Covered Entity Details

DSH040114T BAPTIST HEALTH MEDICAL CENTER - LR (Active) - information as of 5/28/2025 5:17:18 PM

Main Details

Name

BAPTIST HEALTH MEDICAL CENTER - LR

Subdivision Name

Heart Failure Clinic - Heart Failure Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH040114T

Medicare Provider Number

040114

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/21/2020

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Baptist Health
Brent Beaulieu, CFO
(501) 202-2017

Primary Contact

Baptist Health
Stefanie Jaeger, Sr. Reimbursement Specialist
(501) 202-1813

Addresses

Street Address

9500 Kanis Road
Suite 310
Little Rock, AR 72205

Billing Address

Baptist Health Medical Center - Little Rock
9601 Baptist Health Drive
Little Rock, AR 72205

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
AR	104304105	1043240682

Shipping Addresses

Shipping Address 1

Baptist Health Medical Center - Little Rock
9601 Baptist Health Drive
Little Rock, AR 72205

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
DSH040114A	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Sleep Disorder Center	9500 Kanis Road	Little Rock	AR	Active
DSH040114B	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Breast Center	9500 Kanis Road	Little Rock	AR	Active
DSH040114C	Child	DSH	Baptist Health Medical Center - Little Rock	Kidney Transplant	9500 Kanis Road	Little Rock	AR	Terminated
DSH040114D	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Heart Transplant	9500 Kanis Road	Little Rock	AR	Active
DSH040114E	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Eye Center	9800 Baptist Health Drive	Little Rock	AR	Active
DSH040114G	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Arkansas Cardiology Clinic	9501 Baptist Health Drive Suite 600	Little Rock	AR	Active
DSH040114J	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Infusion Therapy	9600 Baptist Health Drive Suite 330	Little Rock	AR	Terminated
DSH040114K	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	MRI	9500 Kanis Road	Little Rock	AR	Active
DSH040114L	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Vein Center	9501 Baptist Health Drive Suite 830	Little Rock	AR	Terminated
DSH040114M	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Pediatric Afterhour Clinic	9601 Baptist Health Drive	Little Rock	AR	Terminated
DSH040114N	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	VAD	9500 Kanis Road	Little Rock	AR	Active
DSH040114P	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BAPTIST HEALTH / Outpatient Imaging Center	9101 KANIS RD	LITTLE ROCK	AR	Active
DSH040114Q	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Heart Inst-Valve Clinic	9500 Kanis Road	Little Rock	AR	Terminated
DSH040114R	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Employee Clinic	9600 Baptist Health Drive	Little Rock	AR	Active
DSH040114S	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	BH Gastroenterology Center - BH Gastroenterology Center	9501 Baptist Health Drive	Little Rock	AR	Active
DSH040114T	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Heart Failure Clinic - Heart Failure Clinic	9500 Kanis Road	Little Rock	AR	Active
DSH040114U	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	LR INFUSION THERAPY - LR INFUSION THERAPY	9500 Kanis Road	Little Rock	AR	Active
DSH040114V	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Oncology Clinic - Oncology Clinic	9500 Kanis Road	Little Rock	AR	Active
DSH040114W	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Neurology Clinic - Neurology Clinic	9600 Baptist Health Drive	Little Rock	AR	Active
DSH040114X	Child	DSH	BAPTIST HEALTH MEDICAL CENTER - LR	Gastroenterology Clinic - Gastroenterology Clinic	9501 Baptist Health Drive	Little Rock	AR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/13/2023 11:28:08 AM	9/3/2024 11:09:02 AM	9/3/2024 11:09 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 12:30:51 PM	9/13/2023 11:28:08 AM	9/13/2023 11:28 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 4:45:33 PM	9/12/2022 12:30:51 PM	9/12/2022 12:30 PM
Details	Last Recertification Date	Update	Recertification		9/3/2021 4:45:33 PM	9/3/2021 4:45 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Beaulieu, Brent CFO Baptist Health 5012022017	10/21/2020 8:10 AM
Details	340B ID	Update	New Registration		DSH040114T	10/21/2020 8:10 AM
Details	Entity Subname	Update	New Registration	Heart Failure Clinic	Heart Failure Clinic - Heart Failure Clinic	10/21/2020 8:10 AM
Dates	Participating Approval Date	Update	New Registration		10/21/2020 8:10:17 AM	10/21/2020 8:10 AM
Details	State	Update	New Registration	Pending	Approved	10/21/2020 8:10 AM
Dates	Signed By Date	Update	New Registration		10/20/2020 6:48:16 PM	10/21/2020 8:10 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/21/2020 8:10 AM
Addresses	Main Address	Insert	New Registration		9500 Kanis Road Suite 310 Little Rock, AR 72205	10/14/2020 4:40 PM
Addresses	Billing Address	Insert	New Registration		Baptist Health Medical Center - Little Rock 9601 Baptist Health Drive Little Rock, AR 72205	10/14/2020 4:40 PM
Addresses	Shipping Address	Insert	New Registration		Baptist Health Medical Center - Little Rock 9601 Baptist Health Drive Little Rock, AR 72205	10/14/2020 4:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 4:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		104304105	10/14/2020 4:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	10/14/2020 4:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1043240682	10/14/2020 4:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	10/14/2020 4:40 PM
Contacts	Primary Contact	Insert	New Registration		Jaeger, Stefanie Sr. Reimbursement Specialist Baptist Health 5012021813	10/14/2020 4:40 PM
Contacts	Authorizing Official	Insert	New Registration		Beaulieu, Brent CFO Baptist Health 5012022017	10/14/2020 4:40 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2020 4:40 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2020 4:40 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2020 4:40 PM
Details	Grant Number	Insert	New Registration			10/14/2020 4:40 PM
Details	340B ID	Insert	New Registration			10/14/2020 4:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2020 4:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2020 4:40 PM
Details	Medicare Provider Number	Insert	New Registration		040114	10/14/2020 4:40 PM
Details	Entity Name	Insert	New Registration		BAPTIST HEALTH MEDICAL CENTER - LR	10/14/2020 4:40 PM
Details	NOFO Number	Insert	New Registration			10/14/2020 4:40 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2020 4:40 PM
Details	Entity Subname	Insert	New Registration		Heart Failure Clinic	10/14/2020 4:40 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2020 4:40 PM
Details	State	Insert	New Registration		Pending	10/14/2020 4:40 PM
Dates	Registration Date	Insert	New Registration		10/14/2020 4:40:54 PM	10/14/2020 4:40 PM
Dates	Signed By Date	Insert	New Registration			10/14/2020 4:40 PM
Dates	Start Date	Insert	New Registration			10/14/2020 4:40 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2020 4:40 PM
Terminations	Termination Date	Insert	New Registration			10/14/2020 4:40 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2020 4:40 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2020 4:40 PM