Covered Entity Details

DSH390009H SAINT VINCENT HEALTH CENTER (Terminated) - information as of 4/29/2025 1:40:12 AM

Main Details

Name

SAINT VINCENT HEALTH CENTER

Subdivision Name

Saint Vincent Imaging Center - West Side - CT SCAN - CT SCAN

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390009H

Medicare Provider Number

390009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/22/2020

Last Recertification Date

8/17/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

SAINT VINCENT HEALTH CENTER
RANDOLPH LEVIS, CFO
(814) 452-5132

Primary Contact

AHN Saint Vincent
Stephen James Henderson, Pharmacist
(814) 452-5443

Addresses

Street Address

4247 WEST RIDGE ROAD
STE 103
ERIE, PA 16506-1746

Billing Address

SAINT VINCENT HEALTH CENTER
232 WEST 25th STREET
ERIE, PA 16544-0002

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
PA	1001625200025,1001625200043	1861435042
CA	1861435042
MI	1861435042
IN	201324270A
NC	1861435042
OH	7649950
NY	03004822
MD	338510800
CT	008063040
GA	003174225A
AZ	565151

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
DSH390009A	Child	DSH	SAINT VINCENT HEALTH CENTER	SAINT VINCENT SURGERY CENTER OF ERIE	312 WEST 25TH ST	ERIE	PA	Active
DSH390009B	Child	DSH	SAINT VINCENT HEALTH CENTER	SAINT VINCENT ENDOSCOPY CENTER/DEPT OF SAINT VINCENT HEALTH CENTER	2501 WEST 12TH STREET	ERIE	PA	Active
DSH390009C	Child	DSH	SAINT VINCENT HEALTH CENTER	Hardner Building-Cardio Tech Services / Heart Center	2315 MYRTLE STREET	Erie	PA	Active
DSH390009D	Child	DSH	SAINT VINCENT HEALTH CENTER	Hardner Builiding / Congestive Heart Failure Clinic	2315 MYRTLE STREET	Erie	PA	Active
DSH390009E	Child	DSH	SAINT VINCENT HEALTH CENTER	AHN Cancer Institute Saint Vincent Medical Oncology	2508 Myrtle Street	Erie	PA	Active
DSH390009F	Child	DSH	SAINT VINCENT HEALTH CENTER	Saint Vincent Imaging Center - West Side - Sonography - Sonography	4247 WEST RIDGE ROAD	Erie	PA	Terminated
DSH390009G	Child	DSH	SAINT VINCENT HEALTH CENTER	Saint Vincent Imaging Center - West Side - RADIOLOGY/XRAY - RADIOLOGY/XRAY	4247 WEST RIDGE ROAD	Erie	PA	Terminated
DSH390009H	Child	DSH	SAINT VINCENT HEALTH CENTER	Saint Vincent Imaging Center - West Side - CT SCAN - CT SCAN	4247 WEST RIDGE ROAD	ERIE	PA	Terminated
DSH390009J	Child	DSH	SAINT VINCENT HEALTH CENTER	Saint Vincent Imaging Center - West Side - MRI - MRI	4247 WEST RIDGE ROAD	Erie	PA	Terminated
DSH390009K	Child	DSH	SAINT VINCENT HEALTH CENTER	Imaging Center - PET CT	2508 MYRTLE ST	ERIE	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Henderson, Stephen James Pharmacist AHN Saint Vincent 8144525438	Henderson, Stephen James Pharmacist AHN Saint Vincent 8144525443	7/22/2023 9:06 AM
Contacts	Primary Contact	Update	Profile Change Request	Henderson, Stephen James Director of Pharmacy AHN Saint Vincent 8144525438	Henderson, Stephen James Pharmacist AHN Saint Vincent 8144525438	7/22/2023 9:06 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2020 12:00:00 AM	2/7/2022 8:39 AM
Details	State	Update	Termination Request	Active	To Be Terminated	2/7/2022 8:39 AM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	2/7/2022 8:39 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2020 12:00:00 AM	2/7/2022 8:39 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	2/7/2022 8:39 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 9:39:13 AM	8/17/2021 9:46:23 AM	8/17/2021 9:46 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861435042 (ND)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861435042 (IL)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0390009 (TN)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	009054100 (FL)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861435042 (VA)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100410190 (KY)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861435042 (CT)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861435042 (MA)		4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008063040	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003174225A	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		565151	4/20/2021 12:43 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	4/20/2021 12:43 PM
