Covered Entity Details

DSH360133AT Kettering Health Dayton (Active) - information as of 4/23/2025 10:54:21 PM

Main Details

Name

Kettering Health Dayton

Subdivision Name

Grandview Medical Infusion Srvs 90.16 / Covid OP Infusion 322930 - infusion

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360133AT

Medicare Provider Number

360133

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2021

Participating Start Date

1/1/2022

Participating Approval Date

10/20/2021

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Kettering Health
Harmat Beebe, Vice President Finance Multi-Hospital Campus
(937) 723-3414

Primary Contact

Kettering Health Network:Grandview/Kettering/Ft Hamilton/Sycamore/Soin
Linda McCall, Pharmacy Director
(937) 458-4946

Addresses

Street Address

3535 SOUTHERN BLVD
Kettering, OH 45429

Billing Address

Kettering Health A/P
1 Prestige Place
Miamisburg, OH 45342

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
OH	3354525,2296706,0194637	1053339507,1811072010,1629511688
IL	31056412100	1053339507
KY	01540053	1053339507
MI	1053339507	1053339507
IN	300088558	1053339507
NE	31056412100	1053339507

Shipping Addresses

Shipping Address 1

KCC Infusion Pharmacy
3700 Southern Blvd
Kettering, OH 45429

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
DSH360133AA	Child	DSH	Kettering Health Dayton	Respiratory Therapy 65.00 / Respiratory Care 450040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133AB	Child	DSH	Kettering Health Dayton	Laboratory 60.00 / Lab 401040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133AC	Child	DSH	Kettering Health Dayton	Radioisotope 56.00 / Nuclear Medicine 422040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133AD	Child	DSH	GRANDVIEW HOSPITAL	Recovery Room 51.00 / Preadmitting Testing 385040	1997 Miamisburg Centerville Rd	Dayton	OH	Terminated
DSH360133AE	Child	DSH	Kettering Health Dayton	Recovery Room 51.00 / Post Anesthesia Care Unit 365040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133AF	Child	DSH	Kettering Health Dayton	Operating Room 50.00 / Hand & Ortho 369040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133AG	Child	DSH	Kettering Health Dayton	Operating Room 50.00 / Pain Center 384030	425 W. Grand Ave.	DAYTON	OH	Active
DSH360133AH	Child	DSH	GRANDVIEW HOSPITAL	Recovery Room 51.00/Short Stay 386030 - infusion	405 W. GRAND AVE.	DAYTON	OH	Terminated
DSH360133AJ	Child	DSH	Kettering Health Dayton	Operating Room 50.00 / Pain Center 384040 - KHWT Pain Center	1997 Miamisburg-Centerville Road	Dayton	OH	Active
DSH360133AK	Child	DSH	Kettering Health Dayton	Adults & Pediatrics 30.00 / Maternity 318440	1997 Miamisburg-Centerville Rd	Centerville	OH	Active
DSH360133AL	Child	DSH	Kettering Health Dayton	Intensive Care Unit 31.00 / ICU 340440	1997 Miamisburg-Centerville Rd	Centerville	OH	Active
DSH360133AM	Child	DSH	Kettering Health Dayton	Southview Clinic 90.09 / Southview Women's Center 473240	1989 Miamisburg-Centerville Rd	Centerville	OH	Active
DSH360133AN	Child	DSH	Kettering Health Dayton	Adults & Pediatrics 30.00 / KHWT Med Surg 310440	1997 Miamisburg-Centerville Rd	Centerville	OH	Active
DSH360133AP	Child	DSH	Kettering Health Dayton	Cassano Clinic 90.13 / Cassano-Specialist Services 472330	165 Edwin C Moses Blvd	Dayton	OH	Active
DSH360133AQ	Child	DSH	Kettering Health Dayton	Grandview Medical Ctr Infusion Srvs 90.16 / KHDO - Troy Infusion 323830 - Infusion	600 W. Main St	Troy	OH	Active
DSH360133AR	Child	DSH	Kettering Health Dayton	KCC Clinic 90.19/KCC Clinic 484830 - Oncology	3700 Southern Blvd	Kettering	OH	Active
DSH360133AS	Child	DSH	Kettering Health Dayton	KCC Clinic 90.19 / KHDO Infusion Ctr KCC 2nd 323730	3700 Southern Blvd	Kettering	OH	Active
DSH360133AT	Child	DSH	Kettering Health Dayton	Grandview Medical Infusion Srvs 90.16 / Covid OP Infusion 322930 - infusion	3535 SOUTHERN BLVD	Kettering	OH	Active
DSH360133C	Child	DSH	Kettering Health Dayton	Operating Room 50.00 / Endoscopy 361040	1997 Miamisburg-Centerville Road	Dayton	OH	Active
DSH360133D	Child	DSH	Kettering Health Dayton	Operating Room 50.00/ Operating Room 360040	1997 Miamisburg-Centerville Road	Dayton	OH	Active
DSH360133E	Child	DSH	Kettering Health Dayton	Radiology-Diagnostic 54.00/Radiology 421040	1997 Miamisburg-Centerville Road	Dayton	OH	Active
DSH360133H	Child	DSH	GRANDVIEW HOSPITAL	Boonshoft Infusion Therapy	3737 Southern Blvd	Kettering	OH	Terminated
DSH360133J	Child	DSH	Kettering Health Dayton	Emergency 91.00 / Emergency Room 378040	1997 Miamisburg-Centerville Road	Dayton	OH	Active
DSH360133K	Child	DSH	Kettering Health Dayton	Huber Heights Clinic 90.04/ Emergency Room HH 378033	8701 Old Troy Pike	Huber Heights	OH	Active
DSH360133L	Child	DSH	Kettering Health Dayton	Grandview Medical Ctr Infusion SRVS 90.16 / KHDO - Soin Infusion 324830	3535 PENTAGON BLVD 400	BEAVERCREEK	OH	Active
DSH360133M	Child	DSH	GRANDVIEW HOSPITAL	GRANDVIEW BOONSHOFT INFUSION CENTER / Women's Cancer Center	3737 SOUTHERN BLVD	KETTERING	OH	Terminated
DSH360133N	Child	DSH	Kettering Health Dayton	KCC Clinic 90.19 / KHDO - KCC Infusion 324430	3700 Southern Blvd STE 5107	Kettering	OH	Active
DSH360133P	Child	DSH	Kettering Health Dayton	Grandview Medical Ctr Infusion SRVS 90.16 / KHDO - KHWT Infusion 324440	1989 MIAMISBURG CENTERVILLE RD 101	DAYTON	OH	Active
DSH360133Q	Child	DSH	Kettering Health Dayton	Electrocardiology 69.00 / Diagnostic Cardiology-Yankee 412340	7677 YANKEE STREET	CENTERVILLE	OH	Active
DSH360133R	Child	DSH	Kettering Health Dayton	Electrocardiology 69.00/ Diagnostic Cardiology-Little York 412230	4160 LITTLE YORK RD	DAYTON	OH	Active
DSH360133S	Child	DSH	Kettering Health Dayton	Preble County 90.05 / Emergency Room PC 378034	450 F Washington Jackson Road	Eaton	OH	Active
DSH360133T	Child	DSH	Kettering Health Dayton	CT Scan 75.02 / MRI 426040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133U	Child	DSH	Kettering Health Dayton	CT Scan 75.02 / CT 420040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133V	Child	DSH	Kettering Health Dayton	Ultrasound 75.01 / Ultrasound 415040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133W	Child	DSH	Kettering Health Dayton	Physical Therapy 66.00 / IPTHERAP-OP 437040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133X	Child	DSH	Kettering Health Dayton	Electrocardiology 69.00 / Non-Invasive Cardiology 457040	1997 Miamisburg Centerville Rd	Dayton	OH	Active
DSH360133Y	Child	DSH	GRANDVIEW HOSPITAL	Electrocardiology 69.00 / Heart Catheterization 424040	1997 Miamisburg Centerville Rd	Dayton	OH	Terminated
