Covered Entity Details

DSH490007U SENTARA NORFOLK GENERAL HOSPITAL (Active) - information as of 5/28/2025 6:32:35 PM

Main Details

Name

SENTARA NORFOLK GENERAL HOSPITAL

Subdivision Name

SNGH Rheumatology - Kempsville - 801 0198

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH490007U

Medicare Provider Number

490007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/7/2020

Participating Start Date

7/1/2020

Participating Approval Date

6/1/2020

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Sentara Norfolk General Hospital
Christopher P Pierson, Chief Operating Officer
(757) 388-4275

Primary Contact

Sentara Healthcare
JON D HORTON, System Director of Pharmacy
(757) 388-5854

Addresses

Street Address

844 Kempsville Road
Suite 103B
Norfolk, VA 23502

Billing Address

Sentara Norfolk General Hospital
1300 Sentara Park
Virginia Beach, VA 23464

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
NC		1346314192,1396275418,1437119310,1649345158,1215024617
VA		1346314192,1396275418,1437119310,1649345158,1215024617

Shipping Addresses

Shipping Address 1

Sentara Norfolk General Hospital
600 Gresham Drive
Norfolk, VA 23507

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
DSH490007A	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	ACUTE CARE	600 GRESHAM DRIVE	NORFOLK	VA	Terminated
DSH490007AA	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Internal Med - Fort Norfolk - IM	301 Riverview Avenue	Norfolk	VA	Active
DSH490007B	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	AMBULATORY CARE	600 GRESHAM DRIVE	NORFOLK	VA	Terminated
DSH490007C	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	RALEIGH OUTPATIENT CLINIC	600 GRESHAM DRIVE	NORFOLK	VA	Terminated
DSH490007D	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	THE INFUSION CENTER A SERVICE OF SENTARA NORFOLK GENERAL HOSPITAL	3000 Coliseum Drive	Hampton	VA	Active
DSH490007E	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SENTARA INFUSION CENTER II	800 Independence Blvd.	Virginia Beach	VA	Active
DSH490007F	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SENTARA INFUSION CENTER III (NDC)	844 Kempsville Road	Norfolk	VA	Active
DSH490007G	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Sentara Infusion Center IV (Obici)	2800 Godwin Blvd.	Suffolk	VA	Active
DSH490007H	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Sentara Ambulatory Care Center	130 Colley Avenue	Norfolk	VA	Active
DSH490007J	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Fort Norfolk Diagnostic Center / Radiology CT Scan/Ambulatory	301 Riverview Ave	Norfolk	VA	Active
DSH490007K	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Sentara PET Mobile / Radiology PET Mobile	5900 Lake Wright Drive	Norfolk	VA	Terminated
DSH490007L	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Sentara Fort Norfolk / Pain Management	301 Riverview Ave	Norfolk	VA	Terminated
DSH490007M	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Infectious Disease - Fort Norfolk	301 Riverview Avenue	Norfolk	VA	Active
DSH490007N	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Infectious Disease - Hampton - 801 0253	4000 Coliseum Drive	Hampton	VA	Active
DSH490007P	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Infectious Disease - Suffolk - 801 0281	2790 Godwin Boulevard	Suffolk	VA	Active
DSH490007Q	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Infectious Disease - Kempsville - 801 0194	850 Kempsville Road	Norfolk	VA	Active
DSH490007R	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Neurology - Hampton - 801 0153	4000 Coliseum Drive	Hampton	VA	Active
DSH490007S	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Neurology - Princess Anne - 801 0159	1950 Glenn Mitchell Drive	Virginia Beach	VA	Active
DSH490007T	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Rheumatology - Hampton - 801 0254	4001 Coliseum Drive	Hampton	VA	Active
DSH490007U	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Rheumatology - Kempsville - 801 0198	844 Kempsville Road	Norfolk	VA	Active
DSH490007V	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Dermatology - Kempsville - 801 0192	850 Kempsville Road	Norfolk	VA	Terminated
DSH490007W	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Neurology - Fort Norfolk - 801 0160	301 Riverview Avenue	Norfolk	VA	Active
DSH490007X	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	SNGH Neurosurgery - Fort Norfolk - - 801 0111	301 Riverview Avenue	Norfolk	VA	Active
DSH490007Y	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Cardiology - Fort Norfolk - Cards	301 Riverview Avenue	Norfolk	VA	Active
DSH490007Z	Child	DSH	SENTARA NORFOLK GENERAL HOSPITAL	Family Medicine - Fort Norfolk - FM	301 Riverview Avenue	Norfolk	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Ortegon, Liisa K President Sentara Norfolk General Hospital 7573883240	Pierson, Christopher P Chief Operating Officer Sentara Norfolk General Hospital 7573884275	3/24/2025 11:24 AM
Addresses	Shipping Address	Insert	Group Change Request		Sentara Norfolk General Hospital 600 Gresham Drive Norfolk, VA 23507	10/8/2024 8:06 AM
Addresses	Billing Address	Update	Recertification	Sentara Norfolk General Hospital 6015 Poplar Hall Drive Norfolk, VA 23502	Sentara Norfolk General Hospital 1300 Sentara Park Virginia Beach, VA 23464	9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1437119310 (NC)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1437119310 (VA)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	49-3007-0 (VA)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	49-0007-3 (VA)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1215024617 (NC)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1215024617 (VA)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	8502714 (VA)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0497094 (NC)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1396275418 (NC)		9/6/2024 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1396275418 (VA)		9/6/2024 11:19 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 10:37:11 AM	9/6/2024 11:19:02 AM	9/6/2024 11:19 AM
Contacts	Primary Contact	Update	Group Change Request	Jennings, Tim VP Pharmacy Sentara Norfolk General Hospital 7573883443	HORTON, JON D System Director of Pharmacy Sentara Healthcare 7573885854	1/8/2024 2:40 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 11:05:55 AM	8/31/2023 10:37:11 AM	8/31/2023 10:37 AM
Details	Last Recertification Date	Update	Recertification	8/25/2021 10:07:14 AM	8/24/2022 11:05:55 AM	8/24/2022 11:05 AM
