Covered Entity Details

DSH200008AG MERCY HOSPITAL (Active) - information as of 4/23/2025 10:54:17 PM

Main Details

Name

MERCY HOSPITAL

Subdivision Name

Northern Light Mercy Surgery - Surgery

Type

Disproportionate Share Hospital

Rural

340B ID

DSH200008AG

Medicare Provider Number

200008

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/17/2022

Participating Start Date

4/1/2022

Participating Approval Date

1/27/2022

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Mercy Hospital
David Kennedy, VP of Finance
(207) 879-3363

Primary Contact

Northern Light Health
Amy Gamble, Director - 340B Program
(978) 549-5617

Addresses

Street Address

195 Fore River Parkway
210
Portland, ME 04102

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
ME	101850000	1629078712

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
DSH200008AC	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Lymphedema Care - Lymphedema Care	1364 Congress Street	Portland	ME	Active
DSH200008AD	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Endocrinology and Diabetes Care - Endocrinology and Diabetes Care	195 Fore River Parkway	Portland	ME	Active
DSH200008AE	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Gastroenterology - Gastroenterology	155 Fore River Parkway	Portland	ME	Active
DSH200008AF	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Breast Care - Breast Clinic	195 Fore River Parkway	Portland	ME	Active
DSH200008AG	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Surgery - Surgery	195 Fore River Parkway	Portland	ME	Active
DSH200008AH	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Cardiovascular Care - Cardiovascular	195 Fore River Parkway	Portland	ME	Active
DSH200008AJ	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Women's Health - OB-GYN	195 Fore River Parkway	Portland	ME	Active
DSH200008AK	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Ear, Nose, and Throat Care - Ear, Nose, and Throat Care	195 Fore River Parkway	Portland	ME	Active
DSH200008AL	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Cancer Care - Oncology	195 Fore River Parkway	Portland	ME	Active
DSH200008AM	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Pain Center - Pain Center	195 Fore River Parkway	Portland	ME	Active
DSH200008AN	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Primary Care, South Portland - Primary Care	225 Gorham Road	South Portland	ME	Active
DSH200008AP	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Primary Care, Yarmouth - Primary Care	385 Route One	Yarmouth	ME	Active
DSH200008AQ	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Primary Care, Windham	409 Roosevelt Trail	Windham	ME	Active
DSH200008AR	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Internal Medicine - Internal Medicine	43 Baxter Boulevard	Portland	ME	Active
DSH200008AS	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Midwives - OB-GYN	195 Fore River Parkway	Portland	ME	Active
DSH200008AT	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Primary Care, Gorham - Primary Care	19 South Gorham Crossing Road	Gorham	ME	Active
DSH200008AU	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Primary Care, Falmouth - Primary Care	75 Gray Road	Falmouth	ME	Active
DSH200008AV	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Pediatrics - Pediatrics	195 Fore River Pwky.	Portland	ME	Active
DSH200008AW	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Spine Surgery - Spine Surgery	195 Fore River Pkwy.	Portland	ME	Active
DSH200008AX	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Orthopedics and Sports Medicine - Ortho	20 Northbrook Drive	Falmouth	ME	Approved
DSH200008AY	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Wound Care - Wound Care	155 Fore River Parkway	Portland	ME	Approved
DSH200008AZ	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Outpatient Surgical Center, Anesthesia - Surgical Center, Anesthesia	155 Fore River Parkway	Portland	ME	Approved
DSH200008B	Child	DSH	MERCY HOSPITAL	Infusion Center	195 Fore River Pkwy	Portland	ME	Active
DSH200008BA	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Outpatient Surgical Center, Recovery Room - Surgical Center, Recovery	155 Fore River Parkway	Portland	ME	Approved
DSH200008BB	Child	DSH	MERCY HOSPITAL	Northern Light Mercy CT Scan - CT Scan	195 Fore River Parkway	Portland	ME	Approved
DSH200008BC	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Outpatient Surgical Center - Surgical Center	155 Fore River Parkway	Portland	ME	Approved
DSH200008BD	Child	DSH	MERCY HOSPITAL	Northern Light Mercy MRI Mobile Unit - MRI	195 Fore River Parkway	Portland	ME	Approved
