Covered Entity Details

DSH500008EN UNIVERSITY OF WASHINGTON MEDICAL CENTER (Terminated) - information as of 5/6/2025 12:03:58 AM

Main Details

Name

UNIVERSITY OF WASHINGTON MEDICAL CENTER

Subdivision Name

U NW - Radiation Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500008EN

Medicare Provider Number

500008

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/5/2022

Participating Start Date

7/1/2022

Participating Approval Date

5/13/2022

Last Recertification Date

8/28/2023

Termination Date
Termination Reason

4/1/2024
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

UW Medicine
Jacqueline L Cabe, Chief Financial Officer
(206) 616-9886

Primary Contact

UW Medicine
Sumona Patel, Pharmacy Audit and Compliance Manager
(206) 598-6936

Addresses

Street Address

1570 N. 115th St.
Seattle, WA 98133

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
AK		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
AZ		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
CA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
CO		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
CT		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
HI		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
ID		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
IL		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
IN		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
IA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
KY		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
LA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
ME		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MD		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MI		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MN		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MT		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
NH		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
NM		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
NV		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
NY		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
OH		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
OK		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
OR		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
PA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
SC		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
SD		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
TN		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
VT		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
VA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
WA		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
AL		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
AR		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
FL		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
GA		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
MO		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
NJ		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
NC		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
TX		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
UT		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
WI		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
WY		1013950336,1144641986,1326002049,1457904625,1548635683,1760891907,1679266241,1104513811
DE		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
KS		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
MS		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
NE		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
ND		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
RI		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811
WV		1013950336,1326002049,1144641986,1457904625,1760891907,1548635683,1679266241,1104513811

