Covered Entity Details

DSH520087DB Gundersen Lutheran Medical Center, Inc. (Active) - information as of 6/3/2025 12:02:16 PM

Main Details

Name

Gundersen Lutheran Medical Center, Inc.

Subdivision Name

Winona Campus - Imaging

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH520087DB

Medicare Provider Number

520087

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2020

Participating Start Date

7/1/2020

Participating Approval Date

5/13/2020

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Gundersen Health system
Michelle Micka, VP Finance
(608) 775-3131 Ext: 53131

Primary Contact

Gundersen Health System
Loren Carrell, Director
(608) 775-6369

Addresses

Street Address

1122 West Hwy. 61
Winona, MN 55987

Billing Address
Same as Street Address

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
WI	11012900	1376593442
MN	765347600	1376593442
IA	0699017	1376593442

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
DSH520087A	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Hemodialysis - Prairie du Chien	610 E. Taylor Street	Prairie du Chien	WI	Active
DSH520087AA	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Center for Breast Care	1836 South Ave	La Crosse	WI	Terminated
DSH520087AB	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Nuclear Medicine	1836 South Ave	La Crosse	WI	Terminated
DSH520087AC	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Intervential Radiology	1836 South Ave	La Crosse	WI	Terminated
DSH520087AD	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Ultrasound	1836 South Ave	La Crosse	WI	Terminated
DSH520087AE	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Ultrasound	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AF	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - OB/Gyn	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AG	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Radiology Diagnostic	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AH	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Radiation Oncology	724 Denton St	La Crosse	WI	Active
DSH520087AJ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Buidling - CT Scan	724 Denton St	La Crosse	WI	Active
DSH520087AK	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - CT Scan	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AL	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Laboratory Clinic La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087AM	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Laboratory	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AN	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Pulmonary	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AP	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Audiology	1836 South Ave	La Crosse	WI	Active
DSH520087AQ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Speech	724 Denton St	La Crosse	WI	Active
DSH520087AR	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Cardiology La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087AS	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Cardiology	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AT	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Neurosurgery	724 Denton St	La Crosse	WI	Active
DSH520087AU	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Neurology	724 Denton St	La Crosse	WI	Active
DSH520087AV	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Founders Building - Sleep Lab	710 Denton St	La Crosse	WI	Active
DSH520087AW	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Medical Oncology La Crosse	724 Denton St	La Crosse	WI	Active
DSH520087AX	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Medical Oncology	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087AY	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Nephrology	1836 South Ave	La Crosse	WI	Terminated
DSH520087AZ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Pediatrics La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087B	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Hemodialysis - Tomah	505 Gopher Drive	Tomah	WI	Active
DSH520087BA	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Cardiothoracic Surgery	1836 South Ave	La Crosse	WI	Active
DSH520087BB	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Surgery Clinic	1836 South Ave	La Crosse	WI	Active
DSH520087BC	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Bariatric Surgical Services La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087BD	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Bariatric Surgical Services	3111 Gundersen Dr	Onalaska	WI	Active
DSH520087BE	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Opthalmology	724 Denton St	La Crosse	WI	Active
DSH520087BF	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Optometry La Crosse	724 Denton St	La Crosse	WI	Active
DSH520087BG	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Orthopedic Surgery	1836 South Ave	La Crosse	WI	Active
DSH520087BH	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Podiatry La Crosse	724 Denton St	La Crosse	WI	Active
