Covered Entity Details

DSH330261L PHELPS MEMORIAL HOSPITAL CENTER (Active) - information as of 5/17/2025 10:47:02 PM

Main Details

Name

PHELPS MEMORIAL HOSPITAL CENTER

Subdivision Name

Phelps at Croton - Radiology-Diagnostic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330261L

Medicare Provider Number

330261

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/2/2021

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

440 South Riverside Avenue
1st floor
Croton-On-Hudson, NY 10520

Billing Address

Phelps Memorial Hospital Center
701 North Broadway
Sleepy Hollow, NY 10591

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
NY	00274162,03356681,2848479	1720185267,1285706077
CT	008058947	1720185267
CO	9000204899	1720185267

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	Last Updated On
Contract Detail	LONG ISLAND JEWISH MEDICAL CENTER AT HOM	VIVO HEALTH PHARMACY AT HOME	225 COMMUNITY DR STE 140	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC	DBA: VIVO HEALTH PHARMACY AT CFAM	450 LAKEVILLE RD	LAKE SUCCESS	NY	11042	11/20/2023	01/01/2024	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC.	DBA: VIVO HEALTH SPECIALTY PHARMACY	225 COMMUNITY DR STE 100	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330261A	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Memorial Hospital / Infusion Center	777 NORTH BROADWAY	Sleepy Hollow	NY	Active
DSH330261B	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Hospital SurgiCenter	755 North Broadway	Sleepy Hollow	NY	Active
DSH330261C	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Northwell Health Cancer Institute at Phelps - Radiation Therapy - Radiology-Therapeutic	777 North Broadway	Sleepy Hollow	NY	Active
DSH330261D	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Wound Healing Institute at Phelps - Clinic	755 North Broadway	Sleepy Hollow	NY	Active
DSH330261F	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Institute for Voice and Swallowing Disorders at Phelps - Speech Pathology	777 North Broadway	Sleepy Hollow	NY	Active
DSH330261G	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Pediatric Infusion - Pediatrics	755 North Broadway	Sleepy Hollow	NY	Active
DSH330261H	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Mental Health Services - Mental Health Clinic	22 Rockledge Ave	Ossining	NY	Active
DSH330261J	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Memorial Hospital Diagnostic Imaging at Dobbs Ferry - Radiology-Diagnostic	11 Ashford Avenue	Dobbs Ferry	NY	Active
DSH330261K	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Memorial Hospital Cardiovascular at Dobbs Ferry - Electrocardiology	11 Ashford Avenue	Dobbs Ferry	NY	Active
DSH330261L	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps at Croton - Radiology-Diagnostic	440 South Riverside Avenue	Croton-On-Hudson	NY	Active
DSH330261M	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Memorial Hospital Diagnostic Imaging at Dobbs Ferry - Ultrasound Diagnostic	11 Ashford Avenue	Dobbs Ferry	NY	Active
DSH330261N	Child	DSH	PHELPS MEMORIAL HOSPITAL CENTER	Phelps Memorial Hospital Donald R Reed Speech & Hearing Center - Speech Pathology	777 North Broadway	Sleepy Hollow	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720185267 (OH)		10/23/2024 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/30/2024 1:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		2848479	9/30/2024 1:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	9/30/2024 1:13 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1285706077	9/30/2024 1:13 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	9/30/2024 1:13 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	05431874 (NY)		9/26/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	04634960 (NY)		9/26/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	04633703 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1669854832 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1730523549 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1851807929 (NY)		9/26/2024 2:03 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 1:20:17 PM	8/19/2024 4:21:28 PM	8/19/2024 4:21 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1720185267 (OH)		8/5/2024 4:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	008060496 (CT)		8/5/2024 4:01 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1720185267	2/28/2024 2:02 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	2/28/2024 2:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		008060496	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CT	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000204899	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	2/28/2024 1:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05431874	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04634960	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04633703	12/14/2023 1:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669854832	12/14/2023 1:11 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730523549	12/14/2023 1:11 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851807929	12/14/2023 1:11 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:11 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Contacts	Signed By	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 1:49:39 PM	8/22/2023 1:20:17 PM	8/22/2023 1:20 PM
Addresses	Main Address	Update	Change Request	440 South Riverside Avenue Croton-On-Hudson, NY 10520	440 South Riverside Avenue 1st floor Croton-On-Hudson, NY 10520	10/7/2022 8:27 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 10:41:40 AM	8/31/2022 1:49:39 PM	8/31/2022 1:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/16/2021 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008058947	11/16/2021 2:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	11/16/2021 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/16/2021 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1720185267	11/16/2021 2:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	11/16/2021 2:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720185267	11/16/2021 2:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	11/16/2021 2:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720185267	11/16/2021 2:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/16/2021 2:25 PM
Details	Last Recertification Date	Update	Recertification		8/24/2021 10:41:40 AM	8/24/2021 10:41 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	6/2/2021 8:00 AM
Details	340B ID	Update	New Registration		DSH330261L	6/2/2021 8:00 AM
Details	Entity Subname	Update	New Registration	Phelps at Croton	Phelps at Croton - Radiology-Diagnostic	6/2/2021 8:00 AM
Dates	Participating Approval Date	Update	New Registration		6/2/2021 8:00:24 AM	6/2/2021 8:00 AM
Details	State	Update	New Registration	Pending	Approved	6/2/2021 8:00 AM
Dates	Signed By Date	Update	New Registration		5/28/2021 2:16:11 PM	6/2/2021 8:00 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	6/2/2021 8:00 AM
Addresses	Main Address	Insert	New Registration		440 South Riverside Avenue Croton-On-Hudson, NY 10520	4/13/2021 1:27 PM
Addresses	Billing Address	Insert	New Registration		Phelps Memorial Hospital Center 701 North Broadway Sleepy Hollow, NY 10591	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00274162	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03356681	4/13/2021 1:27 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/13/2021 1:27 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720185267	4/13/2021 1:27 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/13/2021 1:27 PM
Contacts	Primary Contact	Insert	New Registration		Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	4/13/2021 1:27 PM
Contacts	Authorizing Official	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	4/13/2021 1:27 PM
Details	Assistance Received From Date	Insert	New Registration			4/13/2021 1:27 PM
Details	Assistance Received To Date	Insert	New Registration			4/13/2021 1:27 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2021 1:27 PM
Details	Grant Number	Insert	New Registration			4/13/2021 1:27 PM
Details	340B ID	Insert	New Registration			4/13/2021 1:27 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2021 1:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2021 1:27 PM
Details	Medicare Provider Number	Insert	New Registration		330261	4/13/2021 1:27 PM
Details	Entity Name	Insert	New Registration		PHELPS MEMORIAL HOSPITAL CENTER	4/13/2021 1:27 PM
Details	NOFO Number	Insert	New Registration			4/13/2021 1:27 PM
Details	Program Code	Insert	New Registration		DSH	4/13/2021 1:27 PM
Details	Entity Subname	Insert	New Registration		Phelps at Croton	4/13/2021 1:27 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2021 1:27 PM
Details	State	Insert	New Registration		Pending	4/13/2021 1:27 PM
Dates	Registration Date	Insert	New Registration		4/13/2021 1:27:23 PM	4/13/2021 1:27 PM
Dates	Signed By Date	Insert	New Registration			4/13/2021 1:27 PM
Dates	Start Date	Insert	New Registration			4/13/2021 1:27 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2021 1:27 PM
Terminations	Termination Date	Insert	New Registration			4/13/2021 1:27 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2021 1:27 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2021 1:27 PM