Covered Entity Details

DSH110079X GRADY MEMORIAL HOSPITAL (Active) - information as of 5/9/2025 12:16:00 AM

Main Details

Name

GRADY MEMORIAL HOSPITAL

Subdivision Name

Correll Pavilion - Infusion Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110079X

Medicare Provider Number

110079

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2022

Participating Start Date

1/1/2023

Participating Approval Date

10/11/2022

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Grady Health System
John Haupert, Chief Executive Officer
(404) 616-4254

Primary Contact

Grady Health System
Kelcy Susannah Freeman, Pharmacy Program Coordinator
(404) 616-5909

Addresses

Street Address

80 Gilmer Street SE
Atlanta, GA 30303

Billing Address

Grady Health System Accounts Payable
50 Hurt Plaza SE
Suite 1300
Atlanta, GA 30303-2946

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
GA	000000855A,000000855C,000679808A,000937307B,000937307D,000937307E,000937307F,000937307H,000937307I,003127124A,003213613A,517281744A,556337752A,003282215A,000937307A,00679808	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
AL	1992799050,179239	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
CO	9000213335	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
CT	008056673,008062220	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
FL	913008000	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
LA	2355414	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
MS	05387022	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
NJ	0063649	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
NY	03061947	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
OH	0100489	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
SC	11516A,12050B	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
TN	Q034163	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050
WI	1992799050	1124598362,1205872223,1366400723,1396025367,1427373224,1629297478,1972826766,1992799050,1619014156,1073772919,1083629638,1174538722,1225162894,1316294713,1619982261,1639203110,1700891355,1811018369
NC	110079	1073772919,1083629638,1124598362,1174538722,1205872223,1225162894,1316294713,1366400723,1396025367,1427373224,1619014156,1619982261,1629297478,1639203110,1700891355,1811018369,1972826766,1992799050

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
DSH110079A	Child	DSH	GRADY MEMORIAL HOSPITAL	Kirkwood Health Center	1863 Memorial Drive SE	Atlanta	GA	Active
DSH110079AA	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - ENT Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AB	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GYN Oncology	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AC	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Hem-Oncology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AD	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Emergency Care Center	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AE	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpatient Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AF	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Outpatient Rehab	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AG	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Sickle Cell Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AH	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Asthma Ctr-Excellence	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AJ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Cerebral Palsy & Autism Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AK	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Child Abuse Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AL	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - ACT Team	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AM	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Radiology	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AN	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpt Internal Med Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AP	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Appointment Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AQ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Adolescent Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AR	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Respiratory Care	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AS	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY HEALTH SYSTEM - Geriatric Program	1000 White St. SW	ATLANTA	GA	Active
DSH110079AT	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology IR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AU	Child	DSH	GRADY MEMORIAL HOSPITAL	Cascade Outpatient Center - Cascade Road Outpatient Center	3355 Cascade Rd.	Atlanta	GA	Active
DSH110079AV	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology Ultrasound	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AW	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology MRI	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AX	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology OR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AY	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology CT	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AZ	Child	DSH	GRADY MEMORIAL HOSPITAL	CAMP CREEK COMPREHENSIVE CARE CENTE - Ambulatory Care Coordination	3896 PRINCETON LAKES WAY SW	ATLANTA	GA	Active
DSH110079BA	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology X Ray	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BB	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Pre- Post- PACU	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BC	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - GA Aide Mobile Mammo	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BD	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health South Clinic - PSY FC North-South Outpatient	5600 Stonewall Tell Road	College Park	GA	Active
DSH110079BE	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Correll Surgery	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079C	Child	DSH	GRADY MEMORIAL HOSPITAL	East Point Health Center	1595 W Cleveland Ave	East Point	GA	Active
DSH110079D	Child	DSH	GRADY MEMORIAL HOSPITAL	Asa G. Yancey Health Center	1247 Donald Lee Hollowell Pkwy NW	Atlanta	GA	Active
DSH110079F	Child	DSH	GRADY MEMORIAL HOSPITAL	NORTH DEKALB HEALTH CENTER	3807 CLAIRMONT RD, SE	CHAMBLEE	GA	Terminated
DSH110079G	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079H	Child	DSH	GRADY MEMORIAL HOSPITAL	Ponce De Leon Center	341 Ponce De Leon Ave NE	Atlanta	GA	Active
DSH110079L	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health Outpatient Center	10 Park Place NE	Atlanta	GA	Terminated
DSH110079M	Child	DSH	GRADY MEMORIAL HOSPITAL	North Fulton Health Center	7741 Roswell Rd	Sandy Springs	GA	Active
DSH110079N	Child	DSH	GRADY MEMORIAL HOSPITAL	Brookhaven Health Center	2695 Buford Hwy NE	Atlanta	GA	Active
DSH110079P	Child	DSH	GRADY MEMORIAL HOSPITAL	Edward C. Loughlin Radiation-Oncology Center	145 Edgewood Ave SE	Atlanta	GA	Active
DSH110079Q	Child	DSH	GRADY MEMORIAL HOSPITAL	Walk-In Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079R	Child	DSH	GRADY MEMORIAL HOSPITAL	Manuel J. Maloof Imaging Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079S	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Ophthalmology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079T	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Oral Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079U	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Digital Mammography Services	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079V	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079W	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY EMS - Mobile Integrated Health	745 MEMORIAL DR SE	ATLANTA	GA	Active
DSH110079X	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Infusion Center	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Y	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GI Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Z	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Orthopedic Trauma Clinic	80 Gilmer Street SE	Atlanta	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/8/2023 11:34:31 AM	9/3/2024 10:13:25 AM	9/3/2024 10:13 AM
Addresses	Billing Address	Insert	Group Change Request		Grady Health System Accounts Payable 50 Hurt Plaza SE Suite 1300 Atlanta, GA 30303-2946	7/12/2024 1:13 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1100079 (NC)		9/8/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00679808	9/8/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/8/2023 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2023 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110079	9/8/2023 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/8/2023 11:34 AM
Details	Last Recertification Date	Update	Recertification		9/8/2023 11:34:31 AM	9/8/2023 11:34 AM
Addresses	Main Address	Update	Change Request	80 Gilmer Street Atlanta, GA 30303	80 Gilmer Street SE Atlanta, GA 30303	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003282215A	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000937307A	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		179239	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000213335	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008056673	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008062220	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		913008000	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2355414	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05387022	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1100079	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0063649	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03061947	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0100489	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11516A	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12050B	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q034163	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (GA)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (GA)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (GA)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (AL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (AL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (AL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (FL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (FL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (FL)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (NC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (NC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (NC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (SC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (SC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (SC)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063726339 (TN)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1164966164 (TN)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1891966578 (TN)		7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124598362	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205872223	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1366400723	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396025367	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427373224	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629297478	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972826766	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1992799050	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619014156	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073772919	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083629638	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174538722	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225162894	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316294713	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1619982261	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639203110	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700891355	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811018369	7/19/2023 12:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	7/19/2023 12:25 PM
Details	Entity Subname	Update	Change Request	Grady Memorial Hospital - Infusion Center	Correll Pavilion - Infusion Center	7/19/2023 12:25 PM
Addresses	Main Address	Update	Group Change Request	80 Jesse Hill Jr Drive SE Atlanta, GA 30303-3050	80 Gilmer Street Atlanta, GA 30303	2/23/2023 2:39 PM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Haupert, John Chief Executive Officer Grady Health System 4046164254	10/11/2022 9:45 AM
Details	340B ID	Update	New Registration		DSH110079X	10/11/2022 9:45 AM
Details	Entity Subname	Update	New Registration	Grady Memorial Hospital	Grady Memorial Hospital - Infusion Center	10/11/2022 9:45 AM
Dates	Participating Approval Date	Update	New Registration		10/11/2022 9:45:43 AM	10/11/2022 9:45 AM
Details	State	Update	New Registration	Pending	Approved	10/11/2022 9:45 AM
Dates	Signed By Date	Update	New Registration		10/7/2022 1:34:05 PM	10/11/2022 9:45 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	10/11/2022 9:45 AM
Addresses	Main Address	Insert	New Registration		80 Jesse Hill Jr Drive SE Atlanta, GA 30303-3050	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000855A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000855C	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000679808A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307B	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307D	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307E	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307F	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307H	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000937307I	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003127124A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003213613A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		517281744A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		556337752A	10/4/2022 10:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063726339	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073772919	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083629638	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124598362	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164966164	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1174538722	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205872223	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1225162894	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316294713	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366400723	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396025367	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427373224	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619014156	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619982261	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629297478	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639203110	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700891355	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811018369	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891966578	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972826766	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992799050	10/4/2022 10:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	10/4/2022 10:34 PM
Contacts	Authorizing Official	Insert	New Registration		Haupert, John Chief Executive Officer Grady Health System 4046164254	10/4/2022 10:34 PM
Contacts	Primary Contact	Insert	New Registration		Freeman, Kelcy Susannah Pharmacy Program Coordinator Grady Health System 4046165909	10/4/2022 10:34 PM
Details	Assistance Received From Date	Insert	New Registration			10/4/2022 10:34 PM
Details	Assistance Received To Date	Insert	New Registration			10/4/2022 10:34 PM
Details	Last Recertification Date	Insert	New Registration			10/4/2022 10:34 PM
Details	Grant Number	Insert	New Registration			10/4/2022 10:34 PM
Details	340B ID	Insert	New Registration			10/4/2022 10:34 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2022 10:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2022 10:34 PM
Details	Medicare Provider Number	Insert	New Registration		110079	10/4/2022 10:34 PM
Details	Entity Name	Insert	New Registration		GRADY MEMORIAL HOSPITAL	10/4/2022 10:34 PM
Details	NOFO Number	Insert	New Registration			10/4/2022 10:34 PM
Details	Program Code	Insert	New Registration		DSH	10/4/2022 10:34 PM
Details	Entity Subname	Insert	New Registration		Grady Memorial Hospital	10/4/2022 10:34 PM
Dates	Participating Approval Date	Insert	New Registration			10/4/2022 10:34 PM
Details	State	Insert	New Registration		Pending	10/4/2022 10:34 PM
Dates	Registration Date	Insert	New Registration		10/4/2022 10:34:28 PM	10/4/2022 10:34 PM
Dates	Signed By Date	Insert	New Registration			10/4/2022 10:34 PM
Dates	Start Date	Insert	New Registration			10/4/2022 10:34 PM
Terminations	Termination Comments	Insert	New Registration			10/4/2022 10:34 PM
Terminations	Termination Date	Insert	New Registration			10/4/2022 10:34 PM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2022 10:34 PM
Terminations	Termination Reason	Insert	New Registration			10/4/2022 10:34 PM