Covered Entity Details

DSH070010BQ BRIDGEPORT HOSPITAL (Active) - information as of 5/11/2025 11:47:13 PM

Main Details

Name

BRIDGEPORT HOSPITAL

Subdivision Name

BH AHLBIN REHAB CTR PARK AVE - Rehabilitation

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070010BQ

Medicare Provider Number

070010

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2021

Participating Start Date

7/1/2021

Participating Approval Date

4/15/2021

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Yale New Haven Health Services
Leeann Miller, Chief Pharmacy Officer
(203) 479-3000

Primary Contact

Yale New Haven Health Services
Andrew Joseph Esposito, Sr. Reimbursement Analyst
(203) 688-1993

Addresses

Street Address

5520 PARK AVE, SUITE M1-800
TRUMBULL, CT 06611

Billing Address

Bridgeport Hospital
267 Grant Street
Bridgeport, CT 06610

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
CT	004041703,004025003	1649260845,1992910152
MA	110027576B,110027576A	1649260845,1992910152
NY	03001163	1649260845,1992910152
RI	0070010,1649260845	1649260845,1992910152

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
DSH070010A	Child	DSH	BRIDGEPORT HOSPITAL	0400BH FAIRFIELD CARDIAC SERVICES CS	1305 Post Road	Fairfield	CT	Active
DSH070010AA	Child	DSH	BRIDGEPORT HOSPITAL	0020BH PRIMARY CARE RHEUMATOLOGY	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010AB	Child	DSH	BRIDGEPORT HOSPITAL	0010BH PRIMARY CARE CARDIAC	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010AC	Child	DSH	BRIDGEPORT HOSPITAL	0011BH PRIMARY CARE DERMATOLOGY	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010AD	Child	DSH	BRIDGEPORT HOSPITAL	0026BH PRIMARY CARE HEPATOLOGY	226 MILL HILL AVENUE	BRIDGEPORT	CT	Approved
DSH070010AE	Child	DSH	BRIDGEPORT HOSPITAL	0018BH PRIMARY CARE PODIATRY	226 MILL HILL AVE, 1ST FLOOR	BRIDGEPORT	CT	Active
DSH070010AF	Child	DSH	BRIDGEPORT HOSPITAL	0014BH PRIMARY CARE GI	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010AG	Child	DSH	BRIDGEPORT HOSPITAL	0025 PRIMARY CARE SICKLE CELL	226 MILL HILL AVENUE, LOWER LEVEL	BRIDGEPORT	CT	Active
DSH070010AH	Child	DSH	BRIDGEPORT HOSPITAL	0004BH FAIRFIELD URGENT CARE - URGENT CARE/ED	309 STILLSON ROAD	FAIRFIELD	CT	Active
DSH070010AJ	Child	DSH	BRIDGEPORT HOSPITAL	0017BH PRIMARY CARE ORTHOPEDIC - ORTHOPEDIC CLINIC	226 MILL HILL AVE, 1ST FLOOR	BRIDGEPORT	CT	Active
DSH070010AK	Child	DSH	BRIDGEPORT HOSPITAL	0309BH OUTPATIENT IMAGING PARK AVE IR - IMAGING SERVICES	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010AL	Child	DSH	BRIDGEPORT HOSPITAL	0002BH ANTENATAL PARK AVE - ANTENATAL ULTRASOUND SERVICES	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010AM	Child	DSH	BRIDGEPORT HOSPITAL	0201BH PAMC OR - Ambulatory Surgical Services	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010AN	Child	DSH	BRIDGEPORT HOSPITAL	0202BH PAMC PRE/PACU - Ambulatory PACU	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010AP	Child	DSH	BRIDGEPORT HOSPITAL	BH SURGEASE PACU - MINOR SURGERY PACU SERVICES	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AQ	Child	DSH	BRIDGEPORT HOSPITAL	BH ELECTROPHYSIOLOGY LAB - ELECTROPHYSIOLOGY SERVICES	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AR	Child	DSH	BRIDGEPORT HOSPITAL	BH UROLOGY SUITE - MINOR SURGERY UROLOGY	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AS	Child	DSH	BRIDGEPORT HOSPITAL	BH SURGEASE PRE OP - MINOR SURGERY PRE OP	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AT	Child	DSH	BRIDGEPORT HOSPITAL	BH SURGEASE OR - MINOR SURGERY OPERATING ROOM	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AU	Child	DSH	BRIDGEPORT HOSPITAL	BH ENDOSCOPY - ENDOSCOPY SERVICES	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AV	Child	DSH	BRIDGEPORT HOSPITAL	BH SURGEASE PERIOPERATIVE SERVICES - MINOR SURGERY PERIOPERATIVE SERVICES	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AW	Child	DSH	BRIDGEPORT HOSPITAL	BH PERFUSION - PERFUSION SERVICES IN OR	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AX	Child	DSH	BRIDGEPORT HOSPITAL	BH PULMONARY FUNCTION - PULMONARY FUNCTION TESTING SERVICE	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AY	Child	DSH	BRIDGEPORT HOSPITAL	BH CARDIAC CATH LAB - CARDIAC CATH SERVICES	267 GRANT STREET	BRIDGEPORT	CT	Terminated
DSH070010AZ	Child	DSH	BRIDGEPORT HOSPITAL	BH REACH OUTPATIENT SERVICES - OP PSYCH SERVICES	1558 BARNUM AVENUE	BRIDGEPORT	CT	Active
