Covered Entity Details

DSH330127B JACOBI MEDICAL CENTER (NYCHHC) (Active) - information as of 6/19/2025 11:46:07 PM

Main Details

Name

JACOBI MEDICAL CENTER (NYCHHC)

Subdivision Name

NCB _ Emergency Department - Emergency Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330127B

Medicare Provider Number

330127

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2021

Participating Start Date

4/22/2021

Participating Approval Date

4/22/2021

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

NYC Health + Hospitals
Deborah Alyse Brown, Senior Vice President, Chief External Affairs Officer
(347) 947-0446

Primary Contact

NYC Health + Hospitals
Mark Capuano, Senior Director, Corporate Pharmacy 340B Program
(347) 835-9198

Addresses

Street Address

3424 Kossuth Avenue
Bronx, NY 10467

Billing Address

Jacobi Medical Center (NYCHHC)
1400 Pelham Parkway
Bronx, NY 10461

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	00246048,00246171	1679587679,1023024882

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
DSH330127A	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	Gun Hill Health Center	1012 East Gunhill Road	Bronx	NY	Terminated
DSH330127B	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Emergency Department - Emergency Medicine	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127C	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Operating Room - Operating Room	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127D	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Recovery Room - Recovery Room	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127E	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Labor and Delivery - Labor and Delivery	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127F	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Radiology Diagnostic - Radiology Diagnostic	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127G	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ CT Scan - CT Scan	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127H	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Outpatient Clinic - Outpatient Clinic	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127J	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB_ Mental Health ACT Programs - Mental Health ACT Programs	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127K	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB_ Ambulatory Surgical Services - Ambulatory Surgical Services	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127L	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB_ Mental Health Clinic - Mental Health Clinic	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127M	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Medical Clinic - Medical Clinic - Medical Clinic	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127N	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Virology - Virology - Virology	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127P	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Surgical Clinic - Surgical Clinic - Surgical Clinic	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127Q	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Gynecology - Gynecology - Gynecology	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127R	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Obstetrics - Obstetrics - Obstetrics	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127S	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Rehabilitation Medicine - Rehabilitation Medicine - Rehabilitation Medicine	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127T	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Pediatrics - Pediatrics - Pediatrics	3424 Kossuth Avenue	Bronx	NY	Active
DSH330127U	Child	DSH	JACOBI MEDICAL CENTER (NYCHHC)	NCB _ Family Planning - Family Planning - Family Planning	3424 Kossuth Avenue	Bronx	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2025 1:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00246171	6/12/2025 1:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/12/2025 1:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1023024882	6/12/2025 1:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/12/2025 1:20 PM
Contacts	Authorizing Official	Update	Profile Change Request	Brown, Deborah Alyse Senior Vice President, External and Regulatory Affairs NYC Health + Hospitals 3479470446	Brown, Deborah Alyse Senior Vice President, Chief External Affairs Officer NYC Health + Hospitals 3479470446	11/15/2024 1:26 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 2:29:46 PM	9/3/2024 2:50:07 PM	9/3/2024 2:50 PM
