Covered Entity Details

DSH330195AZ LONG ISLAND JEWISH MEDICAL CENTER (Terminated) - information as of 6/26/2025 12:29:02 AM

Main Details

Name

LONG ISLAND JEWISH MEDICAL CENTER

Subdivision Name

Forest Hospital / Women's Health - Ultrasound Diagnostic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330195AZ

Medicare Provider Number

330195

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/6/2021

Participating Start Date

1/1/2022

Participating Approval Date

10/6/2021

Last Recertification Date

Termination Date
Termination Reason

1/1/2022
Other

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

102-01 66th Road
Forest Hills, NY 11375

Billing Address

Long Island Jewish Medical Center
270-05 76th Ave
New Hyde Park, NY 11040

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
NY	'00243903,'02998887	1285641514
AL	LON0195N	1285641514
AR	239739105	1285641514
AZ	598210	1285641514
CA	1285641514	1285641514
CO	9000182281,44432577	1285641514
CT	003129401,'008051182	1285641514
DE	1285641514	1285641514
FL	092086000,'003273000	1285641514
GA	000105729A,399622993A	1285641514
ID	1316954449	1285641514
IA	1285641514	1285641514
IL	1285641514	1285641514
KS	100446570A	1285641514
KY	01500040	1285641514
MA	110026857C	1285641514
MD	283335200	1285641514
ME	160670000	1285641514
MI	1285641514	1285641514
MN	199217100,1316954449	1285641514
MO	1285641514	1285641514
MS	00096736	1285641514
NC	1285641514,1316954449	1285641514
NE	11224132600	1285641514
NH	3104340	1285641514
NJ	4157303,8844500	1285641514
NM	A8435	1285641514
NV	1288387	1285641514
OH	0608033	1285641514
OK	100689170A	1285641514
OR	1285641514	1285641514
PA	1007620400005,'0014836270001	1285641514
RI	OP30195	1285641514
SC	10858B	1285641514
TN	Q034252	1285641514
TX	072485801	1285641514
UT	1285641514	1285641514
VA	1285641514,1316954449	1285641514
VT	0330195	1285641514
WA	1285641514	1285641514
WI	1285641514	1285641514

