Covered Entity Details

SCH230133-07 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL (Active) - information as of 4/30/2025 10:52:47 PM

Main Details

Name

MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL

Subdivision Name

OMH MEDICAL GROUP - INDIAN RIVER - Walk-In Clinic

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH230133-07

Medicare Provider Number

230133

Outpatient Facility Provider Number

238660

Additional Details

Current Program Status

Active

Registration Date

4/7/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/3/2021

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Munson Healthcare
Kathleen M LaRaia, Vice President
(231) 392-8410

Primary Contact

Munson Healthcare
Sam Patrick Niemi, System Director Reimbursement
(231) 935-7761

Addresses

Street Address

3860 S STRAITS HWY
INDIAN RIVER, MI 49749-5136

Billing Address

Munson Healthcare Ostego Memorial Hospital
825 N. Center Ave.
Gaylord, MI 49735

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
MI	1639420557	1639420557

Shipping Addresses

Shipping Address 1

MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
3860 S STRAITS HWY
INDIAN RIVER, MI 49749

Shipping Address 2

Otsego Memorial Hospital
825 N Center Ave
Gaylord, MI 49735

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
SCH230133-01	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Cancer & Infusion Center	701 N. Otsego Avenue	Gaylord	MI	Active
SCH230133-02	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group Family Practice - Gaylord	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-03	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Lewiston	3040 Bourn Street	Lewiston	MI	Active
SCH230133-04	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Walk-In Clinic	1996 Walden Drive	Gaylord	MI	Active
SCH230133-05	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH MEDICAL GROUP - INDIAN RIVER	3860 S STRAITS HWY	INDIAN RIVER	MI	Active
SCH230133-06	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Elmira	2572 N US HIGHWAY 131	ELMIRA	MI	Terminated
SCH230133-07	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH MEDICAL GROUP - INDIAN RIVER - Walk-In Clinic	3860 S STRAITS HWY	INDIAN RIVER	MI	Active
SCH230133-08	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Gaylord - Surgical Clinic	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-09	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Gaylord - OB/GYN	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-10	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Gaylord - Pediatric Clinic	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-11	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Gaylord - Urology	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-12	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH Medical Group - Gaylord - Internal Medicine	829 N CENTER AVE	GAYLORD	MI	Active
SCH230133-13	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH MEDICAL GROUP - INDIAN RIVER - Pediatrics	3860 S STRAITS HWY	INDIAN RIVER	MI	Active
SCH230133-14	Child	SCH	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	OMH MEDICAL GROUP - INDIAN RIVER - OB/GYN	3860 S STRAITS HWY	INDIAN RIVER	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/15/2025 9:07 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1639420557	4/15/2025 9:07 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	4/15/2025 9:07 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1639420557	4/15/2025 9:07 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/15/2025 9:07 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 9:37:28 AM	8/20/2024 9:41:19 AM	8/20/2024 9:41 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 9:41:33 AM	8/15/2023 9:37:28 AM	8/15/2023 9:37 AM
Contacts	Authorizing Official	Update	Change Request	Maly, Kathleen Maly Interim Chief Financial Officer Munson Healthcare 2488851252	LaRaia, Kathleen M Vice President Munson Healthcare 2313928410	3/22/2023 12:15 PM
