Covered Entity Details

DSH210038K MARYLAND GENERAL HOSPITAL (Active) - information as of 5/23/2025 12:20:13 AM

Main Details

Name

MARYLAND GENERAL HOSPITAL

Subdivision Name

Vascular Center - Vascular

Type

Disproportionate Share Hospital

Rural

340B ID

DSH210038K

Medicare Provider Number

210038

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/12/2022

Participating Start Date

4/1/2022

Participating Approval Date

1/20/2022

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

University of Maryland Medical Center
Joseph Dicubellis, Senior Director of Pharmacy
(410) 328-6746

Primary Contact

UMMC Midtown Campus
Ifeanyi Egbunike, Director of Pharmacy
(410) 225-8009

Addresses

Street Address

821 N. Eutaw Street
Suite 214
Baltimore, MD 21201

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

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

State	Medicaid Number	NPI Number
MD	000085000	1669565180

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
DSH210038A	Child	DSH	MARYLAND GENERAL HOSPITAL	MTC INFECTIOUS DISEASE PRACTICE	800 Linden Avenue	BALTIMORE	MD	Active
DSH210038B	Child	DSH	MARYLAND GENERAL HOSPITAL	CARRUTHERS PSYCH	827 Linden Ave	BALTIMORE	MD	Active
DSH210038C	Child	DSH	MARYLAND GENERAL HOSPITAL	MTC PEDS OP CLINIC	827 Linden Ave	BALTIMORE	MD	Active
DSH210038D	Child	DSH	MARYLAND GENERAL HOSPITAL	MTC OP MENTAL HEALTH CLINIC	821 N EUTAW ST	BALTIMORE	MD	Terminated
DSH210038E	Child	DSH	MARYLAND GENERAL HOSPITAL	MTC JACQUES CLINIC	821 N EUTAW ST	BALTIMORE	MD	Terminated
DSH210038F	Child	DSH	MARYLAND GENERAL HOSPITAL	MTC EYE CLINIC	300 ARMORY PL	BALTIMORE	MD	Terminated
DSH210038G	Child	DSH	MARYLAND GENERAL HOSPITAL	Family Health Center	821 North Eutaw Street	BALTIMORE	MD	Active
DSH210038H	Child	DSH	MARYLAND GENERAL HOSPITAL	UMCDE CLINIC - Diabetes	800 Linden Avenue	Baltimore	MD	Active
DSH210038J	Child	DSH	MARYLAND GENERAL HOSPITAL	Friedenwald Eye Institute - Ophthalmology	800 Linden Ave	Baltimore	MD	Active
DSH210038K	Child	DSH	MARYLAND GENERAL HOSPITAL	Vascular Center - Vascular	821 N. Eutaw Street	Baltimore	MD	Active
DSH210038L	Child	DSH	MARYLAND GENERAL HOSPITAL	Sleep Center - Sleep Center	800 Linden Avenue	Baltimore	MD	Terminated
DSH210038M	Child	DSH	MARYLAND GENERAL HOSPITAL	Midtown Heart Clinic - Cardiology	800 Linden Ave	Baltimore	MD	Terminated
DSH210038N	Child	DSH	MARYLAND GENERAL HOSPITAL	Center for Addiction Medicine - Addiction Medicine	827 Linden Ave	Baltimore	MD	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:41:49 AM	8/20/2024 10:34:01 AM	8/20/2024 10:34 AM
Contacts	Authorizing Official	Update	AO Change Request	Fleischmann, Craig Vice President of Finance University of Maryland Medical System 4103281092	Dicubellis, Joseph Senior Director of Pharmacy University of Maryland Medical Center 4103286746	8/18/2023 6:20 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 9:10:42 AM	8/16/2023 11:41:49 AM	8/16/2023 11:41 AM
Details	Last Recertification Date	Update	Recertification		9/9/2022 9:10:42 AM	9/9/2022 9:10 AM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Fleischmann, Craig Vice President of Finance University of Maryland Medical System 4103281092	1/20/2022 9:02 AM
Details	340B ID	Update	New Registration		DSH210038K	1/20/2022 9:02 AM
Details	Entity Subname	Update	New Registration	Vascular Center	Vascular Center - Vascular	1/20/2022 9:02 AM
Dates	Participating Approval Date	Update	New Registration		1/20/2022 9:02:55 AM	1/20/2022 9:02 AM
Details	State	Update	New Registration	Pending	Approved	1/20/2022 9:02 AM
Dates	Signed By Date	Update	New Registration		1/12/2022 2:26:31 PM	1/20/2022 9:02 AM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	1/20/2022 9:02 AM
Addresses	Main Address	Insert	New Registration		821 N. Eutaw Street Suite 214 Baltimore, MD 21201	1/12/2022 2:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/12/2022 2:26 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000085000	1/12/2022 2:26 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	1/12/2022 2:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1669565180	1/12/2022 2:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	1/12/2022 2:26 PM
Contacts	Primary Contact	Insert	New Registration		Egbunike, Ifeanyi Director of Pharmacy UMMC Midtown Campus 4102258009	1/12/2022 2:26 PM
Contacts	Authorizing Official	Insert	New Registration		Fleischmann, Craig Vice President of Finance University of Maryland Medical System 4103281092	1/12/2022 2:26 PM
Details	Assistance Received From Date	Insert	New Registration			1/12/2022 2:26 PM
Details	Assistance Received To Date	Insert	New Registration			1/12/2022 2:26 PM
Details	Last Recertification Date	Insert	New Registration			1/12/2022 2:26 PM
Details	Grant Number	Insert	New Registration			1/12/2022 2:26 PM
Details	340B ID	Insert	New Registration			1/12/2022 2:26 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2022 2:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2022 2:26 PM
Details	Medicare Provider Number	Insert	New Registration		210038	1/12/2022 2:26 PM
Details	Entity Name	Insert	New Registration		MARYLAND GENERAL HOSPITAL	1/12/2022 2:26 PM
Details	NOFO Number	Insert	New Registration			1/12/2022 2:26 PM
Details	Program Code	Insert	New Registration		DSH	1/12/2022 2:26 PM
Details	Entity Subname	Insert	New Registration		Vascular Center	1/12/2022 2:26 PM
Dates	Participating Approval Date	Insert	New Registration			1/12/2022 2:26 PM
Details	State	Insert	New Registration		Pending	1/12/2022 2:26 PM
Dates	Registration Date	Insert	New Registration		1/12/2022 2:26:28 PM	1/12/2022 2:26 PM
Dates	Signed By Date	Insert	New Registration			1/12/2022 2:26 PM
Dates	Start Date	Insert	New Registration			1/12/2022 2:26 PM
Terminations	Termination Comments	Insert	New Registration			1/12/2022 2:26 PM
Terminations	Termination Date	Insert	New Registration			1/12/2022 2:26 PM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2022 2:26 PM
Terminations	Termination Reason	Insert	New Registration			1/12/2022 2:26 PM