Covered Entity Details

RRC360070-14 CLEVELAND CLINIC MERCY HOSPITAL (Terminated) - information as of 4/25/2025 9:21:09 PM

Main Details

Name

CLEVELAND CLINIC MERCY HOSPITAL

Subdivision Name

MERCY UROLOGY SPECIALISTS - Urology

Type

Rural Referral Center

Rural

Yes

340B ID

RRC360070-14

Medicare Provider Number

360070

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/8/2021

Participating Start Date

4/1/2021

Participating Approval Date

1/28/2021

Last Recertification Date

9/7/2021

Termination Date
Termination Reason

1/1/2022
Outpatient facility moved within the 4 walls of the parent hospital

Contacts

Authorizing Official

Cleveland Clinic Mercy Hospital
David Stewart, Senior Director of Operations II
(330) 489-1131

Primary Contact

Cleveland Clinic Mercy Hospital
Kyle A Sobecki, Director, Pharmacy Services
(330) 489-1111 Ext: 1930

Addresses

Street Address

1330 MERCY DR NW
STE 420
CANTON, OH 44708-2625

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
OH	0298771	1366433195

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
RRC360070-01	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MHC OF TUSCARAWAS COUNTY - Urgent Care	1031 W HIGH AVE	NEW PHILADELPHIA	OH	Terminated
RRC360070-02	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MHC OF CARROLL COUNTY - Urgent Care	125 CANTON RD NW	CARROLLTON	OH	Active
RRC360070-03	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF NORTH CANTON - Urgent Care	6200 WHIPPLE AVE NW	NORTH CANTON	OH	Active
RRC360070-04	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	PROVIDER BASED SURGICAL SUITES - Surgical Services	1330 MERCY NWDR 319	CANTON	OH	Terminated
RRC360070-05	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER PLAIN COMMUNITY - Urgent Care Clinic - PROVIDER BASED PLAIN	2638 EASTON ST NE	CANTON	OH	Active
RRC360070-06	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY PRIMARY CARE BELDEN - Primary Care	4909 MUNSON STREET NW	CANTON	OH	Active
RRC360070-07	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	PROVIDER BASED METRO - Primary Care	601 CLEVELAND NWAVE	CANTON	OH	Terminated
RRC360070-08	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER AND STATCARE OF - Urgent Care	7337 CARITAS CIRCLE N W	MASSILLON	OH	Active
RRC360070-09	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF MASSILLON - Urgent Care	2935 LINCOLN WAY W	MASSILLON	OH	Active
RRC360070-10	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF LOUISVILLE - Primary Care	1302W MAIN ST	LOUISVILLE	OH	Terminated
RRC360070-11	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY FAMILY MEDICAL CENTER OF ALLI - Primary Care	149E SIMPSON ST	ALLIANCE	OH	Terminated
RRC360070-12	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY MEDICAL CENTER AT ST. PAUL SQ - Indigent Primary Care	1459 SUPERIOR AVE N.E.	CANTON	OH	Active
RRC360070-13	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Mercy Pain Center - Jackson - Pain Management	7337 Caritas Circle	Massillon	OH	Active
RRC360070-14	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY UROLOGY SPECIALISTS - Urology	1330 MERCY DR NW	CANTON	OH	Terminated
RRC360070-15	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MHC OF CARROLL COUNTY - Primary Care	125 CANTON RD NW	CARROLLTON	OH	Active
RRC360070-16	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Mercy Pain Center - Alliance - Pain Management	149 E. Simpson Ave.	Alliance	OH	Terminated
RRC360070-17	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER AND STATCARE OF - Primary Care	7337 CARITAS CIRCLE N W	MASSILLON	OH	Active
RRC360070-18	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY RHEUMATOLOGY - Rheumatology	1330 MERCY DR NW	CANTON	OH	Terminated
RRC360070-19	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Ambulatory Care Clinic - Indigent Care/No PCP	1320 Mercy Dr NW	Canton	OH	Terminated
RRC360070-20	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY CENTER FOR ENDOMETRIOSIS PELV - Endometriosis, Pelvic Pain, and Urogynecology	1330 MERCY DR NW	CANTON	OH	Terminated
