Covered Entity Details

DSH100067H ST. ANTHONYS HOSPITAL (Terminated) - information as of 6/9/2025 11:05:47 PM

Main Details

Name

ST. ANTHONYS HOSPITAL

Subdivision Name

PHYSICAL THERAPY - Rehab Services OP I

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100067H

Medicare Provider Number

100067

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/9/2020

Participating Start Date

10/1/2020

Participating Approval Date

8/5/2020

Last Recertification Date

9/6/2023

Termination Date
Termination Reason

7/1/2024
DSH percentage below statutory minimum

Contacts

Authorizing Official

Baycare Health System
Carl Tremonti, Chief Financial Officer
(813) 870-4020

Primary Contact

BayCare Health System
Kyle J Brauer, Manager, BayCare Pharmacy Supply Chain
(813) 901-6376

Addresses

Street Address

500 Dr. MLK Jr St North
#100
St. Petersburg, FL 33705

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
FL	012022700	1427024942

Shipping Addresses

Shipping Address 1

Rehab Services OP I
500 Dr. MLK Jr St North
#100
St. Petersburg, FL 33705

Shipping Address 2

BayCare Integrated Service Center
Dba/ BayCare Central Pharmacy
7802 E Telecom Parkway
Temple Terrace, FL 33637

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
DSH100067A	Child	DSH	ST. ANTHONYS HOSPITAL	OUTPATIENT INFUSION - Outpatient Infusion	620 Tenth St North	St. Petersburg	FL	Terminated
DSH100067B	Child	DSH	ST. ANTHONYS HOSPITAL	RADIOLOGY-DIAGNOSTIC - Breast Center	1201 5th Ave North	St. Petersburg	FL	Terminated
DSH100067C	Child	DSH	ST. ANTHONYS HOSPITAL	SAH CARILLON OP REHAB CTR - Rehab Services OP II	900 CARILLON PKWY, STE 101	ST PETERSBURG	FL	Terminated
DSH100067D	Child	DSH	ST. ANTHONYS HOSPITAL	WOUND CARE - Wound Care Center	500 Dr. MLK Jr St North	St. Petersburg	FL	Terminated
DSH100067E	Child	DSH	ST. ANTHONYS HOSPITAL	MRI - MRI	1201 5th Ave North	St. Petersburg	FL	Terminated
DSH100067F	Child	DSH	ST. ANTHONYS HOSPITAL	DIABETES & WEIGHT MANAGEMENT - Life Help	500 Dr. MLK Jr St North	St. Petersburg	FL	Terminated
DSH100067G	Child	DSH	ST. ANTHONYS HOSPITAL	CARDIOPULMONARY - Cardiac Rehab	1201 5th Ave North	St. Petersburg	FL	Terminated
DSH100067H	Child	DSH	ST. ANTHONYS HOSPITAL	PHYSICAL THERAPY - Rehab Services OP I	500 Dr. MLK Jr St North	St. Petersburg	FL	Terminated
DSH100067J	Child	DSH	ST. ANTHONYS HOSPITAL	CT SCAN - CT Scan	1201 5th Ave North	St. Petersburg	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/30/2024 12:00:00 AM	6/5/2024 7:05 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/5/2024 7:05 AM
Terminations	Termination Date	Update	Termination Request		7/1/2024 12:00:00 AM	6/5/2024 7:05 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2024 12:00:00 AM	6/5/2024 7:05 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/5/2024 7:05 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 8:23:54 AM	9/6/2023 7:40:38 AM	9/6/2023 7:40 AM
Details	Last Recertification Date	Update	Recertification	9/1/2021 8:05:29 AM	9/12/2022 8:23:54 AM	9/12/2022 8:23 AM
Medicaid Billing	NPI: State	Update	Recertification		FL	9/1/2021 8:05 AM
Details	Last Recertification Date	Update	Recertification		9/1/2021 8:05:29 AM	9/1/2021 8:05 AM
Details	State	Update		Approved	Active	10/1/2020 12:01 AM
Contacts	Signed By	Insert	New Registration		Tremonti, Carl Chief Financial Officer Baycare Health System 8138704020	8/5/2020 1:16 PM
Details	340B ID	Update	New Registration		DSH100067H	8/5/2020 1:16 PM
Details	Entity Subname	Update	New Registration	PHYSICAL THERAPY	PHYSICAL THERAPY - Rehab Services OP I	8/5/2020 1:16 PM
Dates	Participating Approval Date	Update	New Registration		8/5/2020 1:16:31 PM	8/5/2020 1:16 PM
Details	State	Update	New Registration	Pending	Approved	8/5/2020 1:16 PM
Dates	Signed By Date	Update	New Registration		7/15/2020 9:28:02 AM	8/5/2020 1:16 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	8/5/2020 1:16 PM
Addresses	Main Address	Insert	New Registration		500 Dr. MLK Jr St North #100 St. Petersburg, FL 33705	7/9/2020 3:20 PM
Addresses	Shipping Address	Insert	New Registration		Rehab Services OP I 500 Dr. MLK Jr St North #100 St. Petersburg, FL 33705	7/9/2020 3:20 PM
Addresses	Shipping Address	Insert	New Registration		BayCare Integrated Service Center Dba/ BayCare Central Pharmacy 7802 E Telecom Parkway Temple Terrace, FL 33637	7/9/2020 3:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2020 3:20 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		012022700	7/9/2020 3:20 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	7/9/2020 3:20 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427024942	7/9/2020 3:20 PM
Contacts	Authorizing Official	Insert	New Registration		Tremonti, Carl Chief Financial Officer Baycare Health System 8138704020	7/9/2020 3:20 PM
Contacts	Primary Contact	Insert	New Registration		Brauer, Kyle J Manager, BayCare Pharmacy Supply Chain BayCare Health System 8139016376	7/9/2020 3:20 PM
Details	Last Recertification Date	Insert	New Registration			7/9/2020 3:20 PM
Details	Grant Number	Insert	New Registration			7/9/2020 3:20 PM
Details	340B ID	Insert	New Registration			7/9/2020 3:20 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/9/2020 3:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/9/2020 3:20 PM
Details	Medicare Provider Number	Insert	New Registration		100067	7/9/2020 3:20 PM
Details	Entity Name	Insert	New Registration		ST. ANTHONYS HOSPITAL	7/9/2020 3:20 PM
Details	Program Code	Insert	New Registration		DSH	7/9/2020 3:20 PM
Details	Entity Subname	Insert	New Registration		PHYSICAL THERAPY	7/9/2020 3:20 PM
Dates	Participating Approval Date	Insert	New Registration			7/9/2020 3:20 PM
Details	State	Insert	New Registration		Pending	7/9/2020 3:20 PM
Dates	Registration Date	Insert	New Registration		7/9/2020 3:20:19 PM	7/9/2020 3:20 PM
Dates	Signed By Date	Insert	New Registration			7/9/2020 3:20 PM
Dates	Start Date	Insert	New Registration			7/9/2020 3:20 PM
Terminations	Termination Comments	Insert	New Registration			7/9/2020 3:20 PM
Terminations	Termination Date	Insert	New Registration			7/9/2020 3:20 PM
Terminations	Termination Effective Date	Insert	New Registration			7/9/2020 3:20 PM
Terminations	Termination Reason	Insert	New Registration			7/9/2020 3:20 PM