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
DSH330195A	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - METHADONE CLINIC	75-59 263RD ST.	GLEN OAKS	NY	Active
DSH330195AA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital-Multi Speciality Clinic Rego Park / Ob/Gyn & Prenatal Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195AB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / CAT Scan	102-01 66th Road	Forest Hills	NY	Active
DSH330195AC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / MRI	102-01 66th Road	Forest Hills	NY	Active
DSH330195AD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Radiology	102-01 66th Road	Forest Hills	NY	Active
DSH330195AE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Interventional/Special Procedures	102-01 66th Road	Forest Hills	NY	Active
DSH330195AF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Endoscopy	102-01 66th Road	Forest Hills	NY	Active
DSH330195AG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Ambulatory Surgery	102-01 66th Road	Forest Hills	NY	Active
DSH330195AH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Emergency Deptartment	102-01 66th Road	Forest Hills	NY	Active
DSH330195AJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Institute - Great South Bay	440 East Main Street	Bayshore	NY	Active
DSH330195AK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SCHOOL BASED HC - John Adams	101-01 Rockaway Blvd	Ozone Park	NY	Active
DSH330195AL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Radiation Oncology	450 Lakeville Road	Lake Success	NY	Active
DSH330195AM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Project Outreach	600 Hempstead Turnpike	West Hempstead	NY	Active
DSH330195AN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Garden City Treatment Center	711 Stewart Avenue	Garden City	NY	Active
DSH330195AP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway Treatment Center	1600 Central Avenue	Far Rockaway	NY	Active
DSH330195AQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore-Radiology Diagnostic	440 East Main Street	Bay Shore	NY	Active
DSH330195AR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - Radioisotope	440 East Main Street	Bay Shore	NY	Active
DSH330195AS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Imaging at Bay Shore - MRI	440 East Main Street	Bay Shore	NY	Active
DSH330195AT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJMC/ Medicine Specialties at Glen Oaks - Clinic	25611 Union Turnpike	Glen Oaks	NY	Active
DSH330195AU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Northwell Health Cancer Center - Cancer Treatment Services	270 Pulaski Rd.	Greenlawn	NY	Active
DSH330195AV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - August Martin - School-based Health Center	156-10 Baisley Blvd	Jamaica	NY	Active
DSH330195AW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / EHS - Employee Health Services	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195AX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Hearing and Speech Center - Clinic	430 Lakeville Road	New Hyde Park	NY	Active
DSH330195AY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Pre-Surgical Testing - Pre Surgical Testing	102-01 66th Road	Forest Hills	NY	Active
DSH330195AZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hospital / Women's Health - Ultrasound Diagnostic	102-01 66th Road	Forest Hills	NY	Terminated
DSH330195B	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zuckerberg Cancer Center	450 LAKEVILLE ROAD	LAKE SUCCESS	NY	Active
DSH330195BA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / EKG/ECHO - Electrocardiology	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Personalized Recovery Oriented Services - All Other OASAS Programs O/P	205-07 Hillside Ave	Hollis	NY	Active
DSH330195BC	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Lab - Laboratory	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BD	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Pre Surgical Testing - Pre Surgical Testing	900 Franklin Ave	Valley Stream	NY	Active
DSH330195BE	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside/ Martin Van Buren High School Clinic - Mental Health Clinic	230-17 Hillside Ave	Queens Village	NY	Active
DSH330195BF	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP PSY/Social Work Svc Tran - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BG	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	STARS Transitions/ LIJOP Occupat Therapy Trans - Physical Therapy	1554 Northern Blvd	Manhasset	NY	Active
DSH330195BH	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - DAERHS - ALL OTHER OASIS PROGRAMS	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BJ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - ELECTROCONVULSIVE THERAPY CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BK	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - MEDICAL SPECIALTIES CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BL	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - AMBULATORY CARE - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BM	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Psych Centers - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BN	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CTC CLINIC - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BP	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - CRISIS INTERVENTION - MENTAL HEALTH CLINIC	75-59 263RD STREET	GLEN OAKS	NY	Active
DSH330195BQ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Urology Clinic - Urology	95-25 Queens Boulevard 2nd floor	Rego Park	NY	Active
DSH330195BR	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	BACKSTRETCH CLINIC AT BELMONT RACETRACK - Clinic	2150 HEMPSTEAD TURNPIKE COTTAGE 58C	BELMONT	NY	Active
DSH330195BS	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Extension Clinic - Peds Immunology	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195BT	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital - OBS Check & Call - OBS Check & Call	102-01 66th Road	Forest Hills	NY	Active
DSH330195BU	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Perinatal	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BV	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - OCD	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BW	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Early Treatment	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BX	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - Bipolar	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BY	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - On Track	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195BZ	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Zucker Hillside Hospital - College Partnership	75-59 263rd St.	Glen Oaks	NY	Active
DSH330195C	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	SBHC - Franklin K Lane	999 Jamaica Ave	Brooklyn	NY	Active
DSH330195CA	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	ZUCKER HILLSIDE HOSPITAL - Ketamine Infusion Services	75-59 263RD ST	GLEN OAKS	NY	Active
DSH330195CB	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Queens Cancer Center	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195D	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	North Shore - LIJ Medical Group Urgent Care Center	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195E	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	LIJ Center for Advanced Medicine-Recovery Room Ambulatory Surgery	450 Lakeville Rd	Lake Success	NY	Active
DSH330195F	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Far Rockaway HS Clinic SBHC	821 Bay 25th Street	Far Rockaway	NY	Active
DSH330195G	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Brian Picolo MS53 Clinic SBHC	1045 Nameoke Street	Far Rockaway	NY	Active
DSH330195H	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / General Pediatrics	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195J	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Pediatric & Adolescent Medicine Clinic / Adolescent Medicine	410 Lakeville Rd	New Hyde Park	NY	Active
DSH330195K	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Eye Care Center	600 Northern Blvd	Great Neck	NY	Terminated
DSH330195L	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Medical Center LIJ Satellite Dialysis Center	220-22 Hillside Avenue	Queens Village	NY	Active
