| Contacts | Authorizing Official | Update | Profile Change Request | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | Dalal, Hardik
SVP, Finance & System-wide Pharmacy Finance
Corewell Health
3127710810 | 2/24/2025 6:26 AM |
| Details | Entity Name | Update | Recertification | Oakwood Healthcare, Inc. d/b/a Beaumont Hospital - Dearborn | Oakwood Healthcare, Inc. d/b/a Corewell Health Dearborn Hospital | 9/6/2024 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 8/14/2023 11:27:56 AM | 8/27/2024 8:26:47 AM | 8/27/2024 8:26 AM |
| Details | Entity Subname | Update | Recertification | Beaumont OBGYN Associates - OB-GYN | Corewell Health Dearborn Hospital Obstetrics & Gynecology - 4700 Schaefer Rd | 8/27/2024 8:26 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | Schaible, Thomas
Mgr, Pharmacy CHE
Corewell Health
9475221169 | 1/30/2024 8:36 AM |
| Contacts | Primary Contact | Update | PC Change Request | Desai, Neha
Director, Pharmacy
Oakwood
3135937255-37268 | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | 1/10/2024 3:28 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | 12/13/2023 7:55 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 2:45:13 PM | 8/14/2023 11:27:56 AM | 8/14/2023 11:27 AM |
| Addresses | Main Address | Update | Change Request |
4900 Mercury Drive
Suite 201
Dearborn, MI 48126 |
4700 Schaefer Rd
Suite 310
Dearborn, MI 48126 | 5/12/2023 7:12 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | 10/17/2022 10:24 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 9:45:43 AM | 8/29/2022 2:45:13 PM | 8/29/2022 2:45 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1003829441 | 3/23/2022 2:59 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 3/23/2022 2:59 PM |
| Details | Last Recertification Date | Update | Recertification | | 8/30/2021 9:45:43 AM | 8/30/2021 9:45 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | 8/20/2021 3:33 PM |
| Details | State | Update | | Approved | Active | 4/1/2021 12:01 AM |
| Contacts | Signed By | Insert | New Registration | | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | 1/8/2021 11:25 AM |
| Details | 340B ID | Update | New Registration | | DSH230020S | 1/8/2021 11:25 AM |
| Details | Entity Name | Update | New Registration | BEAUMONT HOSPITAL - DEARBORN | Oakwood Healthcare, Inc. d/b/a Beaumont Hospital - Dearborn | 1/8/2021 11:25 AM |
| Details | Entity Subname | Update | New Registration | Beaumont OBGYN Associates | Beaumont OBGYN Associates - OB-GYN | 1/8/2021 11:25 AM |
| Dates | Participating Approval Date | Update | New Registration | | 1/8/2021 11:25:39 AM | 1/8/2021 11:25 AM |
| Details | State | Update | New Registration | Pending | Approved | 1/8/2021 11:25 AM |
| Dates | Signed By Date | Update | New Registration | | 1/7/2021 10:46:32 AM | 1/8/2021 11:25 AM |
| Dates | Start Date | Update | New Registration | | 4/1/2021 12:00:00 AM | 1/8/2021 11:25 AM |
| Addresses | Main Address | Insert | New Registration | |
4900 Mercury Drive
Suite 201
Dearborn, MI 48126 | 1/4/2021 10:16 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1740230119 | 1/4/2021 10:16 AM |
| Medicaid Billing | NPI: State | Insert | New Registration | | MI | 1/4/2021 10:16 AM |
| Contacts | Primary Contact | Insert | New Registration | | Desai, Neha
Director, Pharmacy
Oakwood
3135937255-37268 | 1/4/2021 10:16 AM |
| Contacts | Authorizing Official | Insert | New Registration | | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | 1/4/2021 10:16 AM |
| Details | Assistance Received From Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Assistance Received To Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Last Recertification Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Grant Number | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | 340B ID | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Medicare Provider Number | Insert | New Registration | | 230020 | 1/4/2021 10:16 AM |
| Details | Entity Name | Insert | New Registration | | BEAUMONT HOSPITAL - DEARBORN | 1/4/2021 10:16 AM |
| Details | NOFO Number | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | Program Code | Insert | New Registration | | DSH | 1/4/2021 10:16 AM |
| Details | Entity Subname | Insert | New Registration | | Beaumont OBGYN Associates | 1/4/2021 10:16 AM |
| Dates | Participating Approval Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Details | State | Insert | New Registration | | Pending | 1/4/2021 10:16 AM |
| Dates | Registration Date | Insert | New Registration | | 1/4/2021 10:16:57 AM | 1/4/2021 10:16 AM |
| Dates | Signed By Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Dates | Start Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Terminations | Termination Comments | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Terminations | Termination Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 1/4/2021 10:16 AM |
| Terminations | Termination Reason | Insert | New Registration | | | 1/4/2021 10:16 AM |