Covered Entity Details

DSH030111W Banner – University Medical Center South (Terminated) - information as of 5/20/2025 11:43:59 PM

Main Details

Name

Banner – University Medical Center South

Subdivision Name

Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Podiatry)

Type

Disproportionate Share Hospital

Rural

340B ID

DSH030111W

Medicare Provider Number

030111

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2021

Participating Start Date

7/1/2021

Participating Approval Date

5/27/2021

Last Recertification Date

9/8/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Banner University Medical Centers Tucson and South
Brad Hipp, Chief Financial Officer
(520) 694-3446

Primary Contact

Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061

Addresses

Street Address

2800 E Ajo Way
105
Tucson, AZ 85713

Billing Address

Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062

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
AZ	874223,988451	1104887199,1558759498,1770742959,1801284617,1811048895
CO	9000145219	1104887199,1558759498,1770742959,1801284617,1811048895

Shipping Addresses

Shipping Address 1

Banner - University Medical Center South
2800 E Ajo Way
Tucson, AZ 85713

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
DSH030111A	Child	DSH	Banner – University Medical Center South	Arizona Institute for Sports Medicine	2800 E. Ajo Way, Suite 200	Tucson	AZ	Active
DSH030111AA	Child	DSH	Banner – University Medical Center South	PBC-Pain Mgmt-Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111AB	Child	DSH	Banner – University Medical Center South	BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN) - OBGYN	2800 E AJO WAY	TUCSON	AZ	Approved
DSH030111B	Child	DSH	Banner – University Medical Center South	Adult Health Services	2800 E. Ajo Way, Suite 104	Tucson	AZ	Terminated
DSH030111D	Child	DSH	Banner – University Medical Center South	Family Medicine Clinic	3950 S. Country Club Road, Suite 130	Tucson	AZ	Terminated
DSH030111E	Child	DSH	Banner – University Medical Center South	Multi-Specialty Clinic	2800 E. Ajo Way, Suite 102	Tucson	AZ	Terminated
DSH030111F	Child	DSH	Banner – University Medical Center South	Surgical Specialties Clinic	2800 E. Ajo Way, Suite 100	Tucson	AZ	Terminated
DSH030111G	Child	DSH	Banner – University Medical Center South	Neurology Clinic	2800 E. Ajo Way, Suite 105	Tucson	AZ	Terminated
DSH030111H	Child	DSH	Banner – University Medical Center South	Infusion Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111J	Child	DSH	Banner – University Medical Center South	Rheumatology Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111K	Child	DSH	Banner – University Medical Center South	PBC-FP Alvernon-Clinic	707 N Alvernon Way	Tucson	AZ	Active
DSH030111L	Child	DSH	Banner - University Medical Center South	Alvernon Ophthamology and Optometry	707 N. Alvernon, Suite 301	Tucson	AZ	Terminated
DSH030111M	Child	DSH	Banner – University Medical Center South	Psychiatry Clinic	2800 E. Ajo Way, Suites P1241/P3300	Tucson	AZ	Terminated
DSH030111N	Child	DSH	Banner – University Medical Center South	Alvernon Multi-specialty Clinic (Clinic - 2nd floor Alvernon)	707 N Alvernon Way	Tucson	AZ	ToBeTerminated
DSH030111P	Child	DSH	Banner – University Medical Center South	Diabetes Clinic	3950 S. Country Club Road	Tucson	AZ	Terminated
DSH030111Q	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Surgery - PBC SC- Corridor Surgery (ENT)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111R	Child	DSH	Banner – University Medical Center South	Clinic - 2nd Floor Alvernon - PBC-Gen Surg Alvernon-Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111S	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC-OB/Gyn-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111T	Child	DSH	Banner – University Medical Center South	Clinic - Alvernon - PBC Alvernon-Geriatric Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111U	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Neuro - PBC-Neuro EMG- Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111V	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Medicine - PBC-Nephrology-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111W	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Podiatry)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111X	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Gen Surg)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111Y	Child	DSH	Banner – University Medical Center South	Clinic - Alvernon - PBC Alvernon-Intgrtiv Med-Clin	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111Z	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Cardiology - PBC-Cardiology 2nd Floor-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2021 12:00:00 AM	1/14/2022 12:54 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/14/2022 12:54 PM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	1/14/2022 12:54 PM
Terminations	Termination Effective Date	Update	Termination Request		12/31/2021 12:00:00 AM	1/14/2022 12:54 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/14/2022 12:54 PM
