Covered Entity Details

DSH230195B ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital (Active) - information as of 4/25/2025 6:36:19 PM

Main Details

Name

ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital

Subdivision Name

ASCENSION MACOMB OAKLAND HOSPITAL - Internal Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH230195B

Medicare Provider Number

230195

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/14/2021

Participating Start Date

10/1/2021

Participating Approval Date

7/27/2021

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020

Addresses

Street Address

11885 E 13 MILE RD STE 300A
MOTOR CITY INTERNISTS
WARREN, MI 48093-3023

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?
No

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
DSH230195A	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL	ASCENSION MACOMB OAKLAND HOSPITAL - Primary Care	27483 DEQUINDRE ROAD STE 303	MADISON HEIGHTS	MI	Terminated
DSH230195B	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Internal Medicine	11885 E 13 MILE RD STE 300A	WARREN	MI	Active
DSH230195C	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Anesthesiology 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195D	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Diagnostic Cardiology Anc 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195E	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Diagnostic Radiology 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195F	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Interventional Radiology 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195G	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - PBP Sleep Medicine 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195H	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Endoscopy GI 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195J	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Computerized Tomography CT 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195K	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Urology Residency Clinic	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195L	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Rehab Services General 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195M	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Dialysis 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195N	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Oakland MRI	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195P	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Surgery 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195Q	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Nuclear Medicine 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195R	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Emergency Department 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195S	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Surgery Recovery Room 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195T	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Ultrasound 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195U	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Respiratory Therapy 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195V	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Perioperative Care Anc 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195W	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Cardiac Cath Labs Anc 001	27351 DEQUINDRE RD	MADISON HEIGHTS	MI	Active
DSH230195X	Child	DSH	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	ASCENSION MACOMB OAKLAND HOSPITAL - Oakland Primary Care Clinic	27450 SCHOENHERR STE 400	WARREN	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	ST. JOHN MACOMB-OAKLAND HOSPITAL	ST. JOHN MACOMB-OAKLAND HOSPITAL DBA Henry Ford Health Warren Hospital	3/20/2025 1:24 PM
Contacts	Primary Contact	Update	Group Change Request	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	Mansour, Alexander 340B Compliance Officer Henry Ford Hospital 2487230020	1/28/2025 9:42 AM
Contacts	Authorizing Official	Update	Change Request	McCullough, Michael CFO Ascension Michigan 5867530653	Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/10/2024 8:17 AM
Details	Last Recertification Date	Update	Recertification	8/14/2023 6:40:08 AM	8/15/2024 8:50:20 AM	8/15/2024 8:50 AM
Contacts	Primary Contact	Update	Group Change Request	Beldyga, Lyndy 340b manager Ascension Health 9899078000	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	1/8/2024 11:07 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 11:27:14 AM	8/14/2023 6:40:08 AM	8/14/2023 6:40 AM
Contacts	Primary Contact	Update	Group Change Request	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	Beldyga, Lyndy 340b manager Ascension Health 9899078000	8/3/2023 12:48 PM
Contacts	Authorizing Official	Update	Change Request	Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	McCullough, Michael CFO Ascension Michigan 5867530653	6/7/2023 7:41 AM
Details	Last Recertification Date	Update	Recertification		8/30/2022 11:27:14 AM	8/30/2022 11:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Fiser, Kelsey 340B Pharmacy Coordinator Saint Thomas Health 6152225190	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	3/16/2022 6:29 AM
Contacts	Primary Contact	Update	Group Change Request	Rys, Jon 340B Program Coordinator St. John Hospital & Medical Center 5864894237	Fiser, Kelsey 340B Pharmacy Coordinator Saint Thomas Health 6152225190	11/18/2021 8:47 AM
Details	State	Update		Approved	Active	10/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	7/27/2021 12:24 PM
Details	340B ID	Update	New Registration		DSH230195B	7/27/2021 12:24 PM
Details	Entity Name	Update	New Registration	ASCENSION MACOMB-OAKLAND HOSPITAL	ST. JOHN MACOMB-OAKLAND HOSPITAL	7/27/2021 12:24 PM
Details	Entity Subname	Update	New Registration	ASCENSION MACOMB OAKLAND HOSPITAL	ASCENSION MACOMB OAKLAND HOSPITAL - Internal Medicine	7/27/2021 12:24 PM
Dates	Participating Approval Date	Update	New Registration		7/27/2021 12:24:35 PM	7/27/2021 12:24 PM
Details	State	Update	New Registration	Pending	Approved	7/27/2021 12:24 PM
Dates	Signed By Date	Update	New Registration		7/15/2021 10:15:18 AM	7/27/2021 12:24 PM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	7/27/2021 12:24 PM
Addresses	Main Address	Insert	New Registration		11885 E 13 MILE RD STE 300A MOTOR CITY INTERNISTS WARREN, MI 48093-3023	7/14/2021 3:29 PM
Contacts	Primary Contact	Insert	New Registration		Rys, Jon 340B Program Coordinator St. John Hospital & Medical Center 5864894237	7/14/2021 3:29 PM
Contacts	Authorizing Official	Insert	New Registration		Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	7/14/2021 3:29 PM
Details	Assistance Received From Date	Insert	New Registration			7/14/2021 3:29 PM
Details	Assistance Received To Date	Insert	New Registration			7/14/2021 3:29 PM
Details	Last Recertification Date	Insert	New Registration			7/14/2021 3:29 PM
Details	Grant Number	Insert	New Registration			7/14/2021 3:29 PM
Details	340B ID	Insert	New Registration			7/14/2021 3:29 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2021 3:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2021 3:29 PM
Details	Medicare Provider Number	Insert	New Registration		230195	7/14/2021 3:29 PM
Details	Entity Name	Insert	New Registration		ASCENSION MACOMB-OAKLAND HOSPITAL	7/14/2021 3:29 PM
Details	NOFO Number	Insert	New Registration			7/14/2021 3:29 PM
Details	Program Code	Insert	New Registration		DSH	7/14/2021 3:29 PM
Details	Entity Subname	Insert	New Registration		ASCENSION MACOMB OAKLAND HOSPITAL	7/14/2021 3:29 PM
Dates	Participating Approval Date	Insert	New Registration			7/14/2021 3:29 PM
Details	State	Insert	New Registration		Pending	7/14/2021 3:29 PM
Dates	Registration Date	Insert	New Registration		7/14/2021 3:29:41 PM	7/14/2021 3:29 PM
Dates	Signed By Date	Insert	New Registration			7/14/2021 3:29 PM
Dates	Start Date	Insert	New Registration			7/14/2021 3:29 PM
Terminations	Termination Comments	Insert	New Registration			7/14/2021 3:29 PM
Terminations	Termination Date	Insert	New Registration			7/14/2021 3:29 PM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2021 3:29 PM
Terminations	Termination Reason	Insert	New Registration			7/14/2021 3:29 PM