DSH070010B	Child	DSH	BRIDGEPORT HOSPITAL	0400BH TRUMBULL CARDIAC SERVICES CS	999 Silver Lane	Trumbull	CT	Active
DSH070010BA	Child	DSH	BRIDGEPORT HOSPITAL	MC DIAGNOSTIC TREATMENT CENTER - ENDOSCOPY SERVICES - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BC	Child	DSH	BRIDGEPORT HOSPITAL	MC WOUND CENTER - WOUND CARE SERVICES - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BD	Child	DSH	BRIDGEPORT HOSPITAL	MC MAIN PERIOPERATIVE SERVICES - PERIOPERATIVE SERVICES - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BE	Child	DSH	BRIDGEPORT HOSPITAL	MC ED - EMERGENCY DEPARTMENT - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BF	Child	DSH	BRIDGEPORT HOSPITAL	PAMC PREOP - PREOPERATIVE SURGICAL SERVICES	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010BG	Child	DSH	BRIDGEPORT HOSPITAL	MC RESP THER - RESPIRATORY THERAPY SERVICES - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BH	Child	DSH	BRIDGEPORT HOSPITAL	MC SPEECH THERAPY - SPEECH THERAPY SERVICES - MILFORD CAMPUS	300 SEASIDE AVENUE	MILFORD	CT	Active
DSH070010BJ	Child	DSH	BRIDGEPORT HOSPITAL	BH PAMC OR - OP SURGICAL SERVICES	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010BK	Child	DSH	BRIDGEPORT HOSPITAL	MC URGENT CARE - URGENT CARE SERVICES	831 BOSTON POST ROAD	MILFORD	CT	Active
DSH070010BL	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN CTR TRUMBULL - Rehabilitation	2750 RESERVOIR AVENUE	Trumbull	CT	Terminated
DSH070010BM	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN CTR STRATFORD - Rehabilitation	3585 MAIN STREET	STRATFORD	CT	Active
DSH070010BN	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN CTR SOUTHPORT - Rehabilitation	2600 POST ROAD	Southport	CT	Active
DSH070010BP	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN CTR SHELTON - Rehabilitation	4 CORPORATE DRIVE	Shelton	CT	Active
DSH070010BQ	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN REHAB CTR PARK AVE - Rehabilitation	5520 PARK AVE, SUITE M1-800	TRUMBULL	CT	Active
DSH070010BR	Child	DSH	BRIDGEPORT HOSPITAL	BH PARK AVE CARDIAC TESTING - Cardiovascular Disease	5520 PARK AVE	Trumbull	CT	Active
DSH070010BS	Child	DSH	BRIDGEPORT HOSPITAL	BH REACH ADULT - Psychiatry	305 BOSTON AVENUE, FIRST FLOOR	STRATFORD	CT	Terminated
DSH070010BT	Child	DSH	BRIDGEPORT HOSPITAL	BH GENETIC COUNSELING PARK AVE - Genetics	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010BU	Child	DSH	BRIDGEPORT HOSPITAL	BH AHLBIN CTR BRIDGEPORT - Rehabilitation	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010BV	Child	DSH	BRIDGEPORT HOSPITAL	BH PRIMARY CARE BEHAVIORAL HEALTH - Behavioral Health	226 Mill Hill Avenue	Bridgeport	CT	Active
DSH070010BW	Child	DSH	BRIDGEPORT HOSPITAL	BH PRIMARY CARE MEDICAL - EVENING - Internal Medicine	226 MILL HILL AVE, 1ST FLR	BRIDGEPORT	CT	Active
DSH070010BX	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC SPINE CENTER - Neurological Surgery	226 MILL HILL AVE, 1ST FLR	BRIDGEPORT	CT	Active
DSH070010BY	Child	DSH	BRIDGEPORT HOSPITAL	BH PRIMARY CARE COMPLEX CARE TEAM - Primary Care	226 MILL HILL AVE, Lower Level	BRIDGEPORT	CT	Active
DSH070010BZ	Child	DSH	BRIDGEPORT HOSPITAL	MC MAIN PRE/POST - Surgery	300 Seaside Avenue	MILFORD	CT	ToBeTerminated
DSH070010C	Child	DSH	BRIDGEPORT HOSPITAL	0400BH DANBURY CARDIAC SERVICES CS	25 Germantown Road	Danbury	CT	Active
DSH070010CA	Child	DSH	BRIDGEPORT HOSPITAL	MC EKG - Cardiovascular Disease	300 Seaside Avenue	MILFORD	CT	Terminated
DSH070010CB	Child	DSH	BRIDGEPORT HOSPITAL	MC CARDIOLOGY SERVICE - Cardiovascular Disease	300 Seaside Avenue	MILFORD	CT	Approved
DSH070010CC	Child	DSH	BRIDGEPORT HOSPITAL	MC MAIN OR - Surgery	300 Seaside Avenue	MILFORD	CT	Approved
DSH070010CD	Child	DSH	BRIDGEPORT HOSPITAL	BH PRIMARY CARE OB MEDICAL - Obstetrics and Gynecology	226 MILL HILL AVE	BRIDGEPORT	CT	Active
DSH070010CE	Child	DSH	BRIDGEPORT HOSPITAL	BH BREAST CENTER - Female Pelvic Medicine and Reconstructive Surgery	310 MILL HILL AVE.	BRIDGEPORT	CT	ToBeTerminated
DSH070010CF	Child	DSH	BRIDGEPORT HOSPITAL	MC SURGERY SERVICE - MC SURGERY SERVICE	300 Seaside Avenue	MILFORD	CT	Active
DSH070010CG	Child	DSH	BRIDGEPORT HOSPITAL	MH ALLERGY IMM MILFORD - Allergy and Immunology	300 Seaside Ave	MILFORD	CT	Active
DSH070010CH	Child	DSH	BRIDGEPORT HOSPITAL	MC MEDICINE SERVICE - MC MEDICINE SERVICE	300 Seaside Avenue	MILFORD	CT	Terminated
