Covered Entity Details

DSH030064AB Banner - University Medical Center Tucson (Terminated) - information as of 4/25/2025 9:23:02 PM

Main Details

Name

Banner - University Medical Center Tucson

Subdivision Name

North Hills - PBC UC-NH Internal Med Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030064AB

Medicare Provider Number

030064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/8/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/19/2020

Last Recertification Date

Termination Date
Termination Reason

10/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Banner University Medical Centers Tucson and South
Brad Hipp, Chief Financial Officer
(520) 694-3446

Primary Contact

Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061

Addresses

Street Address

265 West Ina Road
Tucson, AZ 85704

Billing Address

Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062

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
AZ	020470-01,988439	1265820179,1508809427,1649668450
CO	9000142345	1265820179,1508809427,1649668450

Shipping Addresses

Shipping Address 1

Banner University Medical Center Tucson
1625 North Campbell Ave
Tucson, AZ 85719

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
DSH030064A	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-PANTANO	7901 EAST 22ND STREET	TUCSON	AZ	Terminated
DSH030064AA	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Orthopedics-clinic	265 West Ina Road	Tucson	AZ	Active
DSH030064AB	Child	DSH	Banner - University Medical Center Tucson	North Hills - PBC UC-NH Internal Med Clinic	265 West Ina Road	Tucson	AZ	Terminated
DSH030064AC	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Nephrology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AD	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Internal Med Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AE	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Podiatry-clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AF	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Urology-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AG	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC- GV Cardiology-clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AH	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC - GV Gynecology Clinic	1141 S. LA CANADA DR.	Green Valley	AZ	Terminated
DSH030064AJ	Child	DSH	Banner - University Medical Center Tucson	Green Valley - PBC UC GV Otolaryngology-Clin	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064AK	Child	DSH	Banner - University Medical Center Tucson	Alvernon - Alvernon Orthopedics-Clinic	707 North Alvernon Way	Tucson	AZ	Active
DSH030064AL	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Pediatrics Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AM	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC-Pan Geriatrics-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AN	Child	DSH	Banner - University Medical Center Tucson	Pantano - Pantano Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AP	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-PAN Internal Med-Clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AQ	Child	DSH	Banner - University Medical Center Tucson	Pantano - PBC UC-Pan Gynecology-clinic	7901 East 22nd Street	Tucson	AZ	Terminated
DSH030064AR	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-CardioThoracic-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Urology-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AT	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Vascular-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-NC Support Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064AV	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurosurgery-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AW	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Int Med/Geriatrics-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AX	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Nephrology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AY	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Endo-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064AZ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Neurology Gen-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064B	Child	DSH	Banner - University Medical Center Tucson	Banner - UNIVERSITY HEALTH CARE-NORTH HILLS	265 WEST INA ROAD	TUCSON	AZ	Active
DSH030064BA	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-ENT-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BB	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Infect Disease-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BC	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Diagnostic Cardiol-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BD	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pacemaker-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BE	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Gastroenterology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BF	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Pulmonary Fnct Test-Cli-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BG	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Rheumatology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BH	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Podiatry-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BJ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Radiation Oncology-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BK	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Primary Care-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BL	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-OB/GYN-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BM	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Ambdom Transplant-Clin-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BN	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Trauma/Burn-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BP	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Sleep-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BQ	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Allergy-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BR	Child	DSH	Banner - University Medical Center Tucson	Clinic F Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BS	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - Surg OP-20PC-Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064BT	Child	DSH	Banner - University Medical Center Tucson	Clinic H Multispecialty	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BU	Child	DSH	Banner - University Medical Center Tucson	North Campus 2 BUMN - C/P-Cardiology-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064BV	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic-Hosp	3838 North Campbell Ave	Tucson	AZ	Terminated
DSH030064BW	Child	DSH	Banner - University Medical Center Tucson	Cancer Center - Medication Mgmt Clinic	3838 North Campbell Ave	Tucson	AZ	Active
DSH030064BX	Child	DSH	Banner - University Medical Center Tucson	C/P-NC Hemonc - Clinic - Hematology / Oncology	3838 N. Campbell Avenue,	Tucson	AZ	Active
DSH030064BY	Child	DSH	Banner - University Medical Center Tucson	PBC UC-NH Pediatrics - Clinic - Pediatrics	265 West Ina Road	Tucson	AZ	Active
DSH030064BZ	Child	DSH	Banner - University Medical Center Tucson	C/P-Imaging-Clinic-NC	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CA	Child	DSH	Banner - University Medical Center Tucson	ENT Audiology-Clinic-NC - Audiology	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064CB	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Gen Surg - Clinic - General Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CC	Child	DSH	Banner - University Medical Center Tucson	PBC UG-GV Vascular Surg Clinic - Vascular Surgery	1141 S. La Canada Dr	Green Valley	AZ	Terminated
