Covered Entity Details

DSH390115K Jefferson Health Northeast (Active) - information as of 5/11/2025 11:49:37 PM

Main Details

Name

Jefferson Health Northeast

Subdivision Name

MRI Roosevelt Blvd - MRI

Type

Disproportionate Share Hospital

Rural

340B ID

DSH390115K

Medicare Provider Number

390115

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2021

Participating Start Date

7/1/2021

Participating Approval Date

4/19/2021

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Jefferson Health
CARRIE FREY, Director of Finance
(215) 612-4313

Primary Contact

Jefferson Health
Dustin Ottemiller, VP, Finance
(215) 503-5219

Addresses

Street Address

2451 Grant Ave.
Philadelphia, PA 19114

Billing Address
Same as Street Address

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
PA	1007705250021	1801963343

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
DSH390115A	Child	DSH	Jefferson Health Northeast	Frankford Campus - Emergency Room	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AA	Child	DSH	Jefferson Health Northeast	Bucks Campus X-Ray - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AB	Child	DSH	Jefferson Health Northeast	Frankford Campus X-Ray - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AC	Child	DSH	Jefferson Health Northeast	Bucks Campus Nuc Med - - Nuclear Medicine	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AD	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Nuclear Medicine	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AE	Child	DSH	Jefferson Health Northeast	Bucks Campus Electrocardiology - - Cardiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AF	Child	DSH	Jefferson Health Northeast	Bucks Campus Mammography - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AG	Child	DSH	Jefferson Health Northeast	Bucks Campus - - Respiratory Therapy	380 N. Oxford Valley Road	Philadelphia	PA	Active
DSH390115AH	Child	DSH	Jefferson Health Northeast	Bucks Campus - - Heart Station - EEG	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115AJ	Child	DSH	Jefferson Health Northeast	Frankford Campus CT - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AK	Child	DSH	Jefferson Health Northeast	Frankford Campus US - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AL	Child	DSH	Jefferson Health Northeast	Frankford Campus Mammo - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AM	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Cardiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AN	Child	DSH	Jefferson Health Northeast	Frankford Campus Heart Station - - EEG	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115AP	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Respiratory Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115B	Child	DSH	Jefferson Health Northeast	Frankford Campus - OP Operating Room	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115C	Child	DSH	Jefferson Health Northeast	Bucks Campus - Cardiac Cath Lab	380 N. Oxford Valley Rd.	Langhorne	PA	Active
DSH390115D	Child	DSH	Jefferson Health Northeast	Bucks Campus - Operating Room	380 N. Oxford Valley Rd.	Langhorne	PA	Active
DSH390115E	Child	DSH	Jefferson Health Northeast	Bucks Campus - Emergency Room	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115F	Child	DSH	ARIA HEALTH	Aria Health Bucks Wound Care - Wound Care	380 N. Oxford Valley Rd.	Langhorne	PA	Terminated
DSH390115G	Child	DSH	ARIA HEALTH	Aria Health Frankford Wound Care - Wound Care	5000 Frankford Ave.	Philadelphia	PA	Terminated
DSH390115H	Child	DSH	Jefferson Health Northeast	Torresdale Cardiac Rehabilitation - Cardiac Rehabilitation	3998 Red Lion Rd	Philadelphia	PA	Active
DSH390115J	Child	DSH	Jefferson Health Northeast	PET Roosevelt Blvd - PET Scan	2451 Grant Ave.	Philadelphia	PA	Active
DSH390115K	Child	DSH	Jefferson Health Northeast	MRI Roosevelt Blvd - MRI	2451 Grant Ave.	Philadelphia	PA	Active
DSH390115L	Child	DSH	Jefferson Health Northeast	Bucks OP Physical Therapy - Physical Therapy	131 Lincoln Highway	Fairless Hills	PA	Active
DSH390115M	Child	DSH	Jefferson Health Northeast	Bucks Hospital - Sleep Lab - Sleep Lab	131 Lincoln Highway	Fairless Hills	PA	Active
DSH390115N	Child	DSH	Jefferson Health Northeast	Torresdale Hospital - OP Rehab - Physical and Occupational Therapy	10700 Knights Rd.	Philadelphia	PA	Active
DSH390115P	Child	DSH	Jefferson Health Northeast	Torresdale Hospital - OP Speech Therapy - Speech Therapy	10700 Knights Rd.	Philadelphia	PA	Active
DSH390115Q	Child	DSH	Jefferson Health Northeast	Frankford Campus PT - - Physical Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115R	Child	DSH	Jefferson Health Northeast	Bucks Campus PT - - Physical Therapy	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115S	Child	DSH	Jefferson Health Northeast	Frankford Campus Rehab - - Speech Therapy	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115T	Child	DSH	Jefferson Health Northeast	Bucks Campus Speech - - Speech Therapy	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115U	Child	DSH	Jefferson Health Northeast	Bucks Campus IR - - Interventional Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115V	Child	DSH	Jefferson Health Northeast	Frankford Campus - - Interventional Radiology	4900 Frankford Ave.	Philadelphia	PA	Active
