Covered Entity Details

DSH330160Y STATEN ISLAND UNIVERSITY HOSPITAL (Active) - information as of 6/28/2025 12:26:06 AM

Main Details

Name

STATEN ISLAND UNIVERSITY HOSPITAL

Subdivision Name

Medical Arts Pavilion - Rehab Services

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330160Y

Medicare Provider Number

330160

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/15/2021

Participating Start Date

1/1/2022

Participating Approval Date

11/29/2021

Last Recertification Date

8/19/2024

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

242 Mason Avenue
1st floor
Staten Island, NY 10305

Billing Address

Staten Island University Hospital
475 Seaview Avenue
Staten Island, NY 10305

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	2204082	1407877137
NY	00244202 (NY),05380841 (NY)	1407877137,1144714171

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	LONG ISLAND JEWISH MEDICAL CENTER AT HOM	VIVO HEALTH PHARMACY AT HOME	225 COMMUNITY DR STE 140	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC	DBA: VIVO HEALTH PHARMACY AT CFAM	450 LAKEVILLE RD	LAKE SUCCESS	NY	11042	11/20/2023	01/01/2024	01/01/2024
Contract Detail	TRUE NORTH HEALTH PHARMACY, INC.	DBA: VIVO HEALTH SPECIALTY PHARMACY	225 COMMUNITY DR STE 100	GREAT NECK	NY	11021-5506	11/20/2023	01/01/2024	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330160A	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Emergency Department	375 SEGUINE AVE	STATEN ISLAND	NY	Active
DSH330160AA	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Vascular Lab - Vascular Lab	375 Seguine Avenue	Staten Island	NY	Active
DSH330160AB	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Eye Clinic	242 Mason Avenue	Staten Island	NY	Active
DSH330160AC	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Radiology - Radiology Diagnostic	375 Seguine Avenue	Staten Island	NY	Active
DSH330160AD	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Ambulatory Surgery - Ambulatory Surgery	375 Seguine Avenue	Staten Island	NY	Active
DSH330160AE	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion-Ambulatory Surgery - Ambulatory Surgery	256 Mason Ave	Staten Island	NY	Active
DSH330160AF	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Hearing and Speech	242 Mason Avenue	Staten Island	NY	Active
DSH330160AG	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion-Coumadin Clinic - Clinic	256 Mason Ave	Staten Island	NY	Active
DSH330160AH	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Urology	242 Mason Avenue	Staten Island	NY	Active
DSH330160AJ	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Outpatient First Episode Clinic - Clinic	450 Seaview Avenue	Staten Island	NY	Active
DSH330160AK	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Adolescent	242 Mason Avenue	Staten Island	NY	Active
DSH330160AL	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Interventional Radiology - Radiology Diagnostic	375 Seguine Avenue	Staten Island	NY	Active
DSH330160AM	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Diabetic Treatment - Clinic	242 Mason Avenue	Staten Island	NY	Active
DSH330160AN	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Clinic	242 Mason Avenue	Staten Island	NY	Active
DSH330160AP	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion-Laboratory - Laboratory	256 Mason Ave	Staten Island	NY	Active
DSH330160AQ	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion-Oncology - Cancer Treatment	256 Mason Ave	Staten Island	NY	Terminated
DSH330160AR	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Early Intervention - Physical Therapy	256C Mason Avenue	Staten Island	NY	Active
DSH330160AS	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - VERRAZANO RADIOLOGY - Radiology Diagnostic	256 MASON AVE	STATEN ISLAND	NY	Active
DSH330160AT	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Allergy - Clinic	242 Mason Avenue	Staten Island	NY	Active
DSH330160AU	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Geriatrics - Geriatrics	242 Mason Avenue	Staten Island	NY	Active
DSH330160AV	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Physical Therapy - Physical Therapy	256C Mason Avenue	Staten Island	NY	Active
DSH330160AW	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Pediatrics - Pediatrics	242 Mason Avenue	Staten Island	NY	Active
DSH330160AX	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Orthopedics - Orthopedics	242 Mason Ave	Staten Island	NY	Active
DSH330160AY	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Post Covid Recovery Center - Clinic	500 Seaview Avenue	Staten Island	NY	Terminated
DSH330160AZ	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South - Cardiac Electrophysiology	375 SEGUINE AVENUE	STATEN ISLAND	NY	Active
DSH330160B	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Canarsie Chemical Dependency Treatment Program	567 East 105th Street	Brooklyn	NY	Active
DSH330160BA	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	STATEN ISLAND UNIVERSITY HOSPITAL - Medical Arts Pavilion - Laboratory Services	242 MASON AVENUE	STATEN ISLAND	NY	Active
DSH330160BB	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South - Respiratory Therapy	375 SEGUINE AVENUE	STATEN ISLAND	NY	Active
DSH330160BC	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	STATEN ISLAND UNIVERSITY HOSPITAL - Diabetes Wellness Clinic	440 SEAVIEW AVENUE	STATEN ISLAND	NY	Active