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
DSH500008A	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ROOSEVELT	4245 ROOSEVELT	SEATTLE	WA	Terminated
DSH500008AA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Radiology - Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008AB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OR Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008AC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Exercise Trng Ctr - Roosv	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008AD	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC Audiology	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / Stadium Clinic - PT	3800 MONTLAKE BLVD	SEATTLE	WA	Active
DSH500008AF	Child	DSH	UNIVERSITY OF WASHINGTON MED CTR	UNIVERSITY OF WASHINGTON / ESC Vascular Lab	3100 NORTHUP WAY	BELLEVUE	WA	Terminated
DSH500008AG	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC Physical Therapy	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AH	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ESC Imaging	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AJ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC GI Endoscopy	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AK	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC Echo Lab	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AL	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / Clinic Nutrition-Dietary	4245 ROOSEVELT WAY NE	SEATTLE	WA	Active
DSH500008AM	Child	DSH	UNIVERSITY OF WASHINGTON MED CTR	UWMC Hec Ed Pavilion / ER Med Svc	3870 Montlake Blvd NE	Seattle	WA	Terminated
DSH500008AN	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC Clinical Lab	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AP	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON / ESC Clinic Admin Drugs	3100 NORTHUP WAY	BELLEVUE	WA	Active
DSH500008AQ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Headache Clinic	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008AR	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON MEDICAL CENTER - UWMC Eastside Specialty Center Hospital Based INJECTION	3100 Northup Way	Bellevue	WA	Active
DSH500008AS	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	University of Washington Med Ctr - Computer Tomography ESC	3100 Northup Way	Bellevue	WA	Active
DSH500008AT	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	University of Washington Med Ctr - Ultrasound ESC	3100 Northup Way	Bellevue	WA	Active
DSH500008AU	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	University of Washington Med Ctr - MRI ESC	3100 Northup Way	Bellevue	WA	Active
DSH500008AV	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ANESTHESIOLOGY - INTERNAL MED CONSULT CLINIC	1550 N 115th St.	Seattle	WA	Active
DSH500008AW	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB IMMUNOLOGY U	1550 N 115th St.	Seattle	WA	Active
DSH500008AX	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RESPIRATORY THERAPY - REFERENCE LAB	1550 N 115th St.	Seattle	WA	Terminated
DSH500008AY	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	McMURRAY CV IMAGING CTR - NUCLEAR CARDIOLOGY U NW	1536 N 115th St	Seattle	WA	Active
DSH500008AZ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - LAB PHLEBOTOMY	1550 N 115th St.	Seattle	WA	Terminated
DSH500008B	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UNIVERSITY OF WASHINGTON - MS CLINIC AT NORTHWEST	1536 NORTH 115TH STREET	SEATTLE	WA	Active
DSH500008BA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	BLOOD STORING, PROCESSING - LAB BLOOD PRODUCTS	1550 N 115th St.	Seattle	WA	Terminated
DSH500008BB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - RADIOLOGY DIAGNOSIS	3800 Montlake Blvd NE	Seattle	WA	Active
DSH500008BC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RECOVERY ROOM - POST ANESTHESIA CARE U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BD	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	BLOOD STORING, PROCESSING - TRANSFUSION SERVICES U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - VASCULAR LAB U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BF	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB-MICROBIOLGY	1550 N 115th St.	Seattle	WA	Active
DSH500008BG	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - RADIOLOGY	1550 N 115th St.	Seattle	WA	Terminated
DSH500008BH	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PSYCHIATRY - MRI N	1550 N 115th St	Seattle	WA	Terminated
DSH500008BJ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - RADIOLOGY OPMC	10330 Meridian Ave N	Seattle	WA	Active
DSH500008BK	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RESPIRATORY THERAPY - RESPIRATORY CARE N	1550 N 115th St	Seattle	WA	Terminated
DSH500008BL	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PHYSICAL THERAPY - PHYSICAL THERAPY N	1550 N 115th St	Seattle	WA	Terminated
DSH500008BM	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Operating Room U NW - U NW OR	1550 N 115th St.	Seattle	WA	Terminated
DSH500008BN	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OP SURGERY OPMC U NW - UNW OP SURGERY CTR	1550 N 115th St.	Seattle	WA	Active
DSH500008BP	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROENCEPHALOGRAPHY - EEG U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BQ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	STRESS TEST - OP CARDIAC REHAB U NW	1536 N 115th St.	Seattle	WA	Active
DSH500008BR	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - PATHOLOGY SATELLITE	1550 N 115th St.	Seattle	WA	Active
DSH500008BS	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB HEMATOLOGY U NW	1550 N 115th St.	Seattle	WA	Terminated
DSH500008BT	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - LAB POINT OF CARE U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BU	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PHYSICAL THERAPY - LUNG FUNCTION U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008BV	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	WOUND CARE CENTER - WOUND CARE CENTER U NW	1560 N 115th Street	Seattle	WA	Active
DSH500008BW	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB GENETICS U	1550 N 115th St.	Seattle	WA	Active
DSH500008BX	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	EMERGENCY - EMERGENCY DEPT PHYSICIANS N	1550 N 115th St	Seattle	WA	Terminated
DSH500008BY	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PSYCHIATRY - VASCULAR CTR PROCEDURES N	1560 N 115th St	Seattle	WA	Terminated
DSH500008BZ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB VIROLOGY U	1550 N 115th St.	Seattle	WA	Active
DSH500008C	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Psychiatry Clinic Rsvlt	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008CA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - ESC VASCULAR LAB	3100 Northup Way	Bellevue	WA	Active