DSH030064CD	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Psych-Clinic-NC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064CE	Child	DSH	Banner - University Medical Center Tucson	BANNER UNIVERSITY MED CENTER TUCSON - Cancer Genetics Counsel-Hosp	3838 N Campbell Ave	Tucson	AZ	Active
DSH030064CF	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Pantano Clinic	7901 E 22ND ST	TUCSON	AZ	Active
DSH030064CG	Child	DSH	Banner - University Medical Center Tucson	BANNER - UNIVERSITY MEDICAL CENTER - Green Valley Clinic-Clinic	1141 S LA CANADA DR	GREEN VALLEY	AZ	Active
DSH030064CH	Child	DSH	Banner - University Medical Center Tucson	NORTH HILLS - PBC-UC Pain Mgmt-Clinic	1891 WEST ORANGE GROVE ROAD	Tucson	AZ	Active
DSH030064CJ	Child	DSH	Banner - University Medical Center Tucson	CLINIC - Plastics Surg-Clinic-NC	3838 NORTH CAMPBELL AVE, BUILDING 2, CLINIC H, 3RD FLOOR	Tucson	AZ	Active
DSH030064H	Child	DSH	Banner - University Medical Center Tucson	Outpatient Infusion-Hosp	3838 North Campbell Avenue	Tucson	AZ	Active
DSH030064I	Child	DSH	Banner - University Medical Center Tucson	C/P-OG Hemeonc-Clinic	1891 W. ORANGE GROVE RD	TUCSON	AZ	Active
DSH030064J	Child	DSH	Banner - University Medical Center Tucson	PBC UC-GV Primary Care-Clinic	1141 S. LA CANADA DR.	GREEN VALLEY	AZ	Terminated
DSH030064K	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon Surgery Center	750 North Alvernon Way	Tucson	AZ	Terminated
DSH030064L	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC Alvernon	707 North Alvernon Way	Tucson	AZ	Terminated
DSH030064M	Child	DSH	Banner - University Medical Center Tucson	Banner - UMC La Cholla Clinic	6261 North La Cholla	Tucson	AZ	Terminated
DSH030064N	Child	DSH	Banner - University Medical Center Tucson	Banner - University Medical Imaging (UMI)	4291 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064P	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Urology	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064Q	Child	DSH	Banner - University Medical Center Tucson	C/P-Mohs Dermatology Clinic	3838 N. Campbell Avenue	Tucson	AZ	Active
DSH030064R	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Radiation Oncology at Orange Grove	1891 W. Orange Grove Rd	Tucson	AZ	Terminated
DSH030064S	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - Bone Marrow Transplant Adult	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064T	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC - North Campus Clinic	3838 N. Campbell Avenue	Tucson	AZ	Terminated
DSH030064U	Child	DSH	Banner - University Medical Center Tucson	Banner - AZCC Bone Marrow Transplant (BMT)	1625 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064V	Child	DSH	Banner - University Medical Center Tucson	Banner - Arizona Cancer Center - Lab - North Campus	3838 North Campbell Avenue	Tucson	AZ	Terminated
DSH030064W	Child	DSH	Banner - University Medical Center Tucson	Surgery 6OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064X	Child	DSH	Banner - University Medical Center Tucson	Surgery 5OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Y	Child	DSH	Banner - University Medical Center Tucson	Surgery 4OPC	3838 N Campbell Ave	Tucson	AZ	Terminated
DSH030064Z	Child	DSH	Banner - University Medical Center Tucson	Medicine 2OPC	3838 N Campbell Ave	Tucson	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		12/31/2020 12:00:00 AM	9/9/2021 8:12 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/9/2021 8:12 AM
Terminations	Termination Date	Update	Recertification		10/1/2021 12:00:00 AM	9/9/2021 8:12 AM
Terminations	Termination Effective Date	Update	Recertification		12/31/2020 12:00:00 AM	9/9/2021 8:12 AM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/9/2021 8:12 AM
Addresses	Billing Address	Update	Change Request	Banner University Medical Center Tucson 1625 North Campbell Ave Tucson, AZ 85719	Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	6/14/2021 10:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10026590500 (NE)		6/14/2021 10:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100542115 (NV)		6/14/2021 10:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	145728400 (WY)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NE)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NE)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NE)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NV)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NV)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NV)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WY)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WY)		6/14/2021 10:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WY)		6/14/2021 10:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1657501 (AK)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (CT)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003189644A (GA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (IA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (ID)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100564160 (KY)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2432435 (LA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	425805300 (MD)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MI)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (MN)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	96009 (MS)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	635921 (MT)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (NC)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	596345 (NJ)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	19852088 (NM)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200784450A (OK)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500707030 (OR)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1031106620001 (PA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11566A (SC)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q028631 (TN)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387902 (TX)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	395387000 (TX)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265820179 (UT)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2017276884 (VA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2060663 (WA)		1/28/2021 5:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100063007 (WI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (AK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (AK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (AK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (CT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (CT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (CT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (GA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (GA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (GA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (IA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (IA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (IA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (ID)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (ID)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (ID)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (KY)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (KY)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (KY)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (LA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (LA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (LA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MD)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MD)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MD)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MS)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MS)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MS)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (MT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (MT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (MT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NJ)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NJ)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NJ)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (NM)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (NM)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (NM)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OK)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (OR)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (OR)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (OR)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (PA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (PA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (PA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (SC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (SC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (SC)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TN)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (TX)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (TX)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (TX)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (UT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (UT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (UT)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (VA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (VA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (VA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WA)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265820179 (WI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1508809427 (WI)		1/28/2021 5:04 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649668450 (WI)		1/28/2021 5:04 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1657501	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000142345	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003189644A	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100564160	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2432435	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		425805300	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		96009	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		635921	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026590500	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		596345	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		19852088	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100542115	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200784450A	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500707030	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1031106620001	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11566A	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q028631	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		395387902	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		395387000	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2017276884	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2060663	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100063007	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		145728400	12/10/2020 6:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265820179	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1508809427	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	12/10/2020 6:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649668450	12/10/2020 6:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	12/10/2020 6:20 PM
Contacts	Signed By	Insert	New Registration		Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	10/19/2020 10:53 AM
Details	340B ID	Update	New Registration		DSH030064AB	10/19/2020 10:53 AM
Details	Entity Name	Update	New Registration	BANNER UNIVERSITY MED CENTER TUCSON	Banner - University Medical Center Tucson	10/19/2020 10:53 AM
Details	Entity Subname	Update	New Registration	North Hills	North Hills - PBC UC-NH Internal Med Clinic	10/19/2020 10:53 AM
Dates	Participating Approval Date	Update	New Registration		10/19/2020 10:53:32 AM	10/19/2020 10:53 AM
Details	State	Update	New Registration	Pending	Approved	10/19/2020 10:53 AM
Dates	Signed By Date	Update	New Registration		10/9/2020 11:17:25 AM	10/19/2020 10:53 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/19/2020 10:53 AM
Addresses	Main Address	Insert	New Registration		265 West Ina Road Tucson, AZ 85704	10/8/2020 7:24 PM
Addresses	Billing Address	Insert	New Registration		Banner University Medical Center Tucson 1625 North Campbell Ave Tucson, AZ 85719	10/8/2020 7:24 PM
Addresses	Shipping Address	Insert	New Registration		Banner University Medical Center Tucson 1625 North Campbell Ave Tucson, AZ 85719	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020470-01	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		988439	10/8/2020 7:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/8/2020 7:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265820179	10/8/2020 7:24 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/8/2020 7:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1508809427	10/8/2020 7:24 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/8/2020 7:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649668450	10/8/2020 7:24 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/8/2020 7:24 PM
Contacts	Primary Contact	Insert	New Registration		Weibel, Kurt Director of Pharmacy Services Banner University Medical Center Tucson 5206946061	10/8/2020 7:24 PM
Contacts	Authorizing Official	Insert	New Registration		Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	10/8/2020 7:24 PM
Details	Assistance Received From Date	Insert	New Registration			10/8/2020 7:24 PM
Details	Assistance Received To Date	Insert	New Registration			10/8/2020 7:24 PM
Details	Last Recertification Date	Insert	New Registration			10/8/2020 7:24 PM
Details	Grant Number	Insert	New Registration			10/8/2020 7:24 PM
Details	340B ID	Insert	New Registration			10/8/2020 7:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2020 7:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2020 7:24 PM
Details	Medicare Provider Number	Insert	New Registration		030064	10/8/2020 7:24 PM
Details	Entity Name	Insert	New Registration		BANNER UNIVERSITY MED CENTER TUCSON	10/8/2020 7:24 PM
Details	NOFO Number	Insert	New Registration			10/8/2020 7:24 PM
Details	Program Code	Insert	New Registration		DSH	10/8/2020 7:24 PM
Details	Entity Subname	Insert	New Registration		North Hills	10/8/2020 7:24 PM
Dates	Participating Approval Date	Insert	New Registration			10/8/2020 7:24 PM
Details	State	Insert	New Registration		Pending	10/8/2020 7:24 PM
Dates	Registration Date	Insert	New Registration		10/8/2020 7:24:34 PM	10/8/2020 7:24 PM
Dates	Signed By Date	Insert	New Registration			10/8/2020 7:24 PM
Dates	Start Date	Insert	New Registration			10/8/2020 7:24 PM
Terminations	Termination Comments	Insert	New Registration			10/8/2020 7:24 PM
Terminations	Termination Date	Insert	New Registration			10/8/2020 7:24 PM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2020 7:24 PM
Terminations	Termination Reason	Insert	New Registration			10/8/2020 7:24 PM