Covered Entity Details

DSH330265C Clifton Springs Hospital (Active) - information as of 5/13/2025 11:00:49 PM

Main Details

Name

Clifton Springs Hospital

Subdivision Name

CMG CANAL PARK FAMILY MEDICINE - Family Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330265C

Medicare Provider Number

330265

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2020

Participating Start Date

1/1/2021

Participating Approval Date

11/3/2020

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Rochester Regional Health
Shawn Bishop, Vice President, RRH Revenue & Reimbursement
(585) 922-0056

Primary Contact

RRH
Robert Michael Scardino, 340B Pharmacy System Manager
(585) 319-6750

Addresses

Street Address

1900 ROUTE 31
11
MACEDON, NY 14502-8995

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
NY	00354641	1366505463

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
DSH330265A	Child	DSH	Clifton Springs Hospital	CLIFTON SPRINGS HOSPITAL AND CLINIC / Behavioral Health	35 NORTH ST	CANANDAIGUA	NY	Active
DSH330265B	Child	DSH	Clifton Springs Hospital	CLIFTON SPRINGS FAMILY MEDICINE - Family Medicine	165 E UNION ST	NEWARK	NY	Active
DSH330265C	Child	DSH	Clifton Springs Hospital	CMG CANAL PARK FAMILY MEDICINE - Family Medicine	1900 ROUTE 31	MACEDON	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 9:47:38 AM	8/19/2024 3:59:31 PM	8/19/2024 3:59 PM
Details	Last Recertification Date	Update	Recertification	9/19/2022 11:27:23 AM	8/24/2023 9:47:38 AM	8/24/2023 9:47 AM
Contacts	Primary Contact	Update	PC Change Request	Kinter, Karen M Vice President of Specialty Revenue Programs Rochester Regional 5853683537	Scardino, Robert Michael 340B Pharmacy System Manager RRH 5853196750	7/20/2023 11:00 AM
Contacts	Authorizing Official	Update	Change Request	Thomas, Hugh Executive Vice President, Chief Administrative Officer Rochester Regional Health 5859224941	Bishop, Shawn Vice President, RRH Revenue & Reimbursement Rochester Regional Health 5859220056	6/8/2023 2:21 PM
Details	Last Recertification Date	Update	Recertification	9/11/2021 1:25:48 PM	9/19/2022 11:27:23 AM	9/19/2022 11:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Kinter, Karen M 340B Program Director Rochester General Hospital 5853683537	Kinter, Karen M Vice President of Specialty Revenue Programs Rochester Regional 5853683537	7/29/2022 8:15 AM
Contacts	Authorizing Official	Update	Profile Change Request	Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	Thomas, Hugh Executive Vice President, Chief Administrative Officer Rochester Regional Health 5859224941	7/8/2022 12:36 PM
Contacts	Signed By	Update	Profile Change Request	Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	Thomas, Hugh Executive Vice President, Chief Administrative Officer Rochester Regional Health 5859224941	7/8/2022 12:36 PM
Details	Last Recertification Date	Update	Recertification		9/11/2021 1:25:48 PM	9/11/2021 1:25 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	11/3/2020 8:11 AM
Details	340B ID	Update	New Registration		DSH330265C	11/3/2020 8:11 AM
Details	Entity Name	Update	New Registration	CLIFTON SPRINGS HOSPITAL & CLINIC	Clifton Springs Hospital	11/3/2020 8:11 AM
Details	Entity Subname	Update	New Registration	CMG CANAL PARK FAMILY MEDICINE	CMG CANAL PARK FAMILY MEDICINE - Family Medicine	11/3/2020 8:11 AM
Dates	Participating Approval Date	Update	New Registration		11/3/2020 8:11:46 AM	11/3/2020 8:11 AM
Details	State	Update	New Registration	Pending	Approved	11/3/2020 8:11 AM
Dates	Signed By Date	Update	New Registration		10/23/2020 3:18:44 PM	11/3/2020 8:11 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	11/3/2020 8:11 AM
Contacts	Primary Contact	Update	New Registration	Kinter, Karen 340B Program Director Rochester General Hospital 5853683537	Kinter, Karen M 340B Program Director Rochester General Hospital 5853683537	10/11/2020 1:47 PM
Addresses	Main Address	Insert	New Registration		1900 ROUTE 31 11 MACEDON, NY 14502-8995	10/11/2020 1:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2020 1:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00354641	10/11/2020 1:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/11/2020 1:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366505463	10/11/2020 1:06 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/11/2020 1:06 PM
Contacts	Authorizing Official	Insert	New Registration		Thomas, Hugh Executive Vice President, Chief Administrative Officer Unity Hospital 5859224941	10/11/2020 1:06 PM
Contacts	Primary Contact	Insert	New Registration		Kinter, Karen 340B Program Director Rochester General Hospital 5853683537	10/11/2020 1:06 PM
Details	Assistance Received From Date	Insert	New Registration			10/11/2020 1:06 PM
Details	Assistance Received To Date	Insert	New Registration			10/11/2020 1:06 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2020 1:06 PM
Details	Grant Number	Insert	New Registration			10/11/2020 1:06 PM
Details	340B ID	Insert	New Registration			10/11/2020 1:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2020 1:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2020 1:06 PM
Details	Medicare Provider Number	Insert	New Registration		330265	10/11/2020 1:06 PM
Details	Entity Name	Insert	New Registration		CLIFTON SPRINGS HOSPITAL & CLINIC	10/11/2020 1:06 PM
Details	NOFO Number	Insert	New Registration			10/11/2020 1:06 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2020 1:06 PM
Details	Entity Subname	Insert	New Registration		CMG CANAL PARK FAMILY MEDICINE	10/11/2020 1:06 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2020 1:06 PM
Details	State	Insert	New Registration		Pending	10/11/2020 1:06 PM
Dates	Registration Date	Insert	New Registration		10/11/2020 1:06:18 PM	10/11/2020 1:06 PM
Dates	Signed By Date	Insert	New Registration			10/11/2020 1:06 PM
Dates	Start Date	Insert	New Registration			10/11/2020 1:06 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2020 1:06 PM
Terminations	Termination Date	Insert	New Registration			10/11/2020 1:06 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2020 1:06 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2020 1:06 PM