Covered Entity Details

DSH330119N LENOX HILL HOSPITAL (Active) - information as of 4/25/2025 12:01:58 AM

Main Details

Name

LENOX HILL HOSPITAL

Subdivision Name

Northwell Greenwich Village Hospital - Radiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330119N

Medicare Provider Number

330119

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2022

Participating Start Date

1/24/2022

Participating Approval Date

1/13/2022

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

30 7th Avenue
NEW YORK
NEW YORK, NY 10011

Billing Address

LENOX HEALTH GREENWICH VILLAGE
30 7TH AVENUE
NEW YORK, NY 10011

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	00243421,05218048	1477616571,1013414069
AR	233561105	1477616571
CT	003025475	1477616571
MA	110066805B	1477616571
NJ	4153201	1477616571
AZ		1477616571
CA		1477616571
CO		1477616571
DC		1477616571
FL		1477616571
GA		1477616571
IA		1477616571
IL		1477616571
IN		1477616571
KY		1477616571
MD		1477616571
ME		1477616571
MO		1477616571
MI		1477616571
NC		1477616571
NH		1477616571
OH		1477616571
OK		1477616571
PA		1477616571
RI		1477616571
SC		1477616571
TN		1477616571
VA		1477616571
VT		1477616571
WI		1477616571

Shipping Addresses

Shipping Address 1

LENOX HEALTH GREENWICH VILLAGE
30 7TH AVENUE
NEW YORK, NY 10011

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective 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	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	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	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330119A	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Mental Health Clinic	210 E 64th St	New York	NY	Active
DSH330119B	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hospital - Emergency	30 7th Avenue	New York	NY	Active
DSH330119C	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Plastic Surgery Clinic	210 E 64th St	New York	NY	Active
DSH330119D	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Operating Room	210 E 64th St	New York	NY	Active
DSH330119E	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, and Throat Hospital - Recovery Room	210 E 64th St	New York	NY	Active
DSH330119F	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Radiology	210 E 64th St	New York	NY	Active
DSH330119G	Child	DSH	LENOX HILL HOSPITAL	MANHATTAN EYE, EAR & THROAT HOSPITAL - LASER CENTER	210 EAST 64TH STREET	NEW YORK	NY	Active
DSH330119H	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hospital- Imaging CT Scan	30 7th Avenue	NEW YORK	NY	Active
DSH330119J	Child	DSH	LENOX HILL HOSPITAL	MANHATTAN EYE, EAR & THROAT HOSPITAL - EYE CLINIC	210 EAST 64TH STREET	NEW YORK	NY	Active
DSH330119K	Child	DSH	LENOX HILL HOSPITAL	MANHATTAN EYE, EAR & THROAT HOSPITAL - PRIMARY CARE RTC	210 EAST 64TH STREET	NEW YORK	NY	Active
DSH330119L	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hosptial - Imaging MRI	30 7th Avenue	NEW YORK	NY	Active
DSH330119M	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hospital- Ultrasound	30 7th Avenue	NEW YORK	NY	Active
DSH330119N	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hospital - Radiology	30 7th Avenue	NEW YORK	NY	Active
DSH330119P	Child	DSH	LENOX HILL HOSPITAL	MANHATTAN EYE, EAR & THROAT HOSPITAL - AMBULATORY INFUSION	210 EAST 64TH STREET	NEW YORK	NY	Active
DSH330119Q	Child	DSH	LENOX HILL HOSPITAL	Manhattan Eye, Ear, and Throat Hospital - Laboratory	210 E 64th St	New York	NY	Active
DSH330119R	Child	DSH	LENOX HILL HOSPITAL	Northwell Greenwich Village Hospital - Ambulatory Surgery	30 7th Avenue	NEW YORK	NY	Active
DSH330119S	Child	DSH	LENOX HILL HOSPITAL	Outpatient Center for Mental Health - Mental Health	20 E 64th St	New York	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	200 WEST 13TH STREET NEW YORK NEW YORK, NY 10011	30 7th Avenue NEW YORK NEW YORK, NY 10011	4/11/2025 11:38 AM
Details	Entity Subname	Update	Change Request	LENOX HEALTH GREENWICH VILLAGE - Radiology Diagnostic	Northwell Greenwich Village Hospital - Radiology	4/11/2025 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/1/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		05218048	10/1/2024 2:03 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	10/1/2024 2:03 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013414069	10/1/2024 2:03 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	10/1/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	05431874 (NY)		9/26/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04634960 (NY)		9/26/2024 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	04633703 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1669854832 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730523549 (NY)		9/26/2024 2:03 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1851807929 (NY)		9/26/2024 2:03 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 2:10:16 PM	8/19/2024 4:02:35 PM	8/19/2024 4:02 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	833823 (AZ)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (CA)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1457888398 (CO)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	044380100 (DC)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	906493100 (FL)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003158071A (GA)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (IA)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	131624070001 (IL)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300032608 (IN)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	7100642240 (KY)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	417411900 (MD)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (ME)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (MO)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (MI)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (NC)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	20001744 (NH)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0640622 (OH)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	200108510A (OK)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1019871520001 (PA)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (RI)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	12105B (SC)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1526996 (TN)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (VA)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1022131 (VT)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1477616571 (WI)		8/5/2024 1:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05431874	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04634960	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		04633703	12/14/2023 1:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	12/14/2023 1:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669854832	12/14/2023 1:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730523549	12/14/2023 1:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851807929	12/14/2023 1:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	12/14/2023 1:10 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
