Covered Entity Details

DSH010033J UNIVERSITY OF ALABAMA HOSPITAL (Active) - information as of 5/10/2025 10:58:20 PM

Main Details

Name

UNIVERSITY OF ALABAMA HOSPITAL

Subdivision Name

UAB MEDICINE EMERGENCY - Gardendale Free Standing Emergency (Gardendale FED)

Type

Disproportionate Share Hospital

Rural

340B ID

DSH010033J

Medicare Provider Number

010033

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/23/2020

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

UAB Hospital
Susan Jennings, CFO, UAB Hospital
(205) 934-7659

Primary Contact

UAB Hospital
TOMIE ANN BOACKLE, Director, Informatics and Regulatory Affairs
(205) 975-9780

Addresses

Street Address

960 MOUNT OLIVE RD
GARDENDALE, AL 35071-4655

Billing Address

The University of Alabama at Birmingham Attn: Accounts Payable
801 Financial Services Building
801 5th Avenue South
Birmingham, AL 35233

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
AL	HOS0033H	1033217708,1154435824,1235237900
GA	000101626A	1033217708,1154435824,1235237900
LA	1744760	1033217708,1154435824,1235237900
MS	00020395	1033217708,1154435824,1235237900

Shipping Addresses

Shipping Address 1

UAB Medicine Free Standing Emergency Department
960 Rocket Way
Building 479
Suite 100
Gardendale, AL 35071-4655

Shipping Address 2

UAB Medicine Free Standing Emergency Department
960 Mount Olive Road
Building 479
Suite 100
Gardendale, AL 35071-4655

Shipping Address 3

UAB Medicine Free Standing Emergency Department
Gardendale FED Pharmacy
960 Mount Olive Road Building 479
Suite 100
Gardendale, AL 35071-4655

Shipping Address 4

UAB Medicine Free Standing Emergency Department
Gardendale FED Pharmacy
960 Rocket Way Building 479
Suite 100
Gardendale, AL 35071-4655