RRC360070-21	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEMATOLOGY AND ONCOLOGY ASSOC - Oncology	1455 HARRISON AVE NW	CANTON	OH	Terminated
RRC360070-22	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF NORTH CANTON - Primary Care	6200 WHIPPLE AVE NW	NORTH CANTON	OH	Terminated
RRC360070-23	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER AND STATCARE OF - Urology - MERCY JACKSON MOB UROLOGY	7337 CARITAS CIR NW	MASSILLON	OH	Active
RRC360070-24	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF NORTH CANTON - Radiology - MERCY NORTH CANTON MOB NUCLEAR MEDICINE	6200 WHIPPLE AVE NW	NORTH CANTON	OH	Terminated
RRC360070-25	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER OF LAKE - Family Medicine - PROVIDER BASED LAKE	432 KING CHURCH AVE SW	UNIONTOWN	OH	Active
RRC360070-26	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MHC OF CARROLL COUNTY - Pain Management - MERCY CAROLLTON FHC PAIN MGMT OUTPATIENT	125 Canton Road NW	CARROLLTON	OH	Active
RRC360070-27	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY HEALTH CENTER PLAIN COMMUNITY - Family Medicine - PROVIDER BASED PLAIN	2638 EASTON ST NE	CANTON	OH	Active
RRC360070-28	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Mercy Health Center of Massillon - Family Medicine - MERCY MASSILLON FHC PROVIDER BASED	2935 LINCOLN WAY NW	MASSILLON	OH	Active
RRC360070-29	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Mercy Health Center and Statcare of Jackson - Family Medicine - CV MED DIAG JACKSON	7337 CARITAS CIR NW	MASSILLON	OH	Active
RRC360070-30	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	Mercy Health Center, Louisville - Family Medicine - LAB RAD LOUISVILLE	1303 CALIFORNIA AVE	LOUISVILLE	OH	Active
RRC360070-31	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	PRIMARY CARE PHYSICIAN ASSOCIATES - Medicine Pediatrics - MERCY BELDEN PROVIDER BASED	4575 STEPHEN CIRCLE NW	CANTON	OH	Active
RRC360070-32	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MEDICAL PARK OF ALLIANCE - Urology - MERCY ALLIANCE UROLOGY	885 S SAWBURG AVE	ALLIANCE	OH	Active
RRC360070-33	Child	RRC	CLEVELAND CLINIC MERCY HOSPITAL	MERCY PRIMARY CARE PORTAGE - Family Medicine - MERCY PORTAGE MOB PROVIDER BASED	1413 Portage St NW	NORTH CANTON	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Stewart, David COO Cleveland Clinic Mercy Hospital 3304891131	Stewart, David Senior Director of Operations II Cleveland Clinic Mercy Hospital 3304891131	4/10/2024 10:59 AM
Contacts	Authorizing Official	Update	Profile Change Request	Stewart, David SVP / COO / CFO Cleveland Clinic Mercy Hospital 3304891007	Stewart, David COO Cleveland Clinic Mercy Hospital 3304891131	9/6/2023 4:15 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/22/2021 12:00:00 AM	12/27/2021 11:37 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/27/2021 11:37 AM
Terminations	Termination Comments	Update	Termination Request		Identified as within the 4 walls. Still eligible for 340B, but not separately registered.	12/27/2021 11:37 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	12/27/2021 11:37 AM
Terminations	Termination Effective Date	Update	Termination Request		12/22/2021 12:00:00 AM	12/27/2021 11:37 AM
Terminations	Termination Reason	Update	Termination Request		Outpatient facility moved within the 4 walls of the parent hospital	12/27/2021 11:37 AM
Details	Last Recertification Date	Update	Recertification		9/7/2021 8:55:26 AM	9/7/2021 8:55 AM
Contacts	Authorizing Official	Update	AO Change Request	Stewart, David K SVP / COO / CFO Cleveland Clinic Mercy Hospital 3304891007	Stewart, David SVP / COO / CFO Cleveland Clinic Mercy Hospital 3304891007	7/15/2021 10:03 AM
Contacts	Authorizing Official	Update	Profile Change Request	Stewart, David K SVP & CFO Cleveland Clinic Mercy Hospital 3304891007	Stewart, David K SVP / COO / CFO Cleveland Clinic Mercy Hospital 3304891007	7/7/2021 8:14 AM
Contacts	Signed By	Update	Profile Change Request	Stewart, David K SVP & CFO Cleveland Clinic Mercy Hospital 3304891007	Stewart, David K SVP / COO / CFO Cleveland Clinic Mercy Hospital 3304891007	7/7/2021 8:14 AM