DSH390115W	Child	DSH	Jefferson Health Northeast	Bucks Campus Radiology - - CT	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115X	Child	DSH	Jefferson Health Northeast	Bucks Campus US - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115Y	Child	DSH	Jefferson Health Northeast	Bucks Campus MRI - - Radiology	380 N. Oxford Valley Road	Langhorne	PA	Active
DSH390115Z	Child	DSH	Jefferson Health Northeast	Frankford Campus MRI - - Radiology	4900 Frankford Ave.	Philadelphia	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2156124313	FREY, CARRIE Director of Finance Jefferson Health 2156124313	4/11/2025 8:54 AM
Contacts	Signed By	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2156124313	FREY, CARRIE Director of Finance Jefferson Health 2156124313	4/11/2025 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/31/2025 5:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007705250021	3/31/2025 5:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/31/2025 5:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1801963343	3/31/2025 5:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	3/31/2025 5:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Ottemiller, Dustin VP, Finance Thomas Jefferson University Hospitals, Inc. 2155035219	Ottemiller, Dustin VP, Finance Jefferson Health 2155035219	9/3/2024 11:17 AM
Contacts	Primary Contact	Update	Change Request	Adams, Neal Pharmacy Manager Aria Health 2156125473	Ottemiller, Dustin VP, Finance Thomas Jefferson University Hospitals, Inc. 2155035219	8/27/2024 10:19 AM
Details	Last Recertification Date	Update	Recertification	8/14/2023 8:04:03 AM	8/19/2024 9:16:51 AM	8/19/2024 9:16 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 7:46:04 AM	8/14/2023 8:04:03 AM	8/14/2023 8:04 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 10:04:39 AM	8/24/2022 7:46:04 AM	8/24/2022 7:46 AM
Details	Entity Name	Update	Change Request	ARIA HEALTH	Jefferson Health Northeast	5/23/2022 7:11 AM
Contacts	Authorizing Official	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2157103755	FREY, CARRIE Director of Finance Aria Health 2156124313	10/14/2021 8:04 AM
Contacts	Signed By	Update	Profile Change Request	FREY, CARRIE Director of Finance Aria Health 2157103755	FREY, CARRIE Director of Finance Aria Health 2156124313	10/14/2021 8:04 AM
Details	Last Recertification Date	Update	Recertification		8/16/2021 10:04:39 AM	8/16/2021 10:04 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		FREY, CARRIE Director of Finance Aria Health 2157103755	4/19/2021 11:04 AM
Details	340B ID	Update	New Registration		DSH390115K	4/19/2021 11:04 AM
Details	Entity Subname	Update	New Registration	MRI Roosevelt Blvd	MRI Roosevelt Blvd - MRI	4/19/2021 11:04 AM
Dates	Participating Approval Date	Update	New Registration		4/19/2021 11:04:40 AM	4/19/2021 11:04 AM
Details	State	Update	New Registration	Pending	Approved	4/19/2021 11:04 AM
Dates	Signed By Date	Update	New Registration		4/15/2021 3:04:18 PM	4/19/2021 11:04 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/19/2021 11:04 AM
Addresses	Main Address	Insert	New Registration		2451 Grant Ave. Philadelphia, PA 19114	4/14/2021 5:50 PM
Contacts	Primary Contact	Insert	New Registration		Adams, Neal Pharmacy Manager Aria Health 2156125473	4/14/2021 5:50 PM
Contacts	Authorizing Official	Insert	New Registration		FREY, CARRIE Director of Finance Aria Health 2157103755	4/14/2021 5:50 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2021 5:50 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2021 5:50 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2021 5:50 PM
Details	Grant Number	Insert	New Registration			4/14/2021 5:50 PM
Details	340B ID	Insert	New Registration			4/14/2021 5:50 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2021 5:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2021 5:50 PM
Details	Medicare Provider Number	Insert	New Registration		390115	4/14/2021 5:50 PM
Details	Entity Name	Insert	New Registration		ARIA HEALTH	4/14/2021 5:50 PM
Details	NOFO Number	Insert	New Registration			4/14/2021 5:50 PM
Details	Program Code	Insert	New Registration		DSH	4/14/2021 5:50 PM
Details	Entity Subname	Insert	New Registration		MRI Roosevelt Blvd	4/14/2021 5:50 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2021 5:50 PM
Details	State	Insert	New Registration		Pending	4/14/2021 5:50 PM
Dates	Registration Date	Insert	New Registration		4/14/2021 5:50:35 PM	4/14/2021 5:50 PM
Dates	Signed By Date	Insert	New Registration			4/14/2021 5:50 PM
Dates	Start Date	Insert	New Registration			4/14/2021 5:50 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2021 5:50 PM
Terminations	Termination Date	Insert	New Registration			4/14/2021 5:50 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2021 5:50 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2021 5:50 PM