Addresses	Billing Address	Update	Change Request	Munson Healthcare Ostego Memorial Hospital 825 N. Otsego Ave. Gaylord, MI 49735	Munson Healthcare Ostego Memorial Hospital 825 N. Center Ave. Gaylord, MI 49735	1/17/2023 4:42 PM
Addresses	Shipping Address	Insert	Change Request		MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL 3860 S STRAITS HWY INDIAN RIVER, MI 49749	11/30/2022 1:12 PM
Addresses	Shipping Address	Insert	Change Request		Otsego Memorial Hospital 825 N Center Ave Gaylord, MI 49735	11/30/2022 1:12 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 10:41:37 AM	8/29/2022 9:41:33 AM	8/29/2022 9:41 AM
Contacts	Authorizing Official	Update	Change Request	Maitland, Alicia CFO Munson Healthcare 2319357840	Maly, Kathleen Maly Interim Chief Financial Officer Munson Healthcare 2488851252	7/28/2022 11:03 AM
Contacts	Primary Contact	Update	Profile Change Request	Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	Niemi, Sam Patrick System Director Reimbursement Munson Healthcare 2319357761	5/2/2022 12:31 PM
Details	Last Recertification Date	Update	Recertification		8/19/2021 10:41:37 AM	8/19/2021 10:41 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	Hepler, Mark CFO Munson Healthcare 2319356702	Maitland, Alicia CFO Munson Healthcare 2319357840	6/23/2021 9:52 AM
Contacts	Signed By	Insert	New Registration		Hepler, Mark CFO Munson Healthcare 2319356702	6/3/2021 12:09 PM
Details	340B ID	Update	New Registration		SCH230133-07	6/3/2021 12:09 PM
Details	Entity Name	Update	New Registration	OTSEGO MEMORIAL HOSPITAL	MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL	6/3/2021 12:09 PM
Details	Entity Subname	Update	New Registration	OMH MEDICAL GROUP - INDIAN RIVER	OMH MEDICAL GROUP - INDIAN RIVER - Walk-In Clinic	6/3/2021 12:09 PM
Dates	Participating Approval Date	Update	New Registration		6/3/2021 12:09:00 PM	6/3/2021 12:09 PM
Details	State	Update	New Registration	Pending	Approved	6/3/2021 12:09 PM
Dates	Signed By Date	Update	New Registration		4/8/2021 9:11:48 AM	6/3/2021 12:09 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	6/3/2021 12:09 PM
Addresses	Main Address	Insert	New Registration		3860 S STRAITS HWY INDIAN RIVER, MI 49749-5136	4/7/2021 6:50 PM
Addresses	Billing Address	Insert	New Registration		Munson Healthcare Ostego Memorial Hospital 825 N. Otsego Ave. Gaylord, MI 49735	4/7/2021 6:50 PM
Contacts	Authorizing Official	Insert	New Registration		Hepler, Mark CFO Munson Healthcare 2319356702	4/7/2021 6:50 PM
Contacts	Primary Contact	Insert	New Registration		Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	4/7/2021 6:50 PM
Details	Assistance Received From Date	Insert	New Registration			4/7/2021 6:50 PM
Details	Assistance Received To Date	Insert	New Registration			4/7/2021 6:50 PM
Details	Last Recertification Date	Insert	New Registration			4/7/2021 6:50 PM
Details	Grant Number	Insert	New Registration			4/7/2021 6:50 PM
Details	340B ID	Insert	New Registration			4/7/2021 6:50 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/7/2021 6:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/7/2021 6:50 PM
Details	Medicare Provider Number	Insert	New Registration		230133	4/7/2021 6:50 PM
Details	Entity Name	Insert	New Registration		OTSEGO MEMORIAL HOSPITAL	4/7/2021 6:50 PM
Details	NOFO Number	Insert	New Registration			4/7/2021 6:50 PM
Details	Program Code	Insert	New Registration		SCH	4/7/2021 6:50 PM
Details	Entity Subname	Insert	New Registration		OMH MEDICAL GROUP - INDIAN RIVER	4/7/2021 6:50 PM
Dates	Participating Approval Date	Insert	New Registration			4/7/2021 6:50 PM
Details	State	Insert	New Registration		Pending	4/7/2021 6:50 PM
Dates	Registration Date	Insert	New Registration		4/7/2021 6:50:46 PM	4/7/2021 6:50 PM
Dates	Signed By Date	Insert	New Registration			4/7/2021 6:50 PM
Dates	Start Date	Insert	New Registration			4/7/2021 6:50 PM
Terminations	Termination Comments	Insert	New Registration			4/7/2021 6:50 PM
Terminations	Termination Date	Insert	New Registration			4/7/2021 6:50 PM
Terminations	Termination Effective Date	Insert	New Registration			4/7/2021 6:50 PM
Terminations	Termination Reason	Insert	New Registration			4/7/2021 6:50 PM