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
DSH010033AA	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Radiology – CT Highlands - Radiology – CT Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AB	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Recovery - Highlands - Recovery - Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AC	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Respiratory Therapy – Highlands - Respiratory Therapy – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AD	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Same Day Surgery – Highlands - Same Day Surgery – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AE	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Sleep Center – Highlands - Sleep Center – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AF	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB EMERGENCY DEPARTMENT - Emergency Department – Highlands	1201 11TH AVENUE SOUTH	BIRMINGHAM	AL	Active
DSH010033AG	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Radiology - Ultrasound Highlands - Radiology - Ultrasound Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AH	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Radiology - MRI Highlands - Radiology - MRI Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AJ	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Radiology - Diagnostic Highlands - Radiology - Diagnostic Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033AK	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road Radiation Oncology Clinic - Rad/ Onc Clinic Acton	2145 Bonner Way	Birmingham	AL	Active
DSH010033AL	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Cardiology Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033AM	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Rheumatology Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033AN	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Neurosurgery Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033AP	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Pulmonary Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033AQ	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Pulmonary Function Test Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033AR	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE AT MEDICAL WEST - UAB Physical Med & Rehab Med West	5000 MEDICAL WEST WAY	BESSEMER	AL	Approved
DSH010033G	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UNIVERSITY OF ALABAMA INFUSION CENTER AT ACTON ROAD	2145 BONNER WAY	BIRMINGHAM	AL	Active
DSH010033J	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	UAB MEDICINE EMERGENCY - Gardendale Free Standing Emergency (Gardendale FED)	960 MOUNT OLIVE RD	GARDENDALE	AL	Active
DSH010033K	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road Hematology/ Oncology Clinic - Hem Onc Clinic Acton	2145 Bonner Way	Birmingham	AL	Active
DSH010033L	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road Breast Health Clinic - Breast Health Clinic	2145 Bonner Way	Birmingham	AL	Active
DSH010033M	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road Cardiology/ Oncology Clinic - Cardiology/ Oncology	2145 Bonner Way	Birmingham	AL	Active
DSH010033N	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road GI Surgery Clinic - Gastroenterology Surgery Clinic	2145 Bonner Way	Birmingham	AL	Active
DSH010033P	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Acton Road Urology Clinic - Urology Clinic	2145 Bonner Way	Birmingham	AL	Active
DSH010033Q	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	ANESTHESIA SERVICES AT UAB HOSPITAL - Anesthesia - Highlands	1201 11TH AVENUE SOUTH	BIRMINGHAM	AL	Active
DSH010033R	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Blood Bank – Highlands - Blood Bank – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033S	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Cardiology/ Radiology – Highlands - Cardiology/ Radiology – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033T	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Endoscopy - Highlands - Endoscopy - Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033U	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Lab – Highlands - Lab – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033V	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Nuclear Medicine – Highlands - Nuclear Medicine – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033W	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Occupational Therapy – Highlands - Occupational Therapy – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033X	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	OR – Highlands - OR – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033Y	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Pain Clinic – Highlands - Pain Clinic – Highlands	1201 11th Avenue South	Birmingham	AL	Active
DSH010033Z	Child	DSH	UNIVERSITY OF ALABAMA HOSPITAL	Physical Therapy – Highlands - Physical Therapy – Highlands	1201 11th Avenue South	Birmingham	AL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Update	Group Change Request	UAB Accounts Payable 701 South 20th Street Birmingham, AL 35294	The University of Alabama at Birmingham Attn: Accounts Payable 801 Financial Services Building 801 5th Avenue South Birmingham, AL 35233	9/27/2024 12:57 PM
Details	Last Recertification Date	Update	Recertification	8/21/2023 6:28:58 PM	8/19/2024 8:50:57 AM	8/19/2024 8:50 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 5:31:55 PM	8/21/2023 6:28:58 PM	8/21/2023 6:28 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	090746400 (FL)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	145159 (OH)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4282228 (TN)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	460850000 (MN)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	11117702 (MO)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100512786 (NV)		8/25/2022 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	5141206 (NJ)		8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033217708	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154435824	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235237900	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033217708	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154435824	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235237900	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033217708	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154435824	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/25/2022 5:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235237900	8/25/2022 5:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/25/2022 5:31 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 6:38:24 PM	8/25/2022 5:31:55 PM	8/25/2022 5:31 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 1:32:42 PM	9/8/2021 6:38:24 PM	9/8/2021 6:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		090746400	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		000101626A	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1744760	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		00020395	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MS	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		145159	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		4282228	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		TN	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		460850000	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		11117702	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MO	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		100512786	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NV	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		5141206	7/9/2021 3:23 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NJ	7/9/2021 3:23 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1154435824 ( )		8/28/2020 1:32 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033217708	8/28/2020 1:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 1:32 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154435824	8/28/2020 1:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 1:32 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235237900	8/28/2020 1:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 1:32 PM
Details	Last Recertification Date	Update	Recertification		8/28/2020 1:32:42 PM	8/28/2020 1:32 PM
Contacts	Authorizing Official	Update	Change Request	FERNIANY, WILL CEO, UAB HEALTH SYSTEM UAB Medicine 2059754844	Jennings, Susan CFO, UAB Hospital UAB Hospital 2059347659	7/29/2020 12:50 PM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		FERNIANY, WILL CEO, UAB HEALTH SYSTEM UAB Medicine 2059754844	4/23/2020 7:22 AM
Details	340B ID	Update	New Registration		DSH010033J	4/23/2020 7:22 AM
Details	Entity Subname	Update	New Registration	UAB MEDICINE EMERGENCY	UAB MEDICINE EMERGENCY - Gardendale Free Standing Emergency (Gardendale FED)	4/23/2020 7:22 AM
Dates	Participating Approval Date	Update	New Registration		4/23/2020 7:22:44 AM	4/23/2020 7:22 AM
Details	State	Update	New Registration	Pending	Approved	4/23/2020 7:22 AM
Dates	Signed By Date	Update	New Registration		4/10/2020 2:23:59 PM	4/23/2020 7:22 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/23/2020 7:22 AM
Addresses	Main Address	Insert	New Registration		960 MOUNT OLIVE RD GARDENDALE, AL 35071-4655	4/10/2020 1:45 PM
Addresses	Billing Address	Insert	New Registration		UAB Accounts Payable 701 South 20th Street Birmingham, AL 35294	4/10/2020 1:45 PM
Addresses	Shipping Address	Insert	New Registration		UAB Medicine Free Standing Emergency Department 960 Rocket Way Building 479 Suite 100 Gardendale, AL 35071-4655	4/10/2020 1:45 PM
Addresses	Shipping Address	Insert	New Registration		UAB Medicine Free Standing Emergency Department 960 Mount Olive Road Building 479 Suite 100 Gardendale, AL 35071-4655	4/10/2020 1:45 PM
Addresses	Shipping Address	Insert	New Registration		UAB Medicine Free Standing Emergency Department Gardendale FED Pharmacy 960 Mount Olive Road Building 479 Suite 100 Gardendale, AL 35071-4655	4/10/2020 1:45 PM
Addresses	Shipping Address	Insert	New Registration		UAB Medicine Free Standing Emergency Department Gardendale FED Pharmacy 960 Rocket Way Building 479 Suite 100 Gardendale, AL 35071-4655	4/10/2020 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2020 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HOS0033H	4/10/2020 1:45 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	4/10/2020 1:45 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1154435824	4/10/2020 1:45 PM
Contacts	Primary Contact	Insert	New Registration		BOACKLE, TOMIE ANN Director, Informatics and Regulatory Affairs UAB Hospital 2059759780	4/10/2020 1:45 PM
Contacts	Authorizing Official	Insert	New Registration		FERNIANY, WILL CEO, UAB HEALTH SYSTEM UAB Medicine 2059754844	4/10/2020 1:45 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2020 1:45 PM
Details	Grant Number	Insert	New Registration			4/10/2020 1:45 PM
Details	340B ID	Insert	New Registration			4/10/2020 1:45 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2020 1:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2020 1:45 PM
Details	Medicare Provider Number	Insert	New Registration		010033	4/10/2020 1:45 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF ALABAMA HOSPITAL	4/10/2020 1:45 PM
Details	Program Code	Insert	New Registration		DSH	4/10/2020 1:45 PM
Details	Entity Subname	Insert	New Registration		UAB MEDICINE EMERGENCY	4/10/2020 1:45 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2020 1:45 PM
Details	State	Insert	New Registration		Pending	4/10/2020 1:45 PM
Dates	Registration Date	Insert	New Registration		4/10/2020 1:45:40 PM	4/10/2020 1:45 PM
Dates	Signed By Date	Insert	New Registration			4/10/2020 1:45 PM
Dates	Start Date	Insert	New Registration			4/10/2020 1:45 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2020 1:45 PM
Terminations	Termination Date	Insert	New Registration			4/10/2020 1:45 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2020 1:45 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2020 1:45 PM