Details	Last Recertification Date	Update	Recertification		9/8/2021 7:54:49 PM	9/8/2021 7:54 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Addresses	Billing Address	Update	Change Request	Banner - University Medical Center South 2800 E Ajo Way Tucson, AZ 85713	Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	6/14/2021 10:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100552404 (NV)		6/14/2021 10:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1104887199 (NV)		6/14/2021 10:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1558759498 (NV)		6/14/2021 10:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1770742959 (NV)		6/14/2021 10:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801284617 (NV)		6/14/2021 10:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1811048895 (NV)		6/14/2021 10:48 PM
Contacts	Signed By	Insert	New Registration		Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	5/27/2021 3:04 PM
Details	340B ID	Update	New Registration		DSH030111W	5/27/2021 3:04 PM
Details	Entity Name	Update	New Registration	BANNER UNIVERSITY MED CENTER SOUTH	Banner – University Medical Center South	5/27/2021 3:04 PM
Details	Entity Subname	Update	New Registration	Clinic - Ajo OB/GYN	Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Podiatry)	5/27/2021 3:04 PM
Dates	Participating Approval Date	Update	New Registration		5/27/2021 3:04:37 PM	5/27/2021 3:04 PM
Details	State	Update	New Registration	Pending	Approved	5/27/2021 3:04 PM
Dates	Signed By Date	Update	New Registration		4/13/2021 10:44:36 AM	5/27/2021 3:04 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	5/27/2021 3:04 PM
Addresses	Main Address	Insert	New Registration		2800 E Ajo Way 105 Tucson, AZ 85713	4/12/2021 3:56 PM
Addresses	Billing Address	Insert	New Registration		Banner - University Medical Center South 2800 E Ajo Way Tucson, AZ 85713	4/12/2021 3:56 PM
Addresses	Shipping Address	Insert	New Registration		Banner - University Medical Center South 2800 E Ajo Way Tucson, AZ 85713	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		874223	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		988451	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000145219	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100552404	4/12/2021 3:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104887199	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1558759498	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770742959	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801284617	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811048895	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104887199	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1558759498	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770742959	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801284617	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811048895	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104887199	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1558759498	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770742959	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801284617	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811048895	4/12/2021 3:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/12/2021 3:56 PM
Contacts	Primary Contact	Insert	New Registration		Weibel, Kurt Director of Pharmacy Services Banner University Medical Center Tucson 5206946061	4/12/2021 3:56 PM
Contacts	Authorizing Official	Insert	New Registration		Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	4/12/2021 3:56 PM
Details	Assistance Received From Date	Insert	New Registration			4/12/2021 3:56 PM
Details	Assistance Received To Date	Insert	New Registration			4/12/2021 3:56 PM
Details	Last Recertification Date	Insert	New Registration			4/12/2021 3:56 PM
Details	Grant Number	Insert	New Registration			4/12/2021 3:56 PM
Details	340B ID	Insert	New Registration			4/12/2021 3:56 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2021 3:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2021 3:56 PM
Details	Medicare Provider Number	Insert	New Registration		030111	4/12/2021 3:56 PM
Details	Entity Name	Insert	New Registration		BANNER UNIVERSITY MED CENTER SOUTH	4/12/2021 3:56 PM
Details	NOFO Number	Insert	New Registration			4/12/2021 3:56 PM
Details	Program Code	Insert	New Registration		DSH	4/12/2021 3:56 PM
Details	Entity Subname	Insert	New Registration		Clinic - Ajo OB/GYN	4/12/2021 3:56 PM
Dates	Participating Approval Date	Insert	New Registration			4/12/2021 3:56 PM
Details	State	Insert	New Registration		Pending	4/12/2021 3:56 PM
Dates	Registration Date	Insert	New Registration		4/12/2021 3:56:15 PM	4/12/2021 3:56 PM
Dates	Signed By Date	Insert	New Registration			4/12/2021 3:56 PM
Dates	Start Date	Insert	New Registration			4/12/2021 3:56 PM
Terminations	Termination Comments	Insert	New Registration			4/12/2021 3:56 PM
Terminations	Termination Date	Insert	New Registration			4/12/2021 3:56 PM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2021 3:56 PM
Terminations	Termination Reason	Insert	New Registration			4/12/2021 3:56 PM