Covered Entity Details

RRC360065-02 FISHER-TITUS MEDICAL CENTER (Active) - information as of 4/25/2025 6:34:16 PM

Main Details

Name

FISHER-TITUS MEDICAL CENTER

Subdivision Name

FISHER TITUS BEHAVIORAL HEALTH - Behavioral Health

Type

Rural Referral Center

Rural

Yes

340B ID

RRC360065-02

Medicare Provider Number

360065

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/12/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/22/2022

Last Recertification Date

8/31/2024

Contacts

Authorizing Official

Fisher-Titus Health
Brent W Burkey, MD, President
(440) 660-2550

Primary Contact

Fisher Titus Medical Center
Scott Endsley, VP of Finance
(419) 668-8101 Ext: 2904

Addresses

Street Address

278 BENEDICT AVE
STE 950
NORWALK, OH 44857-2723

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
OH	2781502	1992738959

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
RRC360065-01	Child	RRC	FISHER-TITUS MEDICAL CENTER	FISHER-TITUS PROCEDURE CENTER - Procedure Center	278 BENEDICT AVE	NORWALK	OH	Active
RRC360065-02	Child	RRC	FISHER-TITUS MEDICAL CENTER	FISHER TITUS BEHAVIORAL HEALTH - Behavioral Health	278 BENEDICT AVE	NORWALK	OH	Active
RRC360065-03	Child	RRC	FISHER-TITUS MEDICAL CENTER	Fisher Titus Convenient Care - Family Medicine	368 Milan Ave	Norwalk	OH	Active
RRC360065-04	Child	RRC	FISHER-TITUS MEDICAL CENTER	FAMILY MEDICINE WAKEMAN - Family Medicine	24 HYDE ST	WAKEMAN	OH	Active
RRC360065-05	Child	RRC	FISHER-TITUS MEDICAL CENTER	FAMILY MEDICINE MILAN - Family Medicine	2114 STATE ROUTE 113 E	MILAN	OH	Active
RRC360065-06	Child	RRC	FISHER-TITUS MEDICAL CENTER	FT UROLOGY- SANDUSKY - Urology	2800 HAYES AVE	SANDUSKY	OH	Active
RRC360065-07	Child	RRC	FISHER-TITUS MEDICAL CENTER	NORWALK PRIMARY CARE - Family Medicine	280 BENEDICT AVE	NORWALK	OH	Active
RRC360065-08	Child	RRC	FISHER-TITUS MEDICAL CENTER	FAMILY PRACTICE NEW LONDON - Family Medicine	187 W MAIN ST	NEW LONDON	OH	Active
RRC360065-09	Child	RRC	FISHER-TITUS MEDICAL CENTER	FISHER TITUS PEDIATRICS- NORWALK - Pediatrics	282 BENEDICT AVE	NORWALK	OH	Active
RRC360065-10	Child	RRC	FISHER-TITUS MEDICAL CENTER	FT GEN SURGERY- NORWALK - General Surgery	278 BENEDICT AVE	NORWALK	OH	Active
RRC360065-11	Child	RRC	FISHER-TITUS MEDICAL CENTER	FAMILY MEDICINE WILLARD - Family Medicine	230 East Walton St	WILLARD	OH	Active
RRC360065-12	Child	RRC	FISHER-TITUS MEDICAL CENTER	Fisher Titus Digestive Health - Gastroenterology	278 Benedict Ave	Norwalk	OH	Active
RRC360065-13	Child	RRC	FISHER-TITUS MEDICAL CENTER	Fisher Titus Urology Norwalk - Urology	278 Benedict Ave, Suite 650	Norwalk	OH	Active
RRC360065-14	Child	RRC	FISHER-TITUS MEDICAL CENTER	Fisher Titus - Bellevue Primary Care & Pediatrics	521 N Sandusky St	Bellevue	OH	Active
RRC360065-15	Child	RRC	FISHER-TITUS MEDICAL CENTER	Fisher Titus Urology Bellevue - Urology	1355 W Main St	Bellevue	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 10:23:16 AM	8/31/2024 8:15:27 AM	8/31/2024 8:15 AM
Details	Last Recertification Date	Update	Recertification		9/5/2023 10:23:16 AM	9/5/2023 10:23 AM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Burkey, MD, Brent W President Fisher-Titus Health 4406602550	11/22/2022 10:38 AM
Details	340B ID	Update	New Registration		RRC360065-02	11/22/2022 10:38 AM
Details	Entity Subname	Update	New Registration	FISHER TITUS BEHAVIORAL HEALTH	FISHER TITUS BEHAVIORAL HEALTH - Behavioral Health	11/22/2022 10:38 AM
Dates	Participating Approval Date	Update	New Registration		11/22/2022 10:38:26 AM	11/22/2022 10:38 AM
Details	State	Update	New Registration	Pending	Approved	11/22/2022 10:38 AM
Dates	Signed By Date	Update	New Registration		10/13/2022 11:26:42 AM	11/22/2022 10:38 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/22/2022 10:38 AM
Addresses	Main Address	Insert	New Registration		278 BENEDICT AVE STