Covered Entity Details

DSH040055M Baptist Health - Fort Smith (Active) - information as of 5/25/2025 1:16:00 AM

Main Details

Name

Baptist Health - Fort Smith

Subdivision Name

Fort Smith Cardiology Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH040055M

Medicare Provider Number

040055

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/6/2021

Participating Start Date

10/1/2021

Participating Approval Date

7/13/2021

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Baptist Health
Brent Beaulieu, CFO
(501) 202-2017

Primary Contact

Baptist Health
Stefanie Jaeger, Sr. Reimbursement Specialist
(501) 202-1813

Addresses

Street Address

1500 Dodson Avenue
Suite 60
Fort Smith, AR 72901

Billing Address

Baptist Health - Fort Smith
1001 Towson Avenue
Fort Smith, AR 72901

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
AR	233506105	1710463146
OK	200827000A	1710463146

Shipping Addresses

Shipping Address 1

Baptist Health - Fort Smith
1001 Towson Avenue
Fort Smith, AR 72901

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
DSH040055E	Child	DSH	Baptist Health - Fort Smith	BH Laboratory - Fort Smith	1500 Dodson Avenue	Fort Smith	AR	Active
DSH040055F	Child	DSH	Baptist Health - Fort Smith	BH Women's Center - Fort Smith	1500 Dodson Avenue	Fort Smith	AR	Active
DSH040055G	Child	DSH	Baptist Health - Fort Smith	BH Radiation Oncology - Fort Smith	1502 Dodson Avenue	Fort Smith	AR	Active
DSH040055H	Child	DSH	Baptist Health - Fort Smith	BH Therapy Center - Fort Smith	624 Towson Avenue	Fort Smith	AR	Active
DSH040055J	Child	DSH	Baptist Health - Fort Smith	BH Imaging Center - Fort Smith	1500 Dodson Avenue	Fort Smith	AR	Active
DSH040055K	Child	DSH	Baptist Health - Fort Smith	BH PREADMISSION TESTING CENTER	1001 Towson Avenue	FORT SMITH	AR	Terminated
DSH040055L	Child	DSH	Baptist Health - Fort Smith	BH-FS CARDIAC REHAB	810 LEXINGTON AVE	FORT SMITH	AR	Active
DSH040055M	Child	DSH	Baptist Health - Fort Smith	Fort Smith Cardiology Clinic	1500 Dodson Avenue	Fort Smith	AR	Active
DSH040055N	Child	DSH	Baptist Health - Fort Smith	BH Lung Center - BH Lung Center	1001 Towson Avenue	Fort Smith	AR	Active
DSH040055P	Child	DSH	Baptist Health - Fort Smith	BH Cancer Center - BH Cancer Center	1001 Towson Avenue	Fort Smith	AR	Active
DSH040055Q	Child	DSH	Baptist Health - Fort Smith	BH Specialty Clinic FS - BH Specialty Clinic FS	1001 Towson Avenue	Fort Smith	AR	Active
DSH040055R	Child	DSH	Baptist Health - Fort Smith	BAPTIST HEALTH FAMILY CLINIC-ALMA - Baptist Health Family Clinic - Alma	937 HIGHWAY 64 E	ALMA	AR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/13/2023 11:29:31 AM	9/3/2024 11:17:02 AM	9/3/2024 11:17 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 12:35:53 PM	9/13/2023 11:29:31 AM	9/13/2023 11:29 AM
Details	Entity Subname	Update	Change Request	Fort Smith Cardiology Clinic - Fort Smith Cardiology Clinic	Fort Smith Cardiology Clinic	10/24/2022 7:22 AM
Details	Last Recertification Date	Update	Recertification		9/12/2022 12:35:53 PM	9/12/2022 12:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/15/2021 4:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200827000A	10/15/2021 4:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	10/15/2021 4:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710463146	10/15/2021 4:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	10/15/2021 4:50 PM
Details	State	Update		Approved	Active	10/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Beaulieu, Brent CFO Baptist Health 5012022017	7/13/2021 8:06 AM
Details	340B ID	Update	New Registration		DSH040055M	7/13/2021 8:06 AM
Details	Entity Name	Update	New Registration	BAPTIST HEALTH MEDICAL CENTER - FS	Baptist Health - Fort Smith	7/13/2021 8:06 AM
Details	Entity Subname	Update	New Registration	Fort Smith Cardiology Clinic	Fort Smith Cardiology Clinic - Fort Smith Cardiology Clinic	7/13/2021 8:06 AM
Dates	Participating Approval Date	Update	New Registration		7/13/2021 8:06:22 AM	7/13/2021 8:06 AM
Details	State	Update	New Registration	Pending	Approved	7/13/2021 8:06 AM
Dates	Signed By Date	Update	New Registration		7/6/2021 6:57:37 PM	7/13/2021 8:06 AM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	7/13/2021 8:06 AM
Addresses	Main Address	Insert	New Registration		1500 Dodson Avenue Suite 60 Fort Smith, AR 72901	7/6/2021 4:08 PM
Addresses	Billing Address	Insert	New Registration		Baptist Health - Fort Smith 1001 Towson Avenue Fort Smith, AR 72901	7/6/2021 4:08 PM
Addresses	Shipping Address	Insert	New Registration		Baptist Health - Fort Smith 1001 Towson Avenue Fort Smith, AR 72901	7/6/2021 4:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/6/2021 4:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		233506105	7/6/2021 4:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	7/6/2021 4:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710463146	7/6/2021 4:08 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	7/6/2021 4:08 PM
Contacts	Primary Contact	Insert	New Registration		Jaeger, Stefanie Sr. Reimbursement Specialist Baptist Health 5012021813	7/6/2021 4:08 PM
Contacts	Authorizing Official	Insert	New Registration		Beaulieu, Brent CFO Baptist Health 5012022017	7/6/2021 4:08 PM
Details	Assistance Received From Date	Insert	New Registration			7/6/2021 4:08 PM
Details	Assistance Received To Date	Insert	New Registration			7/6/2021 4:08 PM
Details	Last Recertification Date	Insert	New Registration			7/6/2021 4:08 PM
Details	Grant Number	Insert	New Registration			7/6/2021 4:08 PM
Details	340B ID	Insert	New Registration			7/6/2021 4:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/6/2021 4:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/6/2021 4:08 PM
Details	Medicare Provider Number	Insert	New Registration		040055	7/6/2021 4:08 PM
Details	Entity Name	Insert	New Registration		BAPTIST HEALTH MEDICAL CENTER - FS	7/6/2021 4:08 PM
Details	NOFO Number	Insert	New Registration			7/6/2021 4:08 PM
Details	Program Code	Insert	New Registration		DSH	7/6/2021 4:08 PM
Details	Entity Subname	Insert	New Registration		Fort Smith Cardiology Clinic	7/6/2021 4:08 PM
Dates	Participating Approval Date	Insert	New Registration			7/6/2021 4:08 PM
Details	State	Insert	New Registration		Pending	7/6/2021 4:08 PM
Dates	Registration Date	Insert	New Registration		7/6/2021 4:08:38 PM	7/6/2021 4:08 PM
Dates	Signed By Date	Insert	New Registration			7/6/2021 4:08 PM
Dates	Start Date	Insert	New Registration			7/6/2021 4:08 PM
Terminations	Termination Comments	Insert	New Registration			7/6/2021 4:08 PM
Terminations	Termination Date	Insert	New Registration			7/6/2021 4:08 PM
Terminations	Termination Effective Date	Insert	New Registration			7/6/2021 4:08 PM
Terminations	Termination Reason	Insert	New Registration			7/6/2021 4:08 PM