DSH330195M	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Nuclear Stress	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195N	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Hospital / Diagnostic Cardiology Echo	102-01 66th Road	Forest Hills	NY	Active
DSH330195P	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Outpatient Recovery Room	900 Franklin Ave	Valley Stream	NY	Active
DSH330195Q	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Radiology	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195R	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / HYPERBARIC OXYGEN THERAPY	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195S	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Wound Care	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195T	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Ambulatory Surgery	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195U	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Long Island Jewish Valley Stream / Emergency Department	900 FRANKLIN AVE.	Valley Stream	NY	Active
DSH330195V	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Internal Medicine	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195W	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / General Surgery	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195X	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Cardiology	95-25 Queens Blvd	Rego Park	NY	Terminated
DSH330195Y	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills Rego Park Multi-Specialty Clinic / Wound Care	95-25 Queens Blvd	Rego Park	NY	Active
DSH330195Z	Child	DSH	LONG ISLAND JEWISH MEDICAL CENTER	Forest Hills-Rego Park Multi-Specialty Clinic / Podiatry	95-25 Queens Blvd	Rego Park	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Contacts	Signed By	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/22/2021 12:00:00 AM	10/26/2021 8:31 AM
Details	State	Update	Termination Request	Approved	To Be Terminated	10/26/2021 8:31 AM
Terminations	Termination Comments	Update	Termination Request		This entity was registered in error	10/26/2021 8:31 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	10/26/2021 8:31 AM
Terminations	Termination Effective Date	Update	Termination Request		10/22/2021 12:00:00 AM	10/26/2021 8:31 AM
Terminations	Termination Reason	Update	Termination Request		Other	10/26/2021 8:31 AM
Contacts	Signed By	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	10/6/2021 1:41 PM
Details	340B ID	Update	New Registration		DSH330195AZ	10/6/2021 1:41 PM
Details	Entity Subname	Update	New Registration	Forest Hospital / Women's Health	Forest Hospital / Women's Health - Ultrasound Diagnostic	10/6/2021 1:41 PM
Dates	Participating Approval Date	Update	New Registration		10/6/2021 1:41:03 PM	10/6/2021 1:41 PM
Details	State	Update	New Registration	Pending	Approved	10/6/2021 1:41 PM
Dates	Signed By Date	Update	New Registration		10/6/2021 11:57:05 AM	10/6/2021 1:41 PM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	10/6/2021 1:41 PM
Addresses	Main Address	Insert	New Registration		102-01 66th Road Forest Hills, NY 11375	10/6/2021 11:56 AM
Addresses	Billing Address	Insert	New Registration		Long Island Jewish Medical Center 270-05 76th Ave New Hyde Park, NY 11040	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		'00243903	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		'02998887	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		LON0195N	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		239739105	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		598210	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000182281	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		44432577	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003129401	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		'008051182	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		DE	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		092086000	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		'003273000	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000105729A	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		399622993A	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1316954449	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100446570A	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01500040	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026857C	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		283335200	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		160670000	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		199217100	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1316954449	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00096736	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1316954449	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11224132600	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3104340	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NH	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4157303	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		8844500	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		A8435	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1288387	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0608033	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100689170A	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007620400005	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		'0014836270001	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		OP30195	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10858B	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q034252	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		072485801	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1316954449	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0330195	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		AR	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		DE	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		ID	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		IA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MD	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		ME	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NE	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NH	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NM	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		NV	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		UT	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		VT	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		WA	10/6/2021 11:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285641514	10/6/2021 11:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/6/2021 11:56 AM
Contacts	Primary Contact	Insert	New Registration		Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	10/6/2021 11:56 AM
Contacts	Authorizing Official	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	10/6/2021 11:56 AM
Details	Assistance Received From Date	Insert	New Registration			10/6/2021 11:56 AM
Details	Assistance Received To Date	Insert	New Registration			10/6/2021 11:56 AM
Details	Last Recertification Date	Insert	New Registration			10/6/2021 11:56 AM
Details	Grant Number	Insert	New Registration			10/6/2021 11:56 AM
Details	340B ID	Insert	New Registration			10/6/2021 11:56 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/6/2021 11:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/6/2021 11:56 AM
Details	Medicare Provider Number	Insert	New Registration		330195	10/6/2021 11:56 AM
Details	Entity Name	Insert	New Registration		LONG ISLAND JEWISH MEDICAL CENTER	10/6/2021 11:56 AM
Details	NOFO Number	Insert	New Registration			10/6/2021 11:56 AM
Details	Program Code	Insert	New Registration		DSH	10/6/2021 11:56 AM
Details	Entity Subname	Insert	New Registration		Forest Hospital / Women's Health	10/6/2021 11:56 AM
Dates	Participating Approval Date	Insert	New Registration			10/6/2021 11:56 AM
Details	State	Insert	New Registration		Pending	10/6/2021 11:56 AM
Dates	Registration Date	Insert	New Registration		10/6/2021 11:56:58 AM	10/6/2021 11:56 AM
Dates	Signed By Date	Insert	New Registration			10/6/2021 11:56 AM
Dates	Start Date	Insert	New Registration			10/6/2021 11:56 AM
Terminations	Termination Comments	Insert	New Registration			10/6/2021 11:56 AM
Terminations	Termination Date	Insert	New Registration			10/6/2021 11:56 AM
Terminations	Termination Effective Date	Insert	New Registration			10/6/2021 11:56 AM
Terminations	Termination Reason	Insert	New Registration			10/6/2021 11:56 AM