DSH500008CB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OPERATING ROOM - INTERVENT RADIOLOGY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	GEOPSYCH OP SERVICES - OP GEROPSYCH U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CD	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - PURCHASE LAB TESTNG	1550 N 115th St.	Seattle	WA	Active
DSH500008CE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROCARDIOLOGY - CARDIOLOGY EPS LAB U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CF	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB-HEMATOLOGY	1550 N 115th St.	Seattle	WA	Active
DSH500008CG	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	EMERGENCY - EMERGENCY DEPT N	1550 N 115th St	Seattle	WA	Terminated
DSH500008CH	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	COMPUTED TOMOGRAPHY (CT) SCAN - COMPUTED TOMOGRAPHY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CJ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB MICROBIO U NW	1550 N 115th St.	Seattle	WA	Terminated
DSH500008CK	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RECOVERY ROOM - OP INFUSION SVCS U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CL	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLINICAL LAB SEND OUTS	1550 N 115th St.	Seattle	WA	Active
DSH500008CM	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - SLU LABORATORY	750 Republican St.	Seattle	WA	Active
DSH500008CN	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - ANTI COAG CLINIC U NW	10330 Meridian Ave N	Seattle	WA	Active
DSH500008CP	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	CARDIAC CATHETERIZATION - SEATTLE BREAST CENTER	1560 N 115th Street	Seattle	WA	Terminated
DSH500008CQ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RECOVERY ROOM - POST ANESTHESIA CARE UNIT	1550 N 115th St.	Seattle	WA	Terminated
DSH500008CR	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB COAGULATION U	1550 N 115th St.	Seattle	WA	Active
DSH500008CS	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROCARDIOLOGY - ECG	10330 Meridian Ave N.	Seattle	WA	Terminated
DSH500008CT	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - ULTRASOUND N	1550 N 115th St.	Seattle	WA	Terminated
DSH500008CU	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	REHABILITATION - RHEUMATOLOGY U	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008CV	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	CHDD Specialty Clinics	1701 NE Columbia Rd.	Seattle	WA	Active
DSH500008CW	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	CARDIOLOGY - ECHO LAB SLU	750 Republican St.	Seattle	WA	Active
DSH500008CX	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ANESTHESIOLOGY - ANESTHESIOLOGY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CY	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RECOVERY ROOM - CARDIAC PROCEDURE UNIT U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008CZ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - PHLEBOTOMY SVCS U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008D	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Internal Medicine Clinic at UWMC-Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008DA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROCARDIOLOGY - ECHOCARDIOGRAPHY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	BREAST CENTER - SEA BREAST CTR MOB U NW	1560 N. 115th	Seattle	WA	Active
DSH500008DC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOISOTOPE - NUCLEAR MEDICINE U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DD	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ANESTHESIOLOGY - ANESTHESIOLOGY N	1550 N 115th St.	Seattle	WA	Terminated
DSH500008DE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PHYSICAL THERAPY - GEROPSYCH OP	1550 N 115th St	Seattle	WA	Terminated
DSH500008DF	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	INTRAVENOUS THERAPY - VASCULAR ACCESS RN U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DG	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OCCUPATIONAL THERAPY - REHAB-OCCUP THERAPY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DH	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	NW Therapies OPMC	10330 Meridian Ave N	Seattle	WA	Active
DSH500008DJ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - LAB SEND OUTS	1550 N 115th St.	Seattle	WA	Terminated
DSH500008DK	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ENDOSCOPY - ENDOSCOPY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DL	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OPERATING ROOM - INFUSION	1550 N 115th St.	Seattle	WA	Terminated
DSH500008DM	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB STEROIDS U	1550 N 115th St.	Seattle	WA	Active
DSH500008DN	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - PATHOLOGY CONSULTS	1550 N 115th St.	Seattle	WA	Terminated
DSH500008DP	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - DEV LAB ANTIBIOTICS U	1550 N 115th St.	Seattle	WA	Active
DSH500008DQ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	SPEECH PATHOLOGY - SPEECH LANG SVCS	1550 N 115th St	Seattle	WA	Terminated
DSH500008DR	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - ULTRASOUND U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DS	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - OP VASCULAR IMAGING U NW	1560 N 115th Street	Seattle	WA	Active
DSH500008DT	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROCARDIOLOGY - CARDIOLOGY HEART CATH U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DU	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB CHEMISTRY	1550 N 115th St.	Seattle	WA	Terminated
DSH500008DV	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	LABORATORY - CLIN LAB CHEMISTRY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DW	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROCARDIOLOGY - CARDIOLOGY-ECG U NW	10330 Meridian Ave N.	Seattle	WA	Active
DSH500008DX	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - RADIOLOGY U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008DY	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - RADIOLOGY OPMC U NW	10330 Meridian Ave N,	Seattle	WA	Terminated
DSH500008DZ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	MAGNETIC RESONANCE IMAGING (MRI) - MRI U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008E	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Virology Clinic at UWMC-Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Terminated
DSH500008EA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OPERATING ROOM - VASCULAR CTR PROC U NW	1560 N 115th Street	Seattle	WA	Active
DSH500008EB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RESPIRATORY THERAPY - RESPIRATORY CARE U NW	1550 N 115th St	Seattle	WA	Active
DSH500008EC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	EMERGENCY - EMERGENCY DEPT U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008ED	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	PHYSICAL THERAPY - REHAB-PHYSICAL THER U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008EE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	COMPUTED TOMOGRAPHY (CT) SCAN - NUCLEAR MEDICINE N	1550 N 115th St	Seattle	WA	Terminated
DSH500008EF	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	SPEECH PATHOLOGY - REHAB-SPEECH PATH U NW	1550 N 115th St.	Seattle	WA	Active
DSH500008EG	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RESPIRATORY THERAPY - HYPERBARIC OXYGEN U NW	1560 N 115th St	Seattle	WA	Active
DSH500008EH	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	IMPLANTABLE DEVICES CHARGED TO PATIENTS - OPERATING ROOM N	1550 N 115th St.	Seattle	WA	Terminated
DSH500008EJ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - ECHOCARDIOGRAPHY	1550 N 115th St	Seattle	WA	Terminated
DSH500008EK	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	ELECTROENCEPHALOGRAPHY - EEG N	1550 N 115th St.	Seattle	WA	Terminated
DSH500008EL	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RADIOLOGY - DIAGNOSTIC - ULTRASOUND DIAGNOSIS	3800 Montlake Blvd NE	Seattle	WA	Active
DSH500008EM	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OCCUPATIONAL THERAPY - OCCUPATIONAL THERAPY	1550 N 115th St	Seattle	WA	Terminated
DSH500008EN	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	U NW - Radiation Oncology	1570 N. 115th St.	Seattle	WA	Terminated
DSH500008EP	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - NW - Gastroenterology U NW	1536 N 115th St.	Seattle	WA	Active
DSH500008EQ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - KIDNEY DIALYSIS	1550 N 115th St	Seattle	WA	Active
DSH500008ER	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - ULTRASOUND OPMC	10330 Meridian Ave N	Seattle	WA	Active
DSH500008ES	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - Mammography ESC	3100 Northup Way	Bellevue	WA	Active
DSH500008ET	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - ENDOCRINOLOGY U	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008EU	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - CVD19 VACCINE DIST UNW	1550 N 115th St	Seattle	WA	Terminated
DSH500008EV	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - COVID19 SPEC COLLECTION U	1530 N 115TH ST	Seattle	WA	Terminated
DSH500008EW	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC - NW - NW IP Prosthetics & Orthotics	1550 N 115th St	Seattle	WA	Active
DSH500008EX	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	University of Washington - UWMC SLU Heart Institute	750 Republican St.	Seattle	WA	Active
DSH500008EY	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	NW ARTHRITIS CLINIC - NW ARTHRITIS CLINIC	10330 Meridian Ave N.	Seattle	WA	Active
DSH500008EZ	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UROLOGY MCMURRAY U NW - UROLOGY MCMURRAY U NW	1536 N 115th St.	Seattle	WA	Active
DSH500008F	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Dermatologic Surgery Center at UWMC-Roosevelt	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008FA	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	NW GYN and GYN ONC - NW GYN and GYN ONC	1560 N. 115th St.	Seattle	WA	Active
DSH500008FB	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Computed Tomography OPMC - UNW CT OPMC	10330 Meridian Ave N.	Seattle	WA	Active
DSH500008FC	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	OP SURGERY OPMC U NW - UWMC NW OSC OR	10330 Meridian Ave N	Seattle	WA	Active
DSH500008FD	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	CARDIOLOGY-ECG U NW - UNW ECG	1550 N 115th St.	Seattle	WA	Active
DSH500008FE	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC NW CBHL Geropsychiatry - U NW 6D W	1550 N 115th St.	Seattle	WA	Active
DSH500008FF	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	U NW CBHL NEUROMODULATION - U NW NEUROMOD	1550 N 115th St.	Seattle	WA	Active
DSH500008G	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Dermatology Clinic at UWMC-Roosevelt	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008H	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Pain Service - Roosevelt	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008J	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Women's Health Care Center at UWMC-Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008K	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	UWMC Reproductive Care	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008L	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Pediatric Care Center at UWMC-Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008M	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Diabetes Care Center	750 REPUBLICAN ST	Seattle	WA	Active
DSH500008N	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Bone & Joint Surgery Center at UWMC	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008P	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Sports and Spine Clinic	4245 Roosevelt Way NE	Seattle	WA	Terminated
DSH500008Q	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	MLT Heart Institute	24360 Van Ry Boulevard	Mountlake Terrace	WA	Active
DSH500008R	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	RHC Alderwood Echo	24360 Van Ry Boulevard	Mountlake Terrace	WA	Active
DSH500008S	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Stadium Sports Medicine Center	3800 Montlake Blvd	Seattle	WA	Active
DSH500008T	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Weight Loss Center	4225 Roosevelt Way NE	Seattle	WA	Active
DSH500008U	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Men's Health Center	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008W	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	CT Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008X	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Magneic Res. Imaging	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008Y	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Ultrasound Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active
DSH500008Z	Child	DSH	UNIVERSITY OF WASHINGTON MEDICAL CENTER	Mammography - Roosevelt	4245 Roosevelt Way NE	Seattle	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/31/2024 12:00:00 AM	1/4/2024 1:29 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/4/2024 1:29 PM
Terminations	Termination Date	Update	Termination Request		4/1/2024 12:00:00 AM	1/4/2024 1:29 PM
Terminations	Termination Effective Date	Update	Termination Request		2/1/2024 12:00:00 AM	1/4/2024 1:29 PM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	1/4/2024 1:29 PM
Details	Last Recertification Date	Update	Recertification	9/15/2022 6:48:19 PM	8/28/2023 6:48:25 PM	8/28/2023 6:48 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		DE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NE	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ND	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		RI	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1013950336	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1326002049	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144641986	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1457904625	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1760891907	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548635683	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	8/14/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	8/14/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AZ	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AK	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CT	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		HI	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ID	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		LA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		ME	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MD	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MT	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NH	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NM	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NV	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OK	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SD	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		TN	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VT	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		AR	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		MO	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NJ	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		TX	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		UT	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1104513811	7/3/2023 6:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WY	7/3/2023 6:34 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AK	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AZ	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CT	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		HI	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		ID	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		IA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		LA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		ME	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MD	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MN	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MT	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NH	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NM	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NV	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OK	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		SD	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TN	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VT	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AR	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MO	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NJ	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TX	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		UT	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	6/1/2023 12:15 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679266241	6/1/2023 12:15 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WY	6/1/2023 12:15 AM
Contacts	Authorizing Official	Update	Change Request	BROOM, MAUREEN Enterprise Finance Officer UW Medicine 2065985362	Cabe, Jacqueline L Chief Financial Officer UW Medicine 2066169886	4/4/2023 11:43 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013950336	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144641986	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326002049	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457904625	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548635683	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760891907	9/15/2022 6:48 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/15/2022 6:48 PM
Details	Last Recertification Date	Update	Recertification		9/15/2022 6:48:19 PM	9/15/2022 6:48 PM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		BROOM, MAUREEN Enterprise Finance Officer UW Medicine 2065985362	5/13/2022 1:41 PM
Details	340B ID	Update	New Registration		DSH500008EN	5/13/2022 1:41 PM
Details	Entity Name	Update	New Registration	UNIVERSITY OF WASHINGTON MED CTR	UNIVERSITY OF WASHINGTON MEDICAL CENTER	5/13/2022 1:41 PM
Details	Entity Subname	Update	New Registration	U NW	U NW - Radiation Oncology	5/13/2022 1:41 PM
Dates	Participating Approval Date	Update	New Registration		5/13/2022 1:41:09 PM	5/13/2022 1:41 PM
Details	State	Update	New Registration	Pending	Approved	5/13/2022 1:41 PM
Dates	Signed By Date	Update	New Registration		5/10/2022 7:12:50 PM	5/13/2022 1:41 PM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	5/13/2022 1:41 PM
Addresses	Main Address	Insert	New Registration		1570 N. 115th St. Seattle, WA 98133	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		SD	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013950336	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326002049	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144641986	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457904625	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760891907	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548635683	4/5/2022 1:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	4/5/2022 1:51 PM
Contacts	Authorizing Official	Insert	New Registration		BROOM, MAUREEN Enterprise Finance Officer UW Medicine 2065985362	4/5/2022 1:51 PM
Contacts	Primary Contact	Insert	New Registration		Patel, Sumona Pharmacy Audit and Compliance Manager UW Medicine 2065986936	4/5/2022 1:51 PM
Details	Assistance Received From Date	Insert	New Registration			4/5/2022 1:51 PM
Details	Assistance Received To Date	Insert	New Registration			4/5/2022 1:51 PM
Details	Last Recertification Date	Insert	New Registration			4/5/2022 1:51 PM
Details	Grant Number	Insert	New Registration			4/5/2022 1:51 PM
Details	340B ID	Insert	New Registration			4/5/2022 1:51 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2022 1:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2022 1:51 PM
Details	Medicare Provider Number	Insert	New Registration		500008	4/5/2022 1:51 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF WASHINGTON MED CTR	4/5/2022 1:51 PM
Details	NOFO Number	Insert	New Registration			4/5/2022 1:51 PM
Details	Program Code	Insert	New Registration		DSH	4/5/2022 1:51 PM
Details	Entity Subname	Insert	New Registration		U NW	4/5/2022 1:51 PM
Dates	Participating Approval Date	Insert	New Registration			4/5/2022 1:51 PM
Details	State	Insert	New Registration		Pending	4/5/2022 1:51 PM
Dates	Registration Date	Insert	New Registration		4/5/2022 1:51:37 PM	4/5/2022 1:51 PM
Dates	Signed By Date	Insert	New Registration			4/5/2022 1:51 PM
Dates	Start Date	Insert	New Registration			4/5/2022 1:51 PM
Terminations	Termination Comments	Insert	New Registration			4/5/2022 1:51 PM
Terminations	Termination Date	Insert	New Registration			4/5/2022 1:51 PM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2022 1:51 PM
Terminations	Termination Reason	Insert	New Registration			4/5/2022 1:51 PM