Covered Entity Details

DSH160033AP GENESIS MEDICAL CENTER - DAVENPORT (Active) - information as of 4/25/2025 12:00:57 AM

Main Details

Name

GENESIS MEDICAL CENTER - DAVENPORT

Subdivision Name

Cardiac Diagnostics - Cardiac Diagnostics

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH160033AP

Medicare Provider Number

160033

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/1/2020

Participating Start Date

10/1/2020

Participating Approval Date

8/27/2020

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

MercyOne Genesis Davenport
Christopher Michael Crome, Chief Operating Officer
(563) 421-6502

Primary Contact

Genesis Health System
Adam Baird, Director of Pharmacy
(563) 421-6212

Addresses

Street Address

1236 E Rusholme
Heart Institute
2nd Floor
Davenport, IA 52803

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
IL	421418847001,421418847	1972542264
IA	0600338	1972542264

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
DSH160033A	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Emergency Care Center	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033AA	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / ULTRASOUND	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AB	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / RADIOLOGY	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AC	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / PACU	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AD	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / OP CARE CENTER	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AE	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / ENDOSCOPY	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AF	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / OP PSYCH	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Active
DSH160033AG	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / DAY REHAB PROGRAM	1401 W CENTRAL PARK AVE	DAVENPORT	IA	Terminated
DSH160033AH	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GIC-53rd st-GenRad - Radiology	1970 East 53rd Street	Davenport	IA	Active
DSH160033AJ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GIC-DG-GenRad - Radiology	2140 East 53rd Ave	Bettendorf	IA	Active
DSH160033AK	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Surgery - Cardiac Surgery	1236 East Rusholme St	Davenport	IA	Active
DSH160033AL	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Neurosurgery - Neurosurgery	1230 East Rusholme St	Davenport	IA	Active
DSH160033AM	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	PT and Sports Med - Bettendorf - PT and Sports Med - Bettendorf	4850 Competition Dr	Bettendorf	IA	Terminated
DSH160033AN	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy - Davenport 3rd - Physical Therapy - Davenport 3rd	1820 West 3rd St	Davenport	IA	Terminated
DSH160033AP	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Diagnostics - Cardiac Diagnostics	1236 E Rusholme	Davenport	IA	Active
DSH160033AQ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy - Clinton - Physical Therapy - Clinton	1663 G Lincoln Way	Clinton	IA	Terminated
DSH160033AR	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Adult Psychiatric Unit - Psychiatric	1401 West Central Park	Davenport	IA	Active
DSH160033AS	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Adolescent Psych Unit - Psychiatric	1401 West Central Park Ave	Davenport	IA	Active
DSH160033AT	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Genesis Vascular Specialist - GHG Davenport Vascular Specialists	1230 East Rusholme St.	Davenport	IA	Active
DSH160033AU	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS PT AT HEADACHE CLINIC - Genesis Davenport Headache Clinic PT	1230 E RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AV	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS DAVENPORT HEADACHE CLINIC - Headache Clinic	1230 E. RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AW	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cancer Genetics Clinic - Cancer Genetics Clinic	1228 East Rusholme St.	Davenport	IA	Active
DSH160033AX	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GHG DAVENPORT EAST GASTROENTEROLOGY - Genesis Gastroenterology	1236 E RUSHOLME ST	DAVENPORT	IA	Active
DSH160033AY	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS MEDICAL CENTER - ED BETT. - Bettendorf ED	2140 53RD AVE	BETTENDORF	IA	Active
DSH160033AZ	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	MercyOne Genesis Neurology Care - Genesis Memory Disorder Clinic	1351 West Central Park Ave	Davenport	IA	Active
DSH160033B	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Neurodiagnostics	1401 W Central Park Ave	Davenport	IA	Active
DSH160033BA	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS PLASTIC SURGERY - Genesis Plastic Surgery 53rd	4334 E 53RD ST	DAVENPORT	IA	Active
DSH160033C	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Cardiac Rehab	1236 E Rusholme St	Davenport	IA	Active
DSH160033D	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Occupational Therapy	1228 E Rusholme St	Davenport	IA	Terminated
DSH160033E	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Occupational Therapy	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033F	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Respiratory Care	1401 W Central Park Ave	Davenport	IA	Terminated
DSH160033G	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GMC / Davenport Laboratory	1401 W Central Park Ave	Davenport	IA	Active
DSH160033H	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / MRI	1401 W Central Park Ave	Davenport	IA	Active
DSH160033J	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / CT Scan	1401 W Central Park Ave	Davenport	IA	Active
DSH160033K	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Nuclear Medicine	1236 East Rusholme	Davenport	IA	Active
DSH160033L	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Wound & Hyperbaric Institute	1351 West Central Park	Davenport	IA	Active
DSH160033M	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Center for Weight Management	1230 East Rusholme Street	Davenport	IA	Active
DSH160033N	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Maplecrest / Rehab Pediatrics	2535 Maplecrest Road	Bettendorf	IA	Active
DSH160033P	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / Lombard	1414 West Lombard Street	Davenport	IA	Terminated
DSH160033Q	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Genesis / Physical Therapy & Wellness Center	4017 Devils Glen Road	Bettendorf	IA	Terminated
DSH160033R	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / LeClaire	1003 Canal Shore Drive	LeClaire	IA	Terminated
DSH160033S	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy / & Sports Medicine Clinic	1702 East 53rd Street	Davenport	IA	Terminated
DSH160033T	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Physical Therapy Clinic / Valley Fair	2720 West Locust Street	Davenport	IA	Terminated
DSH160033U	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Infusion Center	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033V	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Radiation Therapy	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033W	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	Davenport / Cancer Care Institute	1351 West Central Park Avenue	Davenport	IA	Active
DSH160033X	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	McKay / Center For Breast Health	1228 E. Rusholme Street	Davenport	IA	Active
DSH160033Y	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / DIABETES INSTITUTE	2535 MAPLECREST RD STE 13	BETTENDORF	IA	Terminated
DSH160033Z	Child	DSH	GENESIS MEDICAL CENTER - DAVENPORT	GENESIS HEALTH SYSTEM / PAIN AND SPINE CENTER	2535 MAPLECREST ROAD STE 12	BETTENDORF	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	Voigt, Jordan GMC Davenport President Genesis Health System 5634212792	Crome, Christopher Michael Chief Operating Officer MercyOne Genesis Davenport 5634216502	1/10/2025 8:59 AM
Contacts	Primary Contact	Update	PC Change Request	Baird, Adam Pharmacy Manager Genesis Health System 5634216192	Baird, Adam Director of Pharmacy Genesis Health System 5634216212	11/26/2024 8:14 AM
Details	Last Recertification Date	Update	Recertification	9/3/2023 10:46:33 PM	8/16/2024 10:51:11 AM	8/16/2024 10:51 AM
Contacts	Authorizing Official	Update	AO Change Request	Voigt, Jordan GMC Davenport President Genesis Health System 5634212792	Voigt, Jordan GMC Davenport President Genesis Health System 5634212792	8/9/2024 12:29 PM
Contacts	Primary Contact	Update	Recertification	Cassatt, Kevin Director of Pharmacy Genesis Health System 5634216212	Baird, Adam Pharmacy Manager Genesis Health System 5634216192	9/3/2023 10:46 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 2:45:03 PM	9/3/2023 10:46:33 PM	9/3/2023 10:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	600338 (IA)		6/14/2023 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2023 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0600338	6/14/2023 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	6/14/2023 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2023 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		421418847	6/14/2023 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/14/2023 11:45 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 1:28:03 PM	8/29/2022 2:45:03 PM	8/29/2022 2:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1972542264 ( )		8/20/2021 1:28 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972542264	8/20/2021 1:28 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/20/2021 1:28 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972542264	8/20/2021 1:28 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/20/2021 1:28 PM
Details	Last Recertification Date	Update	Recertification		8/20/2021 1:28:03 PM	8/20/2021 1:28 PM
Contacts	Authorizing Official	Update	Change Request	Rogers, Mark CFO Genesis Health System 5634216513	Voigt, Jordan GMC Davenport President Genesis Health System 5634212792	12/3/2020 10:38 AM
Details	State	Update		Approved	Active	10/1/2020 12:01 AM
Contacts	Signed By	Insert	New Registration		Rogers, Mark CFO Genesis Health System 5634216513	8/27/2020 1:54 PM
Details	340B ID	Update	New Registration		DSH160033AP	8/27/2020 1:54 PM
Details	Entity Subname	Update	New Registration	Cardiac Diagnostics	Cardiac Diagnostics - Cardiac Diagnostics	8/27/2020 1:54 PM
Dates	Participating Approval Date	Update	New Registration		8/27/2020 1:54:55 PM	8/27/2020 1:54 PM
Details	State	Update	New Registration	Pending	Approved	8/27/2020 1:54 PM
Dates	Signed By Date	Update	New Registration		7/2/2020 2:35:34 PM	8/27/2020 1:54 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	8/27/2020 1:54 PM
Addresses	Main Address	Insert	New Registration		1236 E Rusholme Heart Institute 2nd Floor Davenport, IA 52803	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600338	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		421418847001	7/1/2020 9:58 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/1/2020 9:58 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972542264	7/1/2020 9:58 AM
Contacts	Authorizing Official	Insert	New Registration		Rogers, Mark CFO Genesis Health System 5634216513	7/1/2020 9:58 AM
Contacts	Primary Contact	Insert	New Registration		Cassatt, Kevin Director of Pharmacy Genesis Health System 5634216212	7/1/2020 9:58 AM
Details	Last Recertification Date	Insert	New Registration			7/1/2020 9:58 AM
Details	Grant Number	Insert	New Registration			7/1/2020 9:58 AM
Details	340B ID	Insert	New Registration			7/1/2020 9:58 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/1/2020 9:58 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/1/2020 9:58 AM
Details	Medicare Provider Number	Insert	New Registration		160033	7/1/2020 9:58 AM
Details	Entity Name	Insert	New Registration		GENESIS MEDICAL CENTER - DAVENPORT	7/1/2020 9:58 AM
Details	Program Code	Insert	New Registration		DSH	7/1/2020 9:58 AM
Details	Entity Subname	Insert	New Registration		Cardiac Diagnostics	7/1/2020 9:58 AM
Dates	Participating Approval Date	Insert	New Registration			7/1/2020 9:58 AM
Details	State	Insert	New Registration		Pending	7/1/2020 9:58 AM
Dates	Registration Date	Insert	New Registration		7/1/2020 9:58:27 AM	7/1/2020 9:58 AM
Dates	Signed By Date	Insert	New Registration			7/1/2020 9:58 AM
Dates	Start Date	Insert	New Registration			7/1/2020 9:58 AM
Terminations	Termination Comments	Insert	New Registration			7/1/2020 9:58 AM
Terminations	Termination Date	Insert	New Registration			7/1/2020 9:58 AM
Terminations	Termination Effective Date	Insert	New Registration			7/1/2020 9:58 AM
Terminations	Termination Reason	Insert	New Registration			7/1/2020 9:58 AM