Covered Entity Details

DSH220046BJ BERKSHIRE MEDICAL CENTER (Active) - information as of 5/14/2025 10:54:23 PM

Main Details

Name

BERKSHIRE MEDICAL CENTER

Subdivision Name

Adams Internist Clinic - Primary Care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH220046BJ

Medicare Provider Number

220046

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/5/2022

Participating Start Date

7/1/2022

Participating Approval Date

4/29/2022

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Berkshire Medical Center
Scott Adam St. George, Chief Financial Officer
(413) 447-3366

Primary Contact

Berkshire Health Systems
Jonathan Douglas, 340B Manager
(413) 447-3064

Addresses

Street Address

2 Park Street
Adams, MA 01220

Billing Address

Berkshire Health Systems
PO Box 4339
Pittsfield, MA 01202-4339

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
MA	110026434D,110026434H,110026434Q,110026434J,110026434T,1100246434,110026434X,110131709A	1235670316,1295765261,1518173871,1528328861,1538221478,1295121861,1871026351,1659436996,1932649753
NY	00366216,04203536,03533988	1235670316,1295765261,1518173871,1528328861,1538221478,1295121861,1871026351,1659436996,1932649753
CT	003023785	1235670316,1295765261,1518173871,1528328861,1538221478,1295121861,1871026351,1659436996,1932649753
RI	OP20046	1235670316,1295765261,1518173871,1528328861,1538221478,1295121861,1871026351,1659436996,1932649753