DSH520087BJ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Otolaryngology	1836 South Ave	La Crosse	WI	Active
DSH520087BK	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Plastic Surgery	724 Denton St	La Crosse	WI	Active
DSH520087BL	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Urology La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087BM	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Urology Onalaksa	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BN	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Physical Medicine and Rehab	724 Denton St	La Crosse	WI	Active
DSH520087BP	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Founder's Building - Injection Clinic	710 Denton St	La Crosse	WI	Active
DSH520087BQ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Palliative Care	724 Denton St	La Crosse	WI	Active
DSH520087BR	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Dermatology	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BS	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Family Medicine	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BT	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Rheumatoloogy	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BU	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Pediatrics	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BV	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - General Surgery	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BW	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Fertility Center	3111 Gundersen Drive	Onalaska	WI	Terminated
DSH520087BX	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Opthalmology	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BY	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Optometry	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087BZ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Orthopedic Surgery	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087C	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Hemodialysis - Onalaska	3075 Kinney Coulee Road	Onalaska	WI	Active
DSH520087CA	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Sports Medicine	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087CB	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Podiatry	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087CC	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Urgent Care	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087CD	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Annex - Transitional Services	123 16th Ave S.	Onalaska	WI	Active
DSH520087CE	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Neuropsychology	724 Denton St	La Crosse	WI	Active
DSH520087CF	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - OB/Gyn La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087CG	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CTR INC / IV Therapy	1836 SOUTH AVE	LA CROSSE	WI	Active
DSH520087CH	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN RENAL DIALYSIS- / Renal OP - Richland	1313W SEMINARY ST	RICHLAND CENTER	WI	Terminated
DSH520087CJ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CENTER I / Renal OP - Viroqua	407S MAIN ST 300	VIROQUA	WI	Terminated
DSH520087CK	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Hospice Home	724 Denton	La Crosse	WI	Active
DSH520087CL	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CTR INC / Preadmission	1836 SOUTH AVE	LA CROSSE	WI	Active
DSH520087CM	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CTR INC / Vascular Institute	1836 SOUTH AVE	LA CROSSE	WI	Active
DSH520087CN	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building / Laboratory	724 DENTON ST	LA CROSSE	WI	Active
DSH520087CP	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building / MRI	724 DENTON ST	LA CROSSE	WI	Active
DSH520087CR	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic / Otolaryngology	3111 GUNDERSEN DR	ONALASKA	WI	Active
DSH520087CS	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building / Outpatient Surgery Center Pre & Post Operations	724 DENTON ST	LA CROSSE	WI	Active
DSH520087CT	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic / Audiology	3111 GUNDERSEN DR	ONALASKA	WI	Active
DSH520087CU	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic / Occupational Therapy	1836 SOUTH AVE	LACROSSE	WI	Active
DSH520087CV	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska / Physical Therapy	3111 GUNDERSEN DR	ONALASKA	WI	Active
DSH520087CW	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building / Physical Therapy	724 DENTON ST	LA CROSSE	WI	Active
DSH520087CX	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building / Diagnostic Radiology	724 DENTON ST	LA CROSSE	WI	Active
DSH520087CY	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Peds OT	1836 South Ave	La Crosse	WI	Terminated
DSH520087CZ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Peds PT	1836 South Ave	La Crosse	WI	Active
DSH520087D	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Hemodialysis - Black River Falls	711 Adams Street	Black River Falls	WI	Terminated