Addresses	Billing Address	Update	Group Change Request	Sentara Norfolk General Hospital 600 Gresham Drive Norfolk, VA 23507	Sentara Norfolk General Hospital 6015 Poplar Hall Drive Norfolk, VA 23502	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0497094	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NC	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1396275418	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NC	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1396275418	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		VA	8/23/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1215024617	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1215024617	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		8502714	6/16/2022 2:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/16/2022 2:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1215024617	6/16/2022 2:13 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	6/16/2022 2:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1215024617	6/16/2022 2:13 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	6/16/2022 2:13 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 9:55:50 AM	8/25/2021 10:07:14 AM	8/25/2021 10:07 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	SEN0007N (AL)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1006410 (AK)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	525199 (AZ)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	152022105 (AR)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (CT)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	31510800 (DC)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	903420000 (FL)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000162665X (GA)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (IL)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300011722 (IN)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (ME)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (MD)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110027176J (MA)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	02339829 (MS)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4222407 (NJ)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01818877 (NY)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0717586 (OH)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100695980B (OK)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007719520013 (PA)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10389A/10216B (SC)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q021619 (TN)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (UT)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (WA)		4/14/2021 2:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1437119310 (WV)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (GA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (GA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (GA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (GA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (NY)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (NY)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (NY)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (NY)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (MS)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (MS)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (MS)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (MS)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (OH)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (OH)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (OH)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (OH)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (AK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (AK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (AK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (AK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (OK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (OK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (OK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (OK)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (PA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (PA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (PA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (PA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (SC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (SC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (SC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (SC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (MA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (MA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (MA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (MA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (CT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (CT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (CT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (CT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (IL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (IL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (IL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (IL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (ME)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (ME)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (ME)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (ME)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (MD)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (MD)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (MD)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (MD)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (UT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (UT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (UT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (UT)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (WA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (WA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (WA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (WA)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (WV)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (WV)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (WV)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (WV)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (AR)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (AR)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (AR)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (AR)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (IN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (IN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (IN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (IN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (DC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (DC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (DC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (DC)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (NJ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (NJ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (NJ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (NJ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (AZ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (AZ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (AZ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (AZ)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (FL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (FL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (FL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (FL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (TN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (TN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (TN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (TN)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1346314192 (AL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396275418 (AL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437119310 (AL)		4/14/2021 2:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649345158 (AL)		4/14/2021 2:48 PM
Contacts	Authorizing Official	Update	Change Request	Melton, Jessica Thompson Interim President Sentara Norfolk General Hospital 7573883420	Ortegon, Liisa K President Sentara Norfolk General Hospital 7573883240	2/25/2021 12:33 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1437119310 ( )		8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649345158 ( )		8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346314192 ( )		8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1396275418 ( )		8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346314192	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396275418	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437119310	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/27/2020 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649345158	8/27/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/27/2020 9:55 AM
Details	Last Recertification Date	Update	Recertification		8/27/2020 9:55:50 AM	8/27/2020 9:55 AM
Contacts	Authorizing Official	Update	Change Request	Carpenter, Carolyn C President Sentara Norfolk General Hospital 7573883494	Melton, Jessica Thompson Interim President Sentara Norfolk General Hospital 7573883420	8/6/2020 5:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1437119310	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1437119310	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		49-3007-0	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		49-0007-3	7/23/2020 2:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	7/23/2020 2:12 PM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Carpenter, Carolyn C President Sentara Norfolk General Hospital 7573883494	6/1/2020 4:40 PM
Details	340B ID	Update	New Registration		DSH490007U	6/1/2020 4:40 PM
Details	Entity Subname	Update	New Registration	SNGH Rheumatology - Kempsville	SNGH Rheumatology - Kempsville - 801 0198	6/1/2020 4:40 PM
Dates	Participating Approval Date	Update	New Registration		6/1/2020 4:40:37 PM	6/1/2020 4:40 PM
Details	State	Update	New Registration	Pending	Approved	6/1/2020 4:40 PM
Dates	Signed By Date	Update	New Registration		4/9/2020 1:26:23 PM	6/1/2020 4:40 PM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	6/1/2020 4:40 PM
Addresses	Main Address	Insert	New Registration		844 Kempsville Road Suite 103B Norfolk, VA 23502	4/7/2020 12:54 PM
Addresses	Billing Address	Insert	New Registration		Sentara Norfolk General Hospital 600 Gresham Drive Norfolk, VA 23507	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		SEN0007N	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1006410	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		525199	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		152022105	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		31510800	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		903420000	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000162665X	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300011722	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110027176J	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02339829	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4222407	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01818877	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0717586	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100695980B	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007719520013	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10389A/10216B	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q021619	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	4/7/2020 12:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1437119310	4/7/2020 12:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649345158	4/7/2020 12:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1346314192	4/7/2020 12:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396275418	4/7/2020 12:54 PM
Contacts	Primary Contact	Insert	New Registration		Jennings, Tim VP Pharmacy Sentara Norfolk General Hospital 7573883443	4/7/2020 12:54 PM
Contacts	Authorizing Official	Insert	New Registration		Carpenter, Carolyn C President Sentara Norfolk General Hospital 7573883494	4/7/2020 12:54 PM
Details	Last Recertification Date	Insert	New Registration			4/7/2020 12:54 PM
Details	Grant Number	Insert	New Registration			4/7/2020 12:54 PM
Details	340B ID	Insert	New Registration			4/7/2020 12:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/7/2020 12:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/7/2020 12:54 PM
Details	Medicare Provider Number	Insert	New Registration		490007	4/7/2020 12:54 PM
Details	Entity Name	Insert	New Registration		SENTARA NORFOLK GENERAL HOSPITAL	4/7/2020 12:54 PM
Details	Program Code	Insert	New Registration		DSH	4/7/2020 12:54 PM
Details	Entity Subname	Insert	New Registration		SNGH Rheumatology - Kempsville	4/7/2020 12:54 PM
Dates	Participating Approval Date	Insert	New Registration			4/7/2020 12:54 PM
Details	State	Insert	New Registration		Pending	4/7/2020 12:54 PM
Dates	Registration Date	Insert	New Registration		4/7/2020 12:54:14 PM	4/7/2020 12:54 PM
Dates	Signed By Date	Insert	New Registration			4/7/2020 12:54 PM
Dates	Start Date	Insert	New Registration			4/7/2020 12:54 PM
Terminations	Termination Comments	Insert	New Registration			4/7/2020 12:54 PM
Terminations	Termination Date	Insert	New Registration			4/7/2020 12:54 PM
Terminations	Termination Effective Date	Insert	New Registration			4/7/2020 12:54 PM
Terminations	Termination Reason	Insert	New Registration			4/7/2020 12:54 PM