Shipping Addresses

Shipping Address 1

Berkshire Medical Center
725 North St
Pittsfield, MA 01201

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
DSH220046A	Child	DSH	BERKSHIRE MEDICAL CENTER	Hillcrest Family Health Clinic	631B North St.	Pittsfield	MA	Active
DSH220046AA	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Ambulatory Surgery	71 Hospital Avenue	North Adams	MA	Terminated
DSH220046AB	Child	DSH	BERKSHIRE MEDICAL CENTER	Endoscopy - Northern Berkshire	71 Hospital Avenue	North Adams	MA	Terminated
DSH220046AC	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Specialty Practices of BMC	71 Hospital Avenue	North Adams	MA	Terminated
DSH220046AD	Child	DSH	BERKSHIRE MEDICAL CENTER	Berkshire Internists of BMC	777 North Street	Pittsfield	MA	Active
DSH220046AE	Child	DSH	BERKSHIRE MEDICAL CENTER	Williamstown Medical of BMC - North Adams	71 Hospital Avenue	North Adams	MA	Terminated
DSH220046AF	Child	DSH	BERKSHIRE MEDICAL CENTER	The Phelps Cancer Center	165 Tor Court	Pittsfield	MA	Active
DSH220046AG	Child	DSH	BERKSHIRE MEDICAL CENTER	Renal Home Training- Central County Dialysis Center	8 Conte Dr	Pittsfield	MA	Active
DSH220046AH	Child	DSH	BERKSHIRE MEDICAL CENTER	BMC Sleep Disorders Center	165 Tor Court	Pittsfield	MA	Active
DSH220046AJ	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Pain Management Clinic	71 Hospital Avenue	North Adams	MA	Active
DSH220046AK	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Endocrinology Clinic	71 Hospital Avenue	North Adams	MA	Active
DSH220046AL	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Renal Clinic	71 Hospital Avenue	North Adams	MA	Active
DSH220046AM	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Renal Dialysis	71 Hospital Avenue	North Adams	MA	Active
DSH220046AP	Child	DSH	BERKSHIRE MEDICAL CENTER	Lenox OB/GYN of Berkshire Medical Center	Lenox Commons	Lenox	MA	Active
DSH220046AQ	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Wound Center	71 Hospital Avenue	North Adams	MA	Terminated
DSH220046AR	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Cardiology Clinic - Cardiology	71 Hospital Ave	North Adams	MA	Active
DSH220046AS	Child	DSH	BERKSHIRE MEDICAL CENTER	Berkshire Osteopathic- Adams - Osteopathic Medicine	2 Park St	Adams	MA	Active
DSH220046AT	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Physiatry Clinic - Physiatry	71 Hospital Ave	North Adams	MA	Active
DSH220046AU	Child	DSH	BERKSHIRE MEDICAL CENTER	WILLIAMSTOWN MEDICAL OF BMC - WMA- Williamstown	197 ADAMS RD	WILLIAMSTOWN	MA	Terminated
DSH220046AV	Child	DSH	BERKSHIRE MEDICAL CENTER	North Adams Urology Clinic - Urology	71 Hospital Ave	North Adams	MA	Active
DSH220046AW	Child	DSH	BERKSHIRE MEDICAL CENTER	South County Renal Clinic - nephrology	10 Maple Ave	Great Barrington	MA	Active
DSH220046AX	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Cancer Center Clinic - Hematology/ Oncology	71 Hospital Ave	North Adams	MA	Active
DSH220046AY	Child	DSH	BERKSHIRE MEDICAL CENTER	Clinical Stabilization Services - CSS	46-48 Kent Ave	Pittsfield	MA	Active
DSH220046AZ	Child	DSH	BERKSHIRE MEDICAL CENTER	Surgical Professional Services - Surgery	777 North St	Pittsfield	MA	Active
DSH220046B	Child	DSH	BERKSHIRE MEDICAL CENTER	Occupational Health Clinic and Travel Clinic	610 North Street	Pittsfield	MA	Terminated
DSH220046BA	Child	DSH	BERKSHIRE MEDICAL CENTER	Occupational Health and Travel Clinic - Lenox - Occupational Health	Lenox Commons, Building 12C	Lenox	MA	Terminated
DSH220046BB	Child	DSH	BERKSHIRE MEDICAL CENTER	Recon & Plastic Surgery Clinic of BMC - Plastic Surgery	Lenox Commons, Building 12C	Lenox	MA	Active
DSH220046BC	Child	DSH	BERKSHIRE MEDICAL CENTER	Radiation Oncology of BMC - Radiology	165 Tor Court	Pittsfield	MA	Active
DSH220046BD	Child	DSH	BERKSHIRE MEDICAL CENTER	Radiology MAC Building - Radiology	777 North Street	Pittsfield	MA	Active
DSH220046BE	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Radiology of BMC - Radiology	71 Hospital Ave	North Adams	MA	Terminated
DSH220046BF	Child	DSH	BERKSHIRE MEDICAL CENTER	Northern Berkshire Gastroenterology Clinic of BMC - Gastroenterology	71 Hospital Ave	North Adams	MA	Active
DSH220046BG	Child	DSH	BERKSHIRE MEDICAL CENTER	BMC OUTPATIENT IMAGING & TESTING - Radiology	610 NORTH STREET	PITTSFIELD	MA	Active
DSH220046BH	Child	DSH	BERKSHIRE MEDICAL CENTER	Woman's Imaging Center of BMC - Radiology	777 North Street	Pittsfield	MA	Active
DSH220046BJ	Child	DSH	BERKSHIRE MEDICAL CENTER	Adams Internist Clinic - Primary Care	2 Park Street	Adams	MA	Active
DSH220046BK	Child	DSH	BERKSHIRE MEDICAL CENTER	North County Infusion Center - Community Infusion	71 Hospital Ave	North Adams	MA	Active