DSH070010CJ	Child	DSH	BRIDGEPORT HOSPITAL	MC OCCUPATIONAL THERAPY - Occupational Therapy	300 Seaside Avenue	MILFORD	CT	Active
DSH070010CK	Child	DSH	BRIDGEPORT HOSPITAL	BH OUTPATIENT IMAGING PARK AVE IR - Vascular and Interventional Radiology	5520 Park Avenue	Trumbull	CT	Active
DSH070010CL	Child	DSH	BRIDGEPORT HOSPITAL	MC ANESTHESIA - MC ANESTHESIA	300 Seaside Avenue	MILFORD	CT	ToBeTerminated
DSH070010CM	Child	DSH	BRIDGEPORT HOSPITAL	MC INTERVENTIONAL RADIOLOGY - Vascular and Interventional Radiology	300 Seaside Avenue	MILFORD	CT	Active
DSH070010CN	Child	DSH	BRIDGEPORT HOSPITAL	BH ANTENATAL PARK AVE - Obstetrics and Gynecology	5520 PARK AVENUE	TRUMBULL	CT	Active
DSH070010CP	Child	DSH	BRIDGEPORT HOSPITAL	MC PHYSICAL THERAPY - Physical Therapy	300 Seaside Avenue	MILFORD	CT	Active
DSH070010CQ	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC NEPHROLOGY CLINIC - Nephrology	226 MILL HILL AVE, 1ST FLR	BRIDGEPORT	CT	Active
DSH070010CR	Child	DSH	BRIDGEPORT HOSPITAL	BH HVC DISEASE MGMT MILL HILL - Cardiovascular Disease	226 Mill Hill Avenue	Bridgeport	CT	Active
DSH070010CS	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC MEDICATION ASST TREATMENT - Primary Care	226 Mill Hill Avenue	Bridgeport	CT	Active
DSH070010CT	Child	DSH	BRIDGEPORT HOSPITAL	BH SMILOW CANCER GENETICS - Genetics	5520 Park Avenue	TRUMBULL	CT	Approved
DSH070010CU	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC YM HVC VASCULAR - Cardiovascular Disease	226 Mill Hill Avenue	BRIDGEPORT	CT	Approved
DSH070010CV	Child	DSH	BRIDGEPORT HOSPITAL	MC EEG/NEUROPHYSIOLOGY - Neurology	300 Seaside Avenue	MILFORD	CT	Approved
DSH070010CW	Child	DSH	BRIDGEPORT HOSPITAL	MC ENDOSCOPY - Gastroenterology	300 Seaside Avenue	MILFORD	CT	Approved
DSH070010CX	Child	DSH	BRIDGEPORT HOSPITAL	BH BREAST CENTER AHLBIN - Complex General Surgical Oncology	226 Mill Hill Avenue	BRIDGEPORT	CT	Approved
DSH070010CY	Child	DSH	BRIDGEPORT HOSPITAL	BH COMPREHENSIVE CARE MILL HILL - Primary Care	226 Mill Hill Avenue	BRIDGEPORT	CT	Approved
DSH070010CZ	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC YM BARIATRIC SURGERY - Bariatric Medicine	226 Mill Hill Avenue	BRIDGEPORT	CT	Approved
DSH070010D	Child	DSH	BRIDGEPORT HOSPITAL	0007BH RADIATION ONCOLOGY TRUMBULL	5520 Park Ave	Trumbull	CT	Active
DSH070010DA	Child	DSH	BRIDGEPORT HOSPITAL	BH PCC METABOLIC PROGRAM - Internal Medicine	226 Mill Hill Avenue	BRIDGEPORT	CT	Approved
DSH070010E	Child	DSH	BRIDGEPORT HOSPITAL	0400BH RIDGEFIELD CARDIAC SERVICES CS	30 Prospect Street	Ridgefield	CT	Active
DSH070010F	Child	DSH	BRIDGEPORT HOSPITAL	BH MILFORD CARDIAC SERVICES CS - COMMERCE	20 Commerce Park	Milford	CT	Active
DSH070010G	Child	DSH	BRIDGEPORT HOSPITAL	0001BH SHELTON CARDIAC SERVICES CS	2 Ivy Brook Road	Shelton	CT	Active
DSH070010H	Child	DSH	BRIDGEPORT HOSPITAL	0028BH WOUND HEALING CENTER	141 Mill Hill Ave	BRIDGEPORT	CT	Active
DSH070010J	Child	DSH	BRIDGEPORT HOSPITAL	0007BH PRIMARY CARE MEDICAL	226 Mill Hill Ave	Bridgeport	CT	Active
DSH070010K	Child	DSH	BRIDGEPORT HOSPITAL	0001BH REACH PROGRAM ADULT	1558 Barnum Avenue	Bridgeport	CT	Active
DSH070010L	Child	DSH	BRIDGEPORT HOSPITAL	0002BH REACH PROGRAM YOUTH	1558 Barnum Avenue	Bridgeport	CT	Active
DSH070010M	Child	DSH	BRIDGEPORT HOSPITAL	0014BH HEPATOLOGY PARK AVE	5520 Park Avenue	Trumbull	CT	Terminated
DSH070010N	Child	DSH	BRIDGEPORT HOSPITAL	0200BH PAMC PERIOPERATIVE SVCS	5520 Park Avenue	Trumbull	CT	Active
DSH070010P	Child	DSH	BRIDGEPORT HOSPITAL	0027BH PCC BEHAVIORAL HEALTH POSTPARTUM CLINIC	226 MILL HILL AVENUE	BRIDGEPORT	CT	Terminated
DSH070010Q	Child	DSH	BRIDGEPORT HOSPITAL	0002BH CARDIAC REHAB PHASE II	1305 POST ROAD	FAIRFIELD	CT	Active
DSH070010R	Child	DSH	BRIDGEPORT HOSPITAL	0012BH PRIMARY CARE DIABETES	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010S	Child	DSH	BRIDGEPORT HOSPITAL	0003BH REACH YOUTH	305 BOSTON AVE	BRIDGEPORT	CT	Terminated
DSH070010T	Child	DSH	BRIDGEPORT HOSPITAL	0019BH PRIMARY CARE PULMONARY	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010U	Child	DSH	BRIDGEPORT HOSPITAL	0008BH PRIMARY CARE OB/GYN	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010V	Child	DSH	BRIDGEPORT HOSPITAL	0013BH PRIMARY CARE ENDO	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010W	Child	DSH	BRIDGEPORT HOSPITAL	0021BH PRIMARY CARE SURGICAL	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010X	Child	DSH	BRIDGEPORT HOSPITAL	0002BH REACH ADULT	305 BOSTON AVE	BRIDGEPORT	CT	Approved