DSH200008BE	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Walk In Care, Gorham - Walk In Care	19 South Gorham Crossing Road	Gorham	ME	Approved
DSH200008BF	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Endoscopy - Endoscopy	155 Fore River Parkway	Portland	ME	Approved
DSH200008BG	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Walk In Care, Windham - Walk In Care	409 Roosevelt Trail	Windham	ME	Approved
DSH200008BH	Child	DSH	MERCY HOSPITAL	Northern Light Mercy Mammography - Mammography	195 Fore River Parkway	Portland	ME	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Change Request	010211534 (ME)		4/14/2025 6:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/14/2025 6:19 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		101850000	4/14/2025 6:19 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	4/14/2025 6:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Gamble, Amy Director of Pharmacy Northern Light Mercy Hospital 2075536780	Gamble, Amy Director - 340B Program Northern Light Health 9785495617	3/18/2025 9:53 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 2:15:29 PM	8/29/2024 1:32:57 PM	8/29/2024 1:32 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 10:08:05 AM	8/31/2023 2:15:29 PM	8/31/2023 2:15 PM
Contacts	Primary Contact	Update	Change Request	Rossi, Jennifer J System Director of 340B Northern Light Health 2079738240	Gamble, Amy Director of Pharmacy Northern Light Mercy Hospital 2075536780	3/23/2023 3:38 PM
Details	Last Recertification Date	Update	Recertification		8/26/2022 10:08:05 AM	8/26/2022 10:08 AM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Kennedy, David VP of Finance Mercy Hospital 2078793363	1/27/2022 12:26 PM
Details	340B ID	Update	New Registration		DSH200008AG	1/27/2022 12:26 PM
Details	Entity Subname	Update	New Registration	Northern Light Mercy Surgery	Northern Light Mercy Surgery - Surgery	1/27/2022 12:26 PM
Dates	Participating Approval Date	Update	New Registration		1/27/2022 12:26:36 PM	1/27/2022 12:26 PM
Details	State	Update	New Registration	Pending	Approved	1/27/2022 12:26 PM
Dates	Signed By Date	Update	New Registration		1/18/2022 7:42:47 AM	1/27/2022 12:26 PM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	1/27/2022 12:26 PM
Addresses	Main Address	Insert	New Registration		195 Fore River Parkway 210 Portland, ME 04102	1/17/2022 1:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/17/2022 1:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010211534	1/17/2022 1:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	1/17/2022 1:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629078712	1/17/2022 1:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	1/17/2022 1:56 PM
Contacts	Primary Contact	Insert	New Registration		Rossi, Jennifer J System Director of 340B Northern Light Health 2079738240	1/17/2022 1:56 PM
Contacts	Authorizing Official	Insert	New Registration		Kennedy, David VP of Finance Mercy Hospital 2078793363	1/17/2022 1:56 PM
Details	Assistance Received From Date	Insert	New Registration			1/17/2022 1:56 PM
Details	Assistance Received To Date	Insert	New Registration			1/17/2022 1:56 PM
Details	Last Recertification Date	Insert	New Registration			1/17/2022 1:56 PM
Details	Grant Number	Insert	New Registration			1/17/2022 1:56 PM
Details	340B ID	Insert	New Registration			1/17/2022 1:56 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/17/2022 1:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/17/2022 1:56 PM
Details	Medicare Provider Number	Insert	New Registration		200008	1/17/2022 1:56 PM
Details	Entity Name	Insert	New Registration		MERCY HOSPITAL	1/17/2022 1:56 PM
Details	NOFO Number	Insert	New Registration			1/17/2022 1:56 PM
Details	Program Code	Insert	New Registration		DSH	1/17/2022 1:56 PM
Details	Entity Subname	Insert	New Registration		Northern Light Mercy Surgery	1/17/2022 1:56 PM
Dates	Participating Approval Date	Insert	New Registration			1/17/2022 1:56 PM
Details	State	Insert	New Registration		Pending	1/17/2022 1:56 PM
Dates	Registration Date	Insert	New Registration		1/17/2022 1:56:54 PM	1/17/2022 1:56 PM
Dates	Signed By Date	Insert	New Registration			1/17/2022 1:56 PM
Dates	Start Date	Insert	New Registration			1/17/2022 1:56 PM
Terminations	Termination Comments	Insert	New Registration			1/17/2022 1:56 PM
Terminations	Termination Date	Insert	New Registration			1/17/2022 1:56 PM
Terminations	Termination Effective Date	Insert	New Registration			1/17/2022 1:56 PM
Terminations	Termination Reason	Insert	New Registration			1/17/2022 1:56 PM