DSH220046BL	Child	DSH	BERKSHIRE MEDICAL CENTER	Rheumatology Clinic - Rheumatology	777 North St	Pittsfield	MA	Active
DSH220046BM	Child	DSH	BERKSHIRE MEDICAL CENTER	Dermatology of BMC - Dermatology	55 Pittsfield Road	Lenox	MA	Active
DSH220046C	Child	DSH	BERKSHIRE MEDICAL CENTER	GYN of the Berkshires - Northern Berkshire	71 Hospital Ave	North Adams	MA	Active
DSH220046D	Child	DSH	BERKSHIRE MEDICAL CENTER	South Berkshire County Dialysis Center	10 Maple Avenue	Great Barrington	MA	Active
DSH220046E	Child	DSH	BERKSHIRE MEDICAL CENTER	Outpatient Infusion Center	165 Tor Court	Pittsfield	MA	Active
DSH220046F	Child	DSH	BERKSHIRE MEDICAL CENTER	HH Family Health Clinic Lenox	Lenox Commons	Lenox	MA	Active
DSH220046G	Child	DSH	BERKSHIRE MEDICAL CENTER	Recon & Plastic Surg Clinic	725 NORTH STREET	PITTSFIELD	MA	Terminated
DSH220046H	Child	DSH	BERKSHIRE MEDICAL CENTER	Crane Center for Ambulatory Surgery	24 Park Street	Pittsfield	MA	Active
DSH220046J	Child	DSH	BERKSHIRE MEDICAL CENTER	Urological Svcs Clinic	41 Wahconah Street	Pittsfield	MA	Active
DSH220046K	Child	DSH	BERKSHIRE MEDICAL CENTER	Wound Center	66 Wahconah Street	Pittsfield	MA	Active
DSH220046L	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Electrocardiology	777 North Street	Pittsfield	MA	Active
DSH220046M	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Cardiology Clinic	777 North Street	Pittsfield	MA	Active
DSH220046N	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Endocrinology Clinic	777 North Street	Pittsfield	MA	Active
DSH220046P	Child	DSH	BERKSHIRE MEDICAL CENTER	BMC Central County Dialysis Center	8 Conte Dr	Pittsfield	MA	Active
DSH220046Q	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Renal Clinic	777 North Street	Pittsfield	MA	Active
DSH220046R	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Neurology Clinic	777 North Street	Pittsfield	MA	Active
DSH220046S	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Neurosurgery Clinic	777 North Street	Pittsfield	MA	Active
DSH220046T	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Physiatry Clinic	777 North Street	Pittsfield	MA	Active
DSH220046U	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Pain Management Clinic	777 North Street	Pittsfield	MA	Active
DSH220046V	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Surgical Svcs Clinic	777 North Street	Pittsfield	MA	Active
DSH220046W	Child	DSH	BERKSHIRE MEDICAL CENTER	MAC Building Gastroenterology	777 North Street	Pittsfield	MA	Active
DSH220046X	Child	DSH	BERKSHIRE MEDICAL CENTER	Pulmonary Professional Services of BMC, Inc.	741 North Street	Pittsfield	MA	Active
DSH220046Y	Child	DSH	BERKSHIRE MEDICAL CENTER	Berkshires of BMC / OB/GYN Services	777 NORTH ST	PITTSFIELD	MA	Active
DSH220046Z	Child	DSH	BERKSHIRE MEDICAL CENTER	BERKSHIRE MEDICAL CENTER / Satellite Emergency Facility of BMC	71 Hospital Ave	North Adams	MA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/7/2023 3:46:58 PM	9/4/2024 6:13:25 PM	9/4/2024 6:13 PM
Details	Last Recertification Date	Update	Recertification	9/11/2022 10:52:55 AM	9/7/2023 3:46:58 PM	9/7/2023 3:46 PM
Contacts	Primary Contact	Update	PC Change Request	Mirante, Erin 340B Program Manager Berkshire Health Systems 4136645324	Douglas, Jonathan 340B Manager Berkshire Health Systems 4134473064	1/19/2023 8:04 AM
Details	Last Recertification Date	Update	Recertification		9/11/2022 10:52:55 AM	9/11/2022 10:52 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		St. George, Scott Adam Chief Financial Officer Berkshire Medical Center 4134473366	4/29/2022 12:13 PM
Details	340B ID	Update	New Registration		DSH220046BJ	4/29/2022 12:13 PM
Details	Entity Subname	Update	New Registration	Adams Internist Clinic	Adams Internist Clinic - Primary Care	4/29/2022 12:13 PM
Dates	Participating Approval Date	Update	New Registration		4/29/2022 12:13:51 PM	4/29/2022 12:13 PM
Details	State	Update	New Registration	Pending	Approved	4/29/2022 12:13 PM
Dates	Signed By Date	Update	New Registration		4/14/2022 10:28:07 AM	4/29/2022 12:13 PM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	4/29/2022 12:13 PM
Addresses	Main Address	Insert	New Registration		2 Park Street Adams, MA 01220	4/5/2022 10:00 AM
Addresses	Billing Address	Insert	New Registration		Berkshire Health Systems PO Box 4339 Pittsfield, MA 01202-4339	4/5/2022 10:00 AM