DSH330160C	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Chemical Dependency Treatment Program	111 Water Street	Staten Island	NY	Active
DSH330160D	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Coney Island Multi Service Center	425-427 Coney Island Avenue	Brooklyn	NY	Terminated
DSH330160E	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Psych/Alcohol Treatment Program	450 Seaview Avenue	Staten Island	NY	Active
DSH330160F	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Bay Street Health Center	57 Bay Street	Staten Island	NY	Terminated
DSH330160G	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Staten Island University Hospital - Alcohol Clinic	450 Seaview Avenue	Staten Island	NY	Active
DSH330160H	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Center for Women's Health-OBGYN	440 Seaview Avenue	Staten Island	NY	Active
DSH330160J	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Adolescent	1133 Forest Hill Road	Staten Island	NY	Terminated
DSH330160K	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	School Health Center at New Dorp	465 New Dorp Lane	Staten Island	NY	Active
DSH330160L	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion-Radiology	256 Mason Avenue	Staten Island	NY	Active
DSH330160M	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Port Richmond School Based Clinic - Adolescent Medicine	85 St. Joseph's Avenue	Staten Island	NY	Active
DSH330160P	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	STATEN ISLAND UNIVERSITY HOSPITAL - Burn	500 SEAVIEW AVE	STATEN ISLAND	NY	Active
DSH330160Q	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Diabetic Education	242 Mason Avenue	Staten Island	NY	Active
DSH330160R	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South OP - Sleep Services	375 Seguine Avenue	Staten Island	NY	Active
DSH330160S	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Diabetic Treatment - Clinic	500 Seaview Avenue	Staten Island	NY	Active
DSH330160T	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Outpatient Mental Health Clinic - Mental Health	450 Seaview Avenue	Staten Island	NY	Active
DSH330160U	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	High Risk Antepartum Testing - Clinic	440 Seaview Avenue	Staten Island	NY	Active
DSH330160V	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Female Pelvic Floor - Clinic	440 Seaview Avenue	Staten Island	NY	Active
DSH330160W	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South OP - Chemical Dependency Treatment Program	392 Seguine Avenue	Staten Island	NY	Active
DSH330160X	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Infectious Disease	242 Mason Avenue	Staten Island	NY	Active
DSH330160Y	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	Medical Arts Pavilion - Rehab Services	242 Mason Avenue	Staten Island	NY	Active
DSH330160Z	Child	DSH	STATEN ISLAND UNIVERSITY HOSPITAL	South-Cardiology Services	375 Seguine Avenue	Staten Island	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144714171	10/25/2024 1:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	10/25/2024 1:34 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	05431874 (NY)		9/26/2024 1:59 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04634960 (NY)		9/26/2024 1:59 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04633703 (NY)		9/26/2024 1:59 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1669854832 (NY)		9/26/2024 1:59 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730523549 (NY)		9/26/2024 1:59 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1851807929 (NY)		9/26/2024 1:59 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 1:37:49 PM	8/19/2024 2:02:06 PM	8/19/2024 2:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05431874	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04634960	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04633703	12/14/2023 12:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 12:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669854832	12/14/2023 12:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 12:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730523549	12/14/2023 12:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 12:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851807929	12/14/2023 12:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 12:46 PM
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
Details	Last Recertification Date	Update	Recertification	9/6/2022 3:39:17 PM	8/22/2023 1:37:49 PM	8/22/2023 1:37 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1700480050 (NY)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396755922 (NY)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1912925199 (NY)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1225062193 (NY)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144714171 (NY)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1700480050 (OH)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396755922 (OH)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1912925199 (OH)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1225062193 (OH)		11/7/2022 12:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144714171 (OH)		11/7/2022 12:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00244202 (NY)		11/2/2022 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2022 