DSH360133Z	Child	DSH	GRANDVIEW HOSPITAL	Occupational Therapy 67.00 / Occupational Therapy 438040	1997 Miamisburg Centerville Rd	Dayton	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/16/2025 8:46 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		31056412100	4/16/2025 8:46 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NE	4/16/2025 8:46 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1053339507	4/16/2025 8:46 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	4/16/2025 8:46 AM
Contacts	Authorizing Official	Update	Change Request	Chavez, Steven Kettering Health VP Finance and Operations Kettering Health Fort Hamilton Hospital 9377621644	Beebe, Harmat Vice President Finance Multi-Hospital Campus Kettering Health 9377233414	12/19/2024 7:38 AM
Details	Last Recertification Date	Update	Recertification	8/22/2023 1:48:38 PM	8/19/2024 5:07:29 PM	8/19/2024 5:07 PM
Contacts	Authorizing Official	Update	AO Change Request	Villegas, William E Regional VP of Finance Fort Hamilton Hospital/Grandview Medical Center/Southview Medical Center/Sycamore Medical Center 9377233414	Chavez, Steven Kettering Health VP Finance and Operations Kettering Health Fort Hamilton Hospital 9377621644	5/29/2024 1:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		300088558	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IN	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0194637	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	4/22/2024 8:08 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1053339507	4/22/2024 8:08 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	4/22/2024 8:08 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1629511688	4/22/2024 8:08 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	4/22/2024 8:08 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (IL)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (IL)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (IN)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (IN)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (KY)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (KY)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MI)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MI)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NE)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NE)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (FL)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (FL)		3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		31056412100	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		01540053	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1053339507	3/14/2024 11:23 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MI	3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (IL)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (IN)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (IN)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (KY)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MI)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NE)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NE)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (FL)		3/14/2024 11:23 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (FL)		3/14/2024 11:23 AM
Details	Entity Name	Update	Recertification	GRANDVIEW HOSPITAL	Kettering Health Dayton	8/22/2023 2:39 PM
Addresses	Billing Address	Update	Recertification	Kettering Health Network A/P 1 Prestige Place Miamisburg, OH 45342	Kettering Health A/P 1 Prestige Place Miamisburg, OH 45342	8/22/2023 1:48 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 3:28:23 PM	8/22/2023 1:48:38 PM	8/22/2023 1:48 PM
Details	Last Recertification Date	Update	Recertification		8/31/2022 3:28:23 PM	8/31/2022 3:28 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (AK)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (AK)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (AL)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (AL)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (AS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (AS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (AZ)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (AZ)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (AR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (AR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (CA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (CA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (CO)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (CO)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (CT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (CT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (DC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (DC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (FM)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (FM)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (HI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (HI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (ID)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (ID)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (IA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (IA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (KS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (KS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (LA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (LA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (ME)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (ME)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MH)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MH)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MD)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MD)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MN)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MN)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MS)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MO)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MO)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NJ)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NJ)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NM)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NM)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NY)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NY)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (ND)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (ND)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (MP)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (MP)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (OK)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (OK)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (OR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (OR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (PW)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (PW)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (PA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (PA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (PR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (PR)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (RI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (RI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (SC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (SC)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (TN)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (TN)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (TX)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (TX)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (UT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (UT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (VT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (VT)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (VI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (VI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (VA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (VA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (WA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (WA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (WV)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (WV)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (WI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (WI)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (WY)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (WY)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (NV)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (NV)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (GA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (GA)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3354525 (GU)		6/24/2022 2:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	2296706 (GU)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (AK)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (AK)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (AL)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (AL)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (AS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (AS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (AZ)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (AZ)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (AR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (AR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (CA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (CA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (CO)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (CO)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (CT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (CT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (DC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (DC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (FM)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (FM)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (HI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (HI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (ID)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (ID)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (IA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (IA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (KS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (KS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (LA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (LA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (ME)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (ME)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MH)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MH)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MD)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MD)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MN)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MN)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MS)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MO)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MO)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NJ)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NJ)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NM)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NM)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NY)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NY)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (ND)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (ND)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (MP)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (MP)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (OK)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (OK)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (OR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (OR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (PW)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (PW)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (PA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (PA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (PR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (PR)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (RI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (RI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (SC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (SC)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (TN)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (TN)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (TX)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (TX)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (UT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (UT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (VT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (VT)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (VI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (VI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (VA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (VA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (WA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (WA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (WV)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (WV)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (WI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (WI)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (WY)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (WY)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (NV)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (NV)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (GA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (GA)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053339507 (GU)		6/24/2022 2:01 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1811072010 (GU)		6/24/2022 2:01 PM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Villegas, William E Regional VP of Finance Fort Hamilton Hospital/Grandview Medical Center/Southview Medical Center/Sycamore Medical Center 9377233414	10/20/2021 7:27 AM
Details	340B ID	Update	New Registration		DSH360133AT	10/20/2021 7:27 AM
Details	Entity Subname	Update	New Registration	Grandview Medical Infusion Srvs 90.16 / Covid OP Infusion 322930	Grandview Medical Infusion Srvs 90.16 / Covid OP Infusion 322930 - infusion	10/20/2021 7:27 AM
Dates	Participating Approval Date	Update	New Registration		10/20/2021 7:27:46 AM	10/20/2021 7:27 AM
Details	State	Update	New Registration	Pending	Approved	10/20/2021 7:27 AM
Dates	Signed By Date	Update	New Registration		10/4/2021 3:01:03 PM	10/20/2021 7:27 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	10/20/2021 7:27 AM
Addresses	Main Address	Insert	New Registration		3535 SOUTHERN BLVD Kettering, OH 45429	10/4/2021 2:40 PM
Addresses	Billing Address	Insert	New Registration		Kettering Health Network A/P 1 Prestige Place Miamisburg, OH 45342	10/4/2021 2:40 PM
Addresses	Shipping Address	Insert	New Registration		KCC Infusion Pharmacy 3700 Southern Blvd Kettering, OH 45429	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FM	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FM	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		HI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		HI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MH	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MH	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MP	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MP	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PW	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PW	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PR	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WY	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3354525	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GU	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2296706	10/4/2021 2:40 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GU	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		DC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		DC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		FM	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		FM	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MH	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MH	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MP	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		MP	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PW	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PW	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		PR	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		RI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		RI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WV	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WV	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		WY	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053339507	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		GU	10/4/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811072010	10/4/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		GU	10/4/2021 2:40 PM
Contacts	Primary Contact	Insert	New Registration		McCall, Linda Pharmacy Director Kettering Health Network:Grandview/Kettering/Ft Hamilton/Sycamore/Soin 9374584946	10/4/2021 2:40 PM
Contacts	Authorizing Official	Insert	New Registration		Villegas, William E Regional VP of Finance Fort Hamilton Hospital/Grandview Medical Center/Southview Medical Center/Sycamore Medical Center 9377233414	10/4/2021 2:40 PM
Details	Assistance Received From Date	Insert	New Registration			10/4/2021 2:40 PM
Details	Assistance Received To Date	Insert	New Registration			10/4/2021 2:40 PM
Details	Last Recertification Date	Insert	New Registration			10/4/2021 2:40 PM
Details	Grant Number	Insert	New Registration			10/4/2021 2:40 PM
Details	340B ID	Insert	New Registration			10/4/2021 2:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2021 2:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2021 2:40 PM
Details	Medicare Provider Number	Insert	New Registration		360133	10/4/2021 2:40 PM
Details	Entity Name	Insert	New Registration		GRANDVIEW HOSPITAL	10/4/2021 2:40 PM
Details	NOFO Number	Insert	New Registration			10/4/2021 2:40 PM
Details	Program Code	Insert	New Registration		DSH	10/4/2021 2:40 PM
Details	Entity Subname	Insert	New Registration		Grandview Medical Infusion Srvs 90.16 / Covid OP Infusion 322930	10/4/2021 2:40 PM
Dates	Participating Approval Date	Insert	New Registration			10/4/2021 2:40 PM
Details	State	Insert	New Registration		Pending	10/4/2021 2:40 PM
Dates	Registration Date	Insert	New Registration		10/4/2021 2:40:50 PM	10/4/2021 2:40 PM
Dates	Signed By Date	Insert	New Registration			10/4/2021 2:40 PM
Dates	Start Date	Insert	New Registration			10/4/2021 2:40 PM
Terminations	Termination Comments	Insert	New Registration			10/4/2021 2:40 PM
Terminations	Termination Date	Insert	New Registration			10/4/2021 2:40 PM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2021 2:40 PM
Terminations	Termination Reason	Insert	New Registration			10/4/2021 2:40 PM