Addresses	Shipping Address	Insert	New Registration		Berkshire Medical Center 725 North St Pittsfield, MA 01201	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434D	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434H	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434Q	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434J	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434T	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1100246434	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026434X	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110131709A	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00366216	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		04203536	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03533988	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003023785	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		OP20046	4/5/2022 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235670316	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295765261	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1518173871	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528328861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538221478	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295121861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1871026351	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1659436996	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1932649753	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235670316	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295765261	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1518173871	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528328861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538221478	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295121861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1871026351	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1659436996	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1932649753	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235670316	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295765261	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1518173871	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528328861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538221478	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295121861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1871026351	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1659436996	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1932649753	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235670316	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295765261	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1518173871	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1528328861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538221478	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295121861	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1871026351	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1659436996	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1932649753	4/5/2022 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		RI	4/5/2022 10:00 AM
Contacts	Primary Contact	Insert	New Registration		Mirante, Erin 340B Program Manager Berkshire Health Systems 4136645324	4/5/2022 10:00 AM
Contacts	Authorizing Official	Insert	New Registration		St. George, Scott Adam Chief Financial Officer Berkshire Medical Center 4134473366	4/5/2022 10:00 AM
Details	Assistance Received From Date	Insert	New Registration			4/5/2022 10:00 AM
Details	Assistance Received To Date	Insert	New Registration			4/5/2022 10:00 AM
Details	Last Recertification Date	Insert	New Registration			4/5/2022 10:00 AM
Details	Grant Number	Insert	New Registration			4/5/2022 10:00 AM
Details	340B ID	Insert	New Registration			4/5/2022 10:00 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2022 10:00 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2022 10:00 AM
Details	Medicare Provider Number	Insert	New Registration		220046	4/5/2022 10:00 AM
Details	Entity Name	Insert	New Registration		BERKSHIRE MEDICAL CENTER	4/5/2022 10:00 AM
Details	NOFO Number	Insert	New Registration			4/5/2022 10:00 AM
Details	Program Code	Insert	New Registration		DSH	4/5/2022 10:00 AM
Details	Entity Subname	Insert	New Registration		Adams Internist Clinic	4/5/2022 10:00 AM
Dates	Participating Approval Date	Insert	New Registration			4/5/2022 10:00 AM
Details	State	Insert	New Registration		Pending	4/5/2022 10:00 AM
Dates	Registration Date	Insert	New Registration		4/5/2022 10:00:14 AM	4/5/2022 10:00 AM
Dates	Signed By Date	Insert	New Registration			4/5/2022 10:00 AM
Dates	Start Date	Insert	New Registration			4/5/2022 10:00 AM
Terminations	Termination Comments	Insert	New Registration			4/5/2022 10:00 AM
Terminations	Termination Date	Insert	New Registration			4/5/2022 10:00 AM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2022 10:00 AM
Terminations	Termination Reason	Insert	New Registration			4/5/2022 10:00 AM