DSH070010Y	Child	DSH	BRIDGEPORT HOSPITAL	0015BH PRIMARY CARE IMMUNE	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active
DSH070010Z	Child	DSH	BRIDGEPORT HOSPITAL	0016BH PRIMARY CARE NEURO	226 MILL HILL AVENUE	BRIDGEPORT	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 5:11:11 PM	9/5/2024 5:41:10 PM	9/5/2024 5:41 PM
Details	Last Recertification Date	Update	Recertification	9/16/2022 2:22:02 PM	9/5/2023 5:11:11 PM	9/5/2023 5:11 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (AL)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	213160105 (AR)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (CA)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	56539746 (CO)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	092586100 (FL)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	000157308X (GA)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (IA)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	60646554001 (IL)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300007591 (IN)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	200332580A (KS)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	010175300 (MD)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (ME)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	157260000 (ME)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (MI)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (MN)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1642960845 (MN)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (NC)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	20001219 (NH)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	16099281 (NJ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (NV)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (OH)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1992910152 (OH)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	200338750A (OK)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10323A (SC)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10325B (SC)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1518291 (TN)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	071737301 (TX)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (VA)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0070010 (VT)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (AZ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1992910152 (AZ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1649260845 (WI)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0008254600001 (PA)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	044610 (AZ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	15726000 (ME)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4079604 (NJ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	164260845 (NJ)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0188881 (OH)		6/5/2023 9:34 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4065436 (UT)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (AL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (AL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (AR)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (AR)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (CA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (CA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (CO)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (CO)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (FL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (FL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (GA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (GA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (IA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (IA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (IL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (IL)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (IN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (IN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (KS)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (KS)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (MD)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (MD)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (ME)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (ME)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (MI)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (MI)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (MN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (MN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (NC)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (NC)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (NH)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (NH)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (NJ)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (NJ)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (NV)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (NV)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (OH)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (OH)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (OK)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (OK)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (PA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (PA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (SC)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (SC)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (TN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (TN)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (TX)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (TX)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (VA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (VA)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (VT)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (VT)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (AZ)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (AZ)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (WI)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (WI)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1649260845 (UT)		6/5/2023 9:34 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1992910152 (UT)		6/5/2023 9:34 AM
Contacts	Authorizing Official	Update	Change Request	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	Miller, Leeann Chief Pharmacy Officer Yale New Haven Health Services 2034793000	10/5/2022 7:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		044610	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		15726000	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4079604	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		164260845	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0188881	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		4065436	9/16/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	9/16/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649260845	9/16/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/16/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992910152	9/16/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/16/2022 2:22 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 5:31:47 PM	9/16/2022 2:22:02 PM	9/16/2022 2:22 PM
Details	Last Recertification Date	Update	Recertification		9/10/2021 5:31:47 PM	9/10/2021 5:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000825460-0001 (PA)		8/9/2021 1:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:38 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0008254600001	8/9/2021 1:38 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	8/9/2021 1:38 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Primary Contact	Update	Profile Change Request	Esposito, Andrew Joseph Sr. Reimbursement Analyst Yale New Haven Health Services 2033762610	Esposito, Andrew Joseph Sr. Reimbursement Analyst Yale New Haven Health Services 2036881993	4/21/2021 9:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		213160105	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		56539746	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092586100	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000157308X	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		60646554001	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300007591	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200332580A	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027576B	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027576A	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010175300	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		157260000	