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00244202 (NY)	11/2/2022 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/2/2022 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05380841 (NY)	11/2/2022 12:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700480050	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396755922	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912925199	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225062193	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144714171	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700480050	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396755922	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912925199	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225062193	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2022 12:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144714171	11/2/2022 12:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	11/2/2022 12:29 PM
Addresses	Main Address	Update	Change Request	242 Mason Avenue Staten Island, NY 10305	242 Mason Avenue 1st floor Staten Island, NY 10305	10/6/2022 2:49 PM
Details	Entity Subname	Update	Change Request	Medical Arts Pavilion - Physical Therapy - Physical Therapy	Medical Arts Pavilion - Rehab Services	10/6/2022 2:49 PM
Contacts	Primary Contact	Update	Recertification	Peana, John Director of Pharmacy Staten Island University Hospital 7182268870	Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	9/6/2022 3:39 PM
Details	Last Recertification Date	Update	Recertification		9/6/2022 3:39:17 PM	9/6/2022 3:39 PM
Contacts	Authorizing Official	Update	Change Request	Ardolic, Brahim Executive Director Staten Island University Hospital 7182269761	Cusack, Michele L SVP & CFO Northwell Health 5163216058	2/22/2022 4:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/21/2022 11:12 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2204082	1/21/2022 11:12 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	1/21/2022 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1407877137	1/21/2022 11:12 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	1/21/2022 11:12 AM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Ardolic, Brahim Executive Director Staten Island University Hospital 7182269761	11/29/2021 6:39 AM
Details	340B ID	Update	New Registration		DSH330160Y	11/29/2021 6:39 AM
Details	Entity Subname	Update	New Registration	Medical Arts Pavilion - Physical Therapy	Medical Arts Pavilion - Physical Therapy - Physical Therapy	11/29/2021 6:39 AM
Dates	Participating Approval Date	Update	New Registration		11/29/2021 6:39:32 AM	11/29/2021 6:39 AM
Details	State	Update	New Registration	Pending	Approved	11/29/2021 6:39 AM
Dates	Signed By Date	Update	New Registration		11/23/2021 2:01:18 PM	11/29/2021 6:39 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/29/2021 6:39 AM
Addresses	Main Address	Insert	New Registration		242 Mason Avenue Staten Island, NY 10305	10/15/2021 12:57 PM
Addresses	Billing Address	Insert	New Registration		Staten Island University Hospital 475 Seaview Avenue Staten Island, NY 10305	10/15/2021 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2021 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00244202	10/15/2021 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/15/2021 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1407877137	10/15/2021 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	10/15/2021 12:57 PM
Contacts	Authorizing Official	Insert	New Registration		Ardolic, Brahim Executive Director Staten Island University Hospital 7182269761	10/15/2021 12:57 PM
Contacts	Primary Contact	Insert	New Registration		Peana, John Director of Pharmacy Staten Island University Hospital 7182268870	10/15/2021 12:57 PM
Details	Assistance Received From Date	Insert	New Registration			10/15/2021 12:57 PM
Details	Assistance Received To Date	Insert	New Registration			10/15/2021 12:57 PM
Details	Last Recertification Date	Insert	New Registration			10/15/2021 12:57 PM
Details	Grant Number	Insert	New Registration			10/15/2021 12:57 PM
Details	340B ID	Insert	New Registration			10/15/2021 12:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/15/2021 12:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/15/2021 12:57 PM
Details	Medicare Provider Number	Insert	New Registration		330160	10/15/2021 12:57 PM
Details	Entity Name	Insert	New Registration		STATEN ISLAND UNIVERSITY HOSPITAL	10/15/2021 12:57 PM
Details	NOFO Number	Insert	New Registration			10/15/2021 12:57 PM
Details	Program Code	Insert	New Registration		DSH	10/15/2021 12:57 PM
Details	Entity Subname	Insert	New Registration		Medical Arts Pavilion - Physical Therapy	10/15/2021 12:57 PM
Dates	Participating Approval Date	Insert	New Registration			10/15/2021 12:57 PM
Details	State	Insert	New Registration		Pending	10/15/2021 12:57 PM
Dates	Registration Date	Insert	New Registration		10/15/2021 12:57:37 PM	10/15/2021 12:57 PM
Dates	Signed By Date	Insert	New Registration			10/15/2021 12:57 PM
Dates	Start Date	Insert	New Registration			10/15/2021 12:57 PM
Terminations	Termination Comments	Insert	New Registration			10/15/2021 12:57 PM
Terminations	Termination Date	Insert	New Registration			10/15/2021 12:57 PM
Terminations	Termination Effective Date	Insert	New Registration			10/15/2021 12:57 PM
Terminations	Termination Reason	Insert	New Registration			10/15/2021 12:57 PM