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	Last Recertification Date	Update	Recertification	8/31/2022 2:34:52 PM	8/22/2023 2:10:16 PM	8/22/2023 2:10 PM
Details	Last Recertification Date	Update	Recertification		8/31/2022 2:34:52 PM	8/31/2022 2:34 PM
Details	State	Update	OPA Edit	Approved	Active	1/24/2022 12:38 PM
Dates	Start Date	Update	OPA Edit	4/1/2022 12:00:00 AM	1/24/2022 12:00:00 AM	1/24/2022 12:38 PM
Contacts	Signed By	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	1/13/2022 12:19 PM
Details	340B ID	Update	New Registration		DSH330119N	1/13/2022 12:19 PM
Details	Entity Subname	Update	New Registration	LENOX HEALTH GREENWICH VILLAGE	LENOX HEALTH GREENWICH VILLAGE - Radiology Diagnostic	1/13/2022 12:19 PM
Dates	Participating Approval Date	Update	New Registration		1/13/2022 12:19:57 PM	1/13/2022 12:19 PM
Details	State	Update	New Registration	Pending	Approved	1/13/2022 12:19 PM
Dates	Signed By Date	Update	New Registration		1/13/2022 11:49:48 AM	1/13/2022 12:19 PM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	1/13/2022 12:19 PM
Addresses	Main Address	Insert	New Registration		200 WEST 13TH STREET NEW YORK NEW YORK, NY 10011	1/13/2022 11:49 AM
Addresses	Billing Address	Insert	New Registration		LENOX HEALTH GREENWICH VILLAGE 30 7TH AVENUE NEW YORK, NY 10011	1/13/2022 11:49 AM
Addresses	Shipping Address	Insert	New Registration		LENOX HEALTH GREENWICH VILLAGE 30 7TH AVENUE NEW YORK, NY 10011	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00243421	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		233561105	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		833823	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1457888398	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003025475	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		044380100	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		906493100	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003158071A	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		131624070001	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300032608	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7100642240	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110066805B	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		417411900	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		20001744	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NH	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4153201	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0640622	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		200108510A	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1019871520001	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		12105B	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1526996	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1022131	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		AR	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		CO	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		DC	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		IA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		IN	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		MD	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		ME	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		NH	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		TN	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		VT	1/13/2022 11:49 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1477616571	1/13/2022 11:49 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	1/13/2022 11:49 AM
Contacts	Primary Contact	Insert	New Registration		Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	1/13/2022 11:49 AM
Contacts	Authorizing Official	Insert	New Registration		Cusack, Michele L SVP & CFO Northwell Health 5163216058	1/13/2022 11:49 AM
Details	Assistance Received From Date	Insert	New Registration			1/13/2022 11:49 AM
Details	Assistance Received To Date	Insert	New Registration			1/13/2022 11:49 AM
Details	Last Recertification Date	Insert	New Registration			1/13/2022 11:49 AM
Details	Grant Number	Insert	New Registration			1/13/2022 11:49 AM
Details	340B ID	Insert	New Registration			1/13/2022 11:49 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2022 11:49 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2022 11:49 AM
Details	Medicare Provider Number	Insert	New Registration		330119	1/13/2022 11:49 AM
Details	Entity Name	Insert	New Registration		LENOX HILL HOSPITAL	1/13/2022 11:49 AM
Details	NOFO Number	Insert	New Registration			1/13/2022 11:49 AM
Details	Program Code	Insert	New Registration		DSH	1/13/2022 11:49 AM
Details	Entity Subname	Insert	New Registration		LENOX HEALTH GREENWICH VILLAGE	1/13/2022 11:49 AM
Dates	Participating Approval Date	Insert	New Registration			1/13/2022 11:49 AM
Details	State	Insert	New Registration		Pending	1/13/2022 11:49 AM
Dates	Registration Date	Insert	New Registration		1/13/2022 11:49:40 AM	1/13/2022 11:49 AM
Dates	Signed By Date	Insert	New Registration			1/13/2022 11:49 AM
Dates	Start Date	Insert	New Registration			1/13/2022 11:49 AM
Terminations	Termination Comments	Insert	New Registration			1/13/2022 11:49 AM
Terminations	Termination Date	Insert	New Registration			1/13/2022 11:49 AM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2022 11:49 AM
Terminations	Termination Reason	Insert	New Registration			1/13/2022 11:49 AM