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1642960845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		20001219	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		16099281	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001163	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200338750A	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000825460-0001	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0070010	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10323A	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10325B	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1518291	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		071737301	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0070010	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		KS	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		KS	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NH	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NH	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649260845	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/20/2021 11:45 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992910152	4/20/2021 11:45 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/20/2021 11:45 AM
Contacts	Signed By	Insert	New Registration		Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	4/15/2021 2:19 PM
Details	340B ID	Update	New Registration		DSH070010BQ	4/15/2021 2:19 PM
Details	Entity Subname	Update	New Registration	BH AHLBIN REHAB CTR PARK AVE	BH AHLBIN REHAB CTR PARK AVE - Rehabilitation	4/15/2021 2:19 PM
Dates	Participating Approval Date	Update	New Registration		4/15/2021 2:19:38 PM	4/15/2021 2:19 PM
Details	State	Update	New Registration	Pending	Approved	4/15/2021 2:19 PM
Dates	Signed By Date	Update	New Registration		4/13/2021 2:02:52 PM	4/15/2021 2:19 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/15/2021 2:19 PM
Addresses	Main Address	Insert	New Registration		5520 PARK AVE, SUITE M1-800 TRUMBULL, CT 06611	4/13/2021 2:02 PM
Addresses	Billing Address	Insert	New Registration		Bridgeport Hospital 267 Grant Street Bridgeport, CT 06610	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004041703	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004025003	4/13/2021 2:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/13/2021 2:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649260845	4/13/2021 2:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/13/2021 2:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992910152	4/13/2021 2:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/13/2021 2:02 PM
Contacts	Authorizing Official	Insert	New Registration		Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	4/13/2021 2:02 PM
Contacts	Primary Contact	Insert	New Registration		Esposito, Andrew Joseph Sr. Reimbursement Analyst Yale New Haven Health Services 2033762610	4/13/2021 2:02 PM
Details	Assistance Received From Date	Insert	New Registration			4/13/2021 2:02 PM
Details	Assistance Received To Date	Insert	New Registration			4/13/2021 2:02 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2021 2:02 PM
Details	Grant Number	Insert	New Registration			4/13/2021 2:02 PM
Details	340B ID	Insert	New Registration			4/13/2021 2:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2021 2:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2021 2:02 PM
Details	Medicare Provider Number	Insert	New Registration		070010	4/13/2021 2:02 PM
Details	Entity Name	Insert	New Registration		BRIDGEPORT HOSPITAL	4/13/2021 2:02 PM
Details	NOFO Number	Insert	New Registration			4/13/2021 2:02 PM
Details	Program Code	Insert	New Registration		DSH	4/13/2021 2:02 PM
Details	Entity Subname	Insert	New Registration		BH AHLBIN REHAB CTR PARK AVE	4/13/2021 2:02 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2021 2:02 PM
Details	State	Insert	New Registration		Pending	4/13/2021 2:02 PM
Dates	Registration Date	Insert	New Registration		4/13/2021 2:02:49 PM	4/13/2021 2:02 PM
Dates	Signed By Date	Insert	New Registration			4/13/2021 2:02 PM
Dates	Start Date	Insert	New Registration			4/13/2021 2:02 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2021 2:02 PM
Terminations	Termination Date	Insert	New Registration			4/13/2021 2:02 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2021 2:02 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2021 2:02 PM