DSH520087DA	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CENTER - Infusion	1122 W HIGHWAY 61	WINONA	MN	Active
DSH520087DB	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Imaging	1122 West Hwy. 61	Winona	MN	Active
DSH520087DC	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CENTER - Laboratory	1122 W HIGHWAY 61	WINONA	MN	Active
DSH520087DD	Child	DSH	Gundersen Lutheran Medical Center, Inc.	GUNDERSEN LUTHERAN MEDICAL CENTER - Urgent Care	1122 W HIGHWAY 61	WINONA	MN	Active
DSH520087DE	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Outpatient Surgery Center	1122 West Hwy. 61	Winona	MN	Active
DSH520087DF	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Neurology	1122 West Hwy. 61	Winona	MN	Active
DSH520087DG	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus -Pediatrics	1122 West Hwy. 61	Winona	MN	Active
DSH520087DH	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - General Internal Medicine	1122 West Hwy. 61	Winona	MN	Active
DSH520087DJ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Family Medicine	1122 West Hwy. 61	Winona	MN	Active
DSH520087DK	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Gastroenterology	1122 West Hwy. 61	Winona	MN	Active
DSH520087DL	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Sleep Lab	1122 West Hwy. 61	Winona	MN	Active
DSH520087DM	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona - Therapy	1122 West Hwy. 61	Winona	MN	Active
DSH520087DN	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Audiology	1122 West Hwy. 61	Winona	MN	Active
DSH520087DP	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - OB/GYN	1122 West Hwy. 61	Winona	MN	Active
DSH520087DQ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Optometry	1122 West Hwy. 61	Winona	MN	Active
DSH520087DR	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Podiatry	1122 West Hwy. 61	Winona	MN	Active
DSH520087DS	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Orthopedics/Sports Medicine	1122 West Hwy. 61	Winona	MN	Active
DSH520087DT	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - General Surgery	1122 West Hwy. 61	Winona	MN	Active
DSH520087DU	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Otolaryngology	1122 West Hwy. 61	Winona	MN	Active
DSH520087DV	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Physical Medical Rehab	1122 West Hwy. 61	Winona	MN	Active
DSH520087DW	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Winona Shared Specialties	1122 West Hwy. 61	Winona	MN	Active
DSH520087DX	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Pain Medicine	1122 West Hwy. 61	Winona	MN	Active
DSH520087DY	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Anesthesiology	1122 West Hwy. 61	Winona	MN	Active
DSH520087DZ	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Winona Campus - Winona Campus - Ophthalmology	1122 West Hwy. 61	Winona	MN	Active
DSH520087E	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Behavioral Health - Onalaska	123 16th Ave S.	Onalaska	WI	Active
DSH520087EA	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - La Crosse Flu Shot Clinic	1836 South Ave	La Crosse	WI	Active
DSH520087EB	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Physical Medicine and Rehab	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087EC	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic - Onalaska Flu Shot Clinic	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087F	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Behavioral health - Onalaska Clinic	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087G	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Outpatient AODA Services - Unity House for Women	1918-1924 Miller Street	La Crosse	WI	Terminated
DSH520087H	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Unity House for Men	1312 5th Avenue South	La Crosse	WI	Terminated
DSH520087J	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Wound Clinic	1836 South Avenue	La Crosse	WI	Active
DSH520087K	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Infusion - La Crosse	724 Denton Street	La Crosse	WI	Active
DSH520087L	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Emergency (Urgent Care)	1900 South Avenue	La Crosse	WI	Terminated
DSH520087M	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Medlink Air	1900 South Avenue	La Crosse	WI	Active
DSH520087N	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Pain Management & Outpatient Surgery	724 Denton Street	La Crosse	WI	Active
DSH520087P	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Infusion- Onalaska Clinic	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087Q	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic-Endocrinology La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087R	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic-Infectious Disease	1836 South Ave	La Crosse	WI	Active
DSH520087S	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building-Hematology	724 Denton St	La Crosse	WI	Active
DSH520087T	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic-General Internal Medicine Onalaska	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087U	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic-General Internal Medicine La Crosse	1836 South Ave	La Crosse	WI	Active