Contacts	Primary Contact	Update	Profile Change Request	Henderson, Stephen James Pharmacist AHN Saint Vincent 8144525438	Henderson, Stephen James Director of Pharmacy AHN Saint Vincent 8144525438	4/14/2021 1:38 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/8/2020 9:39 AM
Details	Last Recertification Date	Update	Recertification		9/8/2020 9:39:13 AM	9/8/2020 9:39 AM
Addresses	Main Address	Update	Change Request	4247 W RIDGE RD 103 ERIE, PA 16505	4247 WEST RIDGE ROAD STE 103 ERIE, PA 16506-1746	7/16/2020 8:15 AM
Addresses	Billing Address	Update	Change Request	SAINT VINCENT HEALTH CENTER 232 W 25th ST ERIE, PA 16544	SAINT VINCENT HEALTH CENTER 232 WEST 25th STREET ERIE, PA 16544-0002	7/16/2020 8:15 AM
Medicaid Billing	Medicaid: State	Update	Change Request	ME	MA	7/16/2020 8:15 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		LEVIS, RANDOLPH CFO SAINT VINCENT HEALTH CENTER 8144525132	4/22/2020 9:18 AM
Details	340B ID	Update	New Registration		DSH390009H	4/22/2020 9:18 AM
Details	Entity Name	Update	New Registration	SAINT VINCENT HOSPITAL	SAINT VINCENT HEALTH CENTER	4/22/2020 9:18 AM
Details	Entity Subname	Update	New Registration	Saint Vincent Imaging Center - West Side - CT SCAN	Saint Vincent Imaging Center - West Side - CT SCAN - CT SCAN	4/22/2020 9:18 AM
Dates	Participating Approval Date	Update	New Registration		4/22/2020 9:18:14 AM	4/22/2020 9:18 AM
Details	State	Update	New Registration	Pending	Approved	4/22/2020 9:18 AM
Dates	Signed By Date	Update	New Registration		4/15/2020 5:54:20 PM	4/22/2020 9:18 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/22/2020 9:18 AM
Addresses	Main Address	Insert	New Registration		4247 W RIDGE RD 103 ERIE, PA 16505	4/15/2020 11:03 AM
Addresses	Billing Address	Insert	New Registration		SAINT VINCENT HEALTH CENTER 232 W 25th ST ERIE, PA 16544	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001625200025	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1001625200043	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		201324270A	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0390009	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		009054100	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7100410190	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7649950	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03004822	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		338510800	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/15/2020 11:03 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1861435042	4/15/2020 11:03 AM
Contacts	Authorizing Official	Insert	New Registration		LEVIS, RANDOLPH CFO SAINT VINCENT HEALTH CENTER 8144525132	4/15/2020 11:03 AM
Contacts	Primary Contact	Insert	New Registration		Henderson, Stephen James Pharmacist AHN Saint Vincent 8144525438	4/15/2020 11:03 AM
Details	Last Recertification Date	Insert	New Registration			4/15/2020 11:03 AM
Details	Grant Number	Insert	New Registration			4/15/2020 11:03 AM
Details	340B ID	Insert	New Registration			4/15/2020 11:03 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2020 11:03 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2020 11:03 AM
Details	Medicare Provider Number	Insert	New Registration		390009	4/15/2020 11:03 AM
Details	Entity Name	Insert	New Registration		SAINT VINCENT HOSPITAL	4/15/2020 11:03 AM
Details	Program Code	Insert	New Registration		DSH	4/15/2020 11:03 AM
Details	Entity Subname	Insert	New Registration		Saint Vincent Imaging Center - West Side - CT SCAN	4/15/2020 11:03 AM
Dates	Participating Approval Date	Insert	New Registration			4/15/2020 11:03 AM
Details	State	Insert	New Registration		Pending	4/15/2020 11:03 AM
Dates	Registration Date	Insert	New Registration		4/15/2020 11:03:29 AM	4/15/2020 11:03 AM
Dates	Signed By Date	Insert	New Registration			4/15/2020 11:03 AM
Dates	Start Date	Insert	New Registration			4/15/2020 11:03 AM
Terminations	Termination Comments	Insert	New Registration			4/15/2020 11:03 AM
Terminations	Termination Date	Insert	New Registration			4/15/2020 11:03 AM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2020 11:03 AM
Terminations	Termination Reason	Insert	New Registration			4/15/2020 11:03 AM