2021 2:10 PM
Details	Entity Subname	Update	Recertification	Baylor Scott & White Clinic - Belton - Radiology	Baylor Scott & White Clinic - Belton/Radiology	9/7/2021 2:10 PM
Contacts	Primary Contact	Update	Change Request	Rainey, Sara Pharmacy Specialist Scott & White Medical Center - Temple 2547242081	Rosatti, Rosie 340B Pharmacist Baylor Scott & White Medical Center - Temple 2547242081	2/12/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/11/2020 7:23 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137249206	12/11/2020 7:23 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	12/11/2020 7:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		244018	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		229670105	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AR	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		21659200	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003211405A	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		20200401	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		741166904002	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300037858	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7100539640	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1733962	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110154147A	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		010053942	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		46130829	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		05180290	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		244220	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100701070C	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0017785520003	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q055242	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q055242	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137249208	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		6701939	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2150692	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100088292	8/29/2020 11:56 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		HI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		HI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		KS	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		KS	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NV	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NV	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NH	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NH	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ND	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		ND	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		RI	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		SD	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		SD	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477516466	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/29/2020 11:56 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497833685	8/29/2020 11:56 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/29/2020 11:56 AM
Details	Last Recertification Date	Update	Recertification		8/29/2020 11:56:53 AM	8/29/2020 11:56 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Motakef, Shahin CEO Baylor Scott & White Medical Center - Temple 2547246583	4/7/2020 12:11 PM
Details	340B ID	Update	New Registration		DSH450054GN	4/7/2020 12:11 PM
Details	Entity Subname	Update	New Registration	Baylor Scott & White Clinic - Belton	Baylor Scott & White Clinic - Belton - Radiology	4/7/2020 12:11 PM
Dates	Participating Approval Date	Update	New Registration		4/7/2020 12:11:18 PM	4/7/2020 12:11 PM
Details	State	Update	New Registration	Pending	Approved	4/7/2020 12:11 PM
Dates	Signed By Date	Update	New Registration		4/3/2020 8:01:34 AM	4/7/2020 12:11 PM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/7/2020 12:11 PM
Addresses	Main Address	Insert	New Registration		1505 N Main St Belton, TX 76513	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1372492-08	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1372492-07	4/2/2020 12:15 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/2/2020 12:15 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1477516466	4/2/2020 12:15 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720102528	4/2/2020 12:15 PM
Contacts	Primary Contact	Insert	New Registration		Rainey, Sara Pharmacy Specialist Scott & White Medical Center - Temple 2547242081	4/2/2020 12:15 PM
Contacts	Authorizing Official	Insert	New Registration		Motakef, Shahin CEO Baylor Scott & White Medical Center - Temple 2547246583	4/2/2020 12:15 PM
Details	Last Recertification Date	Insert	New Registration			4/2/2020 12:15 PM
Details	Grant Number	Insert	New Registration			4/2/2020 12:15 PM
Details	340B ID	Insert	New Registration			4/2/2020 12:15 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/2/2020 12:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/2/2020 12:15 PM
Details	Medicare Provider Number	Insert	New Registration		450054	4/2/2020 12:15 PM
Details	Entity Name	Insert	New Registration		SCOTT AND WHITE MEMORIAL HOSPITAL	4/2/2020 12:15 PM
Details	Program Code	Insert	New Registration		DSH	4/2/2020 12:15 PM
Details	Entity Subname	Insert	New Registration		Baylor Scott & White Clinic - Belton	4/2/2020 12:15 PM
Dates	Participating Approval Date	Insert	New Registration			4/2/2020 12:15 PM
Details	State	Insert	New Registration		Pending	4/2/2020 12:15 PM
Dates	Registration Date	Insert	New Registration		4/2/2020 12:15:50 PM	4/2/2020 12:15 PM
Dates	Signed By Date	Insert	New Registration			4/2/2020 12:15 PM
Dates	Start Date	Insert	New Registration			4/2/2020 12:15 PM
Terminations	Termination Comments	Insert	New Registration			4/2/2020 12:15 PM
Terminations	Termination Date	Insert	New Registration			4/2/2020 12:15 PM
Terminations	Termination Effective Date	Insert	New Registration			4/2/2020 12:15 PM
Terminations	Termination Reason	Insert	New Registration			4/2/2020 12:15 PM