DSH520087V	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Founders Building-Family Medicine La Crosse	710 Denton St	La Crosse	WI	Active
DSH520087W	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Onalaska Clinic-Endocrinology Onalaska	3111 Gundersen Drive	Onalaska	WI	Active
DSH520087Y	Child	DSH	Gundersen Lutheran Medical Center, Inc.	Main Clinic - Diagnostic Radiology La Crosse	1836 South Ave	La Crosse	WI	Terminated
DSH520087Z	Child	DSH	Gundersen Lutheran Medical Center, Inc.	East Building - Center for Breast Care	724 Denton St	La Crosse	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 6:54:49 PM	8/28/2024 1:09:21 PM	8/28/2024 1:09 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 9:12:27 AM	9/5/2023 6:54:49 PM	9/5/2023 6:54 PM
Contacts	Authorizing Official	Update	AO Change Request	Oetzel, Jerry chief financial officer Gundersen Health System 6087757914	Micka, Michelle VP Finance Gundersen Health system 6087753131-53131	8/14/2023 3:12 PM
Contacts	Authorizing Official	Update	Change Request	Fee, Joe P Accounting Manager Gundersen Health System 6087755558	Oetzel, Jerry chief financial officer Gundersen Health System 6087757914	1/10/2023 3:56 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 2:04:13 PM	8/30/2022 9:12:27 AM	8/30/2022 9:12 AM
Contacts	Authorizing Official	Update	Change Request	Marsyla, Kay P Director, Reimbursement Gundersen Health System, La Crosse, WI 6087750171	Fee, Joe P Accounting Manager Gundersen Health System 6087755558	3/29/2022 4:32 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 3:55:21 PM	8/17/2021 2:04:13 PM	8/17/2021 2:04 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1376593442 ( )		8/25/2020 3:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1376593442	8/25/2020 3:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/25/2020 3:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1376593442	8/25/2020 3:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/25/2020 3:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1376593442	8/25/2020 3:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/25/2020 3:55 PM
Details	Last Recertification Date	Update	Recertification		8/25/2020 3:55:21 PM	8/25/2020 3:55 PM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Marsyla, Kay P Director, Reimbursement Gundersen Health System, La Crosse, WI 6087750171	5/13/2020 1:57 PM
Details	340B ID	Update	New Registration		DSH520087DB	5/13/2020 1:57 PM
Details	Entity Name	Update	New Registration	GUNDERSEN LUTHERAN MEDICAL CENTER I	Gundersen Lutheran Medical Center, Inc.	5/13/2020 1:57 PM
Details	Entity Subname	Update	New Registration	Winona Campus	Winona Campus - Imaging	5/13/2020 1:57 PM
Dates	Participating Approval Date	Update	New Registration		5/13/2020 1:57:11 PM	5/13/2020 1:57 PM
Details	State	Update	New Registration	Pending	Approved	5/13/2020 1:57 PM
Dates	Signed By Date	Update	New Registration		4/14/2020 8:41:19 AM	5/13/2020 1:57 PM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	5/13/2020 1:57 PM
Addresses	Main Address	Insert	New Registration		1122 West Hwy. 61 Winona, MN 55987	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11012900	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		765347600	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0699017	4/14/2020 8:41 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	4/14/2020 8:41 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1376593442	4/14/2020 8:41 AM
Contacts	Primary Contact	Insert	New Registration		Carrell, Loren Director Gundersen Health System 6087756369	4/14/2020 8:41 AM
Contacts	Authorizing Official	Insert	New Registration		Marsyla, Kay P Director, Reimbursement Gundersen Health System, La Crosse, WI 6087750171	4/14/2020 8:41 AM
Details	Last Recertification Date	Insert	New Registration			4/14/2020 8:41 AM
Details	Grant Number	Insert	New Registration			4/14/2020 8:41 AM
Details	340B ID	Insert	New Registration			4/14/2020 8:41 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2020 8:41 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2020 8:41 AM
Details	Medicare Provider Number	Insert	New Registration		520087	4/14/2020 8:41 AM
Details	Entity Name	Insert	New Registration		GUNDERSEN LUTHERAN MEDICAL CENTER I	4/14/2020 8:41 AM
Details	Program Code	Insert	New Registration		DSH	4/14/2020 8:41 AM
Details	Entity Subname	Insert	New Registration		Winona Campus	4/14/2020 8:41 AM
Dates	Participating Approval Date	Insert	New Registration			4/14/2020 8:41 AM
Details	State	Insert	New Registration		Pending	4/14/2020 8:41 AM
Dates	Registration Date	Insert	New Registration		4/14/2020 8:41:15 AM	4/14/2020 8:41 AM
Dates	Signed By Date	Insert	New Registration			4/14/2020 8:41 AM
Dates	Start Date	Insert	New Registration			4/14/2020 8:41 AM
Terminations	Termination Comments	Insert	New Registration			4/14/2020 8:41 AM
Terminations	Termination Date	Insert	New Registration			4/14/2020 8:41 AM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2020 8:41 AM
Terminations	Termination Reason	Insert	New Registration			4/14/2020 8:41 AM