Details	Last Recertification Date	Update	Recertification	9/2/2022 11:23:48 AM	8/29/2023 2:29:46 PM	8/29/2023 2:29 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 7:22:49 PM	9/2/2022 11:23:48 AM	9/2/2022 11:23 AM
Contacts	Primary Contact	Update	Group Change Request	Than, Min Assistant Vice President New York City Health and Hospitals 2124423854	Capuano, Mark Senior Director, Corporate Pharmacy 340B Program NYC Health + Hospitals 3478359198	8/23/2022 7:17 AM
Contacts	Authorizing Official	Update	AO Change Request	Albertson, Paul Vice President New York City Health and Hospitals 2127482256	Brown, Deborah Alyse Senior Vice President, External and Regulatory Affairs NYC Health + Hospitals 3479470446	8/16/2022 7:23 AM
Contacts	Primary Contact	Update	Profile Change Request	Than, Min Sr. Director New York City Health and Hospitals 2124423854	Than, Min Assistant Vice President New York City Health and Hospitals 2124423854	8/24/2021 6:37 PM
Details	Last Recertification Date	Update	Recertification		8/19/2021 7:22:49 PM	8/19/2021 7:22 PM
Details	State	Update	OPA Edit	Approved	Active	4/22/2021 9:28 AM
Dates	Start Date	Update	OPA Edit	7/1/2021 12:00:00 AM	4/22/2021 12:00:00 AM	4/22/2021 9:28 AM
Contacts	Signed By	Insert	New Registration		Albertson, Paul Vice President New York City Health and Hospitals 2127482256	4/22/2021 9:22 AM
Details	340B ID	Update	New Registration		DSH330127B	4/22/2021 9:22 AM
Details	Entity Name	Update	New Registration	JACOBI MEDICAL CENTER	JACOBI MEDICAL CENTER (NYCHHC)	4/22/2021 9:22 AM
Details	Entity Subname	Update	New Registration	NCB _ Emergency Department	NCB _ Emergency Department - Emergency Medicine	4/22/2021 9:22 AM
Dates	Participating Approval Date	Update	New Registration		4/22/2021 9:22:44 AM	4/22/2021 9:22 AM
Details	State	Update	New Registration	Pending	Approved	4/22/2021 9:22 AM
Dates	Signed By Date	Update	New Registration		4/21/2021 4:31:05 PM	4/22/2021 9:22 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/22/2021 9:22 AM
Addresses	Main Address	Insert	New Registration		3424 Kossuth Avenue Bronx, NY 10467	4/14/2021 10:13 AM
Addresses	Billing Address	Insert	New Registration		Jacobi Medical Center (NYCHHC) 1400 Pelham Parkway Bronx, NY 10461	4/14/2021 10:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2021 10:13 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00246048	4/14/2021 10:13 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/14/2021 10:13 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1679587679	4/14/2021 10:13 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/14/2021 10:13 AM
Contacts	Authorizing Official	Insert	New Registration		Albertson, Paul Vice President New York City Health and Hospitals 2127482256	4/14/2021 10:13 AM
Contacts	Primary Contact	Insert	New Registration		Than, Min Sr. Director New York City Health and Hospitals 2124423854	4/14/2021 10:13 AM
Details	Assistance Received From Date	Insert	New Registration			4/14/2021 10:13 AM
Details	Assistance Received To Date	Insert	New Registration			4/14/2021 10:13 AM
Details	Last Recertification Date	Insert	New Registration			4/14/2021 10:13 AM
Details	Grant Number	Insert	New Registration			4/14/2021 10:13 AM
Details	340B ID	Insert	New Registration			4/14/2021 10:13 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2021 10:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2021 10:13 AM
Details	Medicare Provider Number	Insert	New Registration		330127	4/14/2021 10:13 AM
Details	Entity Name	Insert	New Registration		JACOBI MEDICAL CENTER	4/14/2021 10:13 AM
Details	NOFO Number	Insert	New Registration			4/14/2021 10:13 AM
Details	Program Code	Insert	New Registration		DSH	4/14/2021 10:13 AM
Details	Entity Subname	Insert	New Registration		NCB _ Emergency Department	4/14/2021 10:13 AM
Dates	Participating Approval Date	Insert	New Registration			4/14/2021 10:13 AM
Details	State	Insert	New Registration		Pending	4/14/2021 10:13 AM
Dates	Registration Date	Insert	New Registration		4/14/2021 10:13:49 AM	4/14/2021 10:13 AM
Dates	Signed By Date	Insert	New Registration			4/14/2021 10:13 AM
Dates	Start Date	Insert	New Registration			4/14/2021 10:13 AM
Terminations	Termination Comments	Insert	New Registration			4/14/2021 10:13 AM
Terminations	Termination Date	Insert	New Registration			4/14/2021 10:13 AM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2021 10:13 AM
Terminations	Termination Reason	Insert	New Registration			4/14/2021 10:13 AM