Contacts	Primary Contact	Update	Group Change Request	Sobecki, Kyle A Director, Pharmacy Services Cleveland Clinic Mercy Hospital 3304891111-1930	Sobecki, Kyle A Director, Pharmacy Services Cleveland Clinic Mercy Hospital 3304891111-1930	7/6/2021 10:54 AM
Details	Entity Name	Update	Change Request	MERCY MEDICAL CENTER	CLEVELAND CLINIC MERCY HOSPITAL	5/20/2021 2:52 PM
Contacts	Authorizing Official	Update	Profile Change Request	Stewart, David K SVP & CFO Mercy Medical Center 3304891007	Stewart, David K SVP & CFO Cleveland Clinic Mercy Hospital 3304891007	5/20/2021 11:20 AM
Contacts	Signed By	Update	Profile Change Request	Stewart, David K SVP & CFO Mercy Medical Center 3304891007	Stewart, David K SVP & CFO Cleveland Clinic Mercy Hospital 3304891007	5/20/2021 11:20 AM
Contacts	Primary Contact	Update	Profile Change Request	Sobecki, Kyle A Director, Pharmacy Services Mercy Medical Center 3304891111-1930	Sobecki, Kyle A Director, Pharmacy Services Cleveland Clinic Mercy Hospital 3304891111-1930	5/19/2021 1:31 PM
Details	State	Update		Approved	Active	4/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Stewart, David K SVP & CFO Mercy Medical Center 3304891007	1/28/2021 8:48 AM
Details	340B ID	Update	New Registration		RRC360070-14	1/28/2021 8:48 AM
Details	Entity Subname	Update	New Registration	MERCY UROLOGY SPECIALISTS	MERCY UROLOGY SPECIALISTS - Urology	1/28/2021 8:48 AM
Dates	Participating Approval Date	Update	New Registration		1/28/2021 8:48:34 AM	1/28/2021 8:48 AM
Details	State	Update	New Registration	Pending	Approved	1/28/2021 8:48 AM
Dates	Signed By Date	Update	New Registration		1/18/2021 10:31:13 AM	1/28/2021 8:48 AM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	1/28/2021 8:48 AM
Addresses	Main Address	Insert	New Registration		1330 MERCY DR NW STE 420 CANTON, OH 44708-2625	1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0298771	1/8/2021 1:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	1/8/2021 1:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366433195	1/8/2021 1:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	1/8/2021 1:48 PM
Contacts	Authorizing Official	Insert	New Registration		Stewart, David K SVP & CFO Mercy Medical Center 3304891007	1/8/2021 1:48 PM
Contacts	Primary Contact	Insert	New Registration		Sobecki, Kyle A Director, Pharmacy Services Mercy Medical Center 3304891111-1930	1/8/2021 1:48 PM
Details	Assistance Received From Date	Insert	New Registration			1/8/2021 1:48 PM
Details	Assistance Received To Date	Insert	New Registration			1/8/2021 1:48 PM
Details	Last Recertification Date	Insert	New Registration			1/8/2021 1:48 PM
Details	Grant Number	Insert	New Registration			1/8/2021 1:48 PM
Details	340B ID	Insert	New Registration			1/8/2021 1:48 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/8/2021 1:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/8/2021 1:48 PM
Details	Medicare Provider Number	Insert	New Registration		360070	1/8/2021 1:48 PM
Details	Entity Name	Insert	New Registration		MERCY MEDICAL CENTER	1/8/2021 1:48 PM
Details	NOFO Number	Insert	New Registration			1/8/2021 1:48 PM
Details	Program Code	Insert	New Registration		RRC	1/8/2021 1:48 PM
Details	Entity Subname	Insert	New Registration		MERCY UROLOGY SPECIALISTS	1/8/2021 1:48 PM
Dates	Participating Approval Date	Insert	New Registration			1/8/2021 1:48 PM
Details	State	Insert	New Registration		Pending	1/8/2021 1:48 PM
Dates	Registration Date	Insert	New Registration		1/8/2021 1:48:57 PM	1/8/2021 1:48 PM
Dates	Signed By Date	Insert	New Registration			1/8/2021 1:48 PM
Dates	Start Date	Insert	New Registration			1/8/2021 1:48 PM
Terminations	Termination Comments	Insert	New Registration			1/8/2021 1:48 PM
Terminations	Termination Date	Insert	New Registration			1/8/2021 1:48 PM
Terminations	Termination Effective Date	Insert	New Registration			1/8/2021 1:48 PM
Terminations	Termination Reason	Insert	New Registration			1/8/2021 1:48 PM