| Details | Last Recertification Date | Update | Recertification | 2/17/2024 11:53:59 AM | 3/5/2025 4:16:02 PM | 3/5/2025 4:16 PM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2023 3:15:23 PM | 2/17/2024 11:53:59 AM | 2/17/2024 11:53 AM |
| Details | Last Recertification Date | Update | Recertification | 2/10/2022 3:43:03 PM | 2/13/2023 3:15:23 PM | 2/13/2023 3:15 PM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2021 3:31:12 AM | 2/10/2022 3:43:03 PM | 2/10/2022 3:43 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 2/5/2021 3:31 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 2/5/2021 3:31 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 2/5/2021 3:31 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 2/5/2021 3:31 AM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 10:44:35 AM | 2/5/2021 3:31:12 AM | 2/5/2021 3:31 AM |
| Contacts | Primary Contact | Update | Change Request | Horne, Gary L
Director of Pharmacy
San Mateo Medical Center
6505732366 | Armendariz, Victor
Director of Pharmacy
San Mateo Medical Center
6505732366 | 1/29/2021 10:17 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 11:09:13 AM | 1/28/2020 10:44:35 AM | 1/28/2020 10:44 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2018 10:47:13 AM | 1/29/2019 11:09:13 AM | 1/29/2019 11:09 AM |
| Contacts | Primary Contact | Update | Recertification | Horne, Gary
Director of Pharmacy
San Mateo Medical Center
6505732366 | Horne, Gary L
Director of Pharmacy
San Mateo Medical Center
6505732366 | 8/15/2018 11:22 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2017 12:00:00 AM | 2/8/2018 10:47:13 AM | 2/8/2018 10:47 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1841379765 | 10/20/2017 8:30 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1568540557 | 10/1/2017 12:35 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | KUNNAPPILLY, CHESTER J.
CEO
San Mateo Medical Center
6505732041 | KUNNAPPILLY, CHESTER J.
CEO
San Mateo Medical Center
6505732305 | 10/1/2017 12:34 PM |
| Contacts | Authorizing Official | Update | | KUNNAPPILLY, CHESTER J.
CEO
6505732041 | KUNNAPPILLY, CHESTER J.
CEO
San Mateo Medical Center
6505732041 | 9/21/2017 8:20 PM |
| Contacts | Primary Contact | Update | | Horne, Gary
Director of Pharmacy
6505732366 | Horne, Gary
Director of Pharmacy
San Mateo Medical Center
6505732366 | 9/21/2017 2:40 PM |
| Contacts | Primary Contact | Insert | | | Horne, Gary
Director of Pharmacy
6505732366 | 5/24/2017 12:16 PM |
| Contacts | Authorizing Official | Update | | OGDEN, RITA
DEPUTY DIRECTOR OF AMBULATORY SERVICES
6505732222 | KUNNAPPILLY, CHESTER J.
CEO
6505732041 | 3/31/2017 11:28 AM |
| Addresses | Main Address | Insert | | |
225 S CABRILLO HIGHWAY, #100A
HALF MOON BAY, CA 94019 | 1/30/2017 1:19 AM |
| Details | Last Recertification Date | Update | | 2/23/2016 12:00:00 AM | 1/30/2017 12:00:00 AM | 1/30/2017 1:19 AM |
| Details | Last Recertification Date | Update | | 1/28/2015 12:00:00 AM | 2/23/2016 12:00:00 AM | 2/23/2016 12:14 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/28/2015 3:32 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | HSP400113W | 1/28/2015 3:32 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 1/28/2015 3:32 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/28/2015 3:32 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | HSP400113F | 1/28/2015 3:32 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 1/28/2015 3:32 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1275753378 | 1/28/2015 3:32 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1003985755 | 1/28/2015 3:32 PM |
| Details | Last Recertification Date | Update | | 2/19/2014 12:00:00 AM | 1/28/2015 12:00:00 AM | 1/28/2015 3:32 PM |
| Contacts | Authorizing Official | Insert | | | OGDEN, RITA
DEPUTY DIRECTOR OF AMBULATORY SERVICES
6505732222 | 3/10/2014 3:24 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/19/2014 12:00:00 AM | 2/19/2014 3:56 PM |
| Dates | Participating Approval Date | Update | | 11/9/2004 2:55:28 PM | 11/9/2004 12:00:00 AM | 7/11/2013 12:59 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/7/2013 11:58 AM |
| Details | Last Recertification Date | Insert | | | | 10/1/2001 12:00 AM |
| Details | Grant Number | Insert | | | H80CS00051 | 10/1/2001 12:00 AM |
| Details | 340B ID | Insert | | | CH09114N | 10/1/2001 12:00 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/1/2001 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/1/2001 12:00 AM |
| Details | Medicare Provider Number | Insert | | | | 10/1/2001 12:00 AM |
| Details | Entity Name | Insert | | | SAN MATEO MEDICAL CENTER | 10/1/2001 12:00 AM |
| Details | Program Code | Insert | | | CH | 10/1/2001 12:00 AM |
| Details | Entity Subname | Insert | | | COASTSIDE HEALTH CENTER | 10/1/2001 12:00 AM |
| Dates | Participating Approval Date | Insert | | | 11/9/2004 2:55:28 PM | 10/1/2001 12:00 AM |
| Details | State | Insert | | | Active | 10/1/2001 12:00 AM |
| Dates | Registration Date | Insert | | | 10/1/2001 12:00:00 AM | 10/1/2001 12:00 AM |
| Dates | Signed By Date | Insert | | | | 10/1/2001 12:00 AM |
| Dates | Start Date | Insert | | | 10/1/2001 12:00:00 AM | 10/1/2001 12:00 AM |
| Terminations | Termination Comments | Insert | | | | 10/1/2001 12:00 AM |
| Terminations | Termination Date | Insert | | | | 10/1/2001 12:00 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/1/2001 12:00 AM |
| Terminations | Termination Reason | Insert | | | | 10/1/2001 12:00 AM |
| Details | Comments Public | Insert | | | 11/9/04 - ADMIN CORRECTION REPLACES HO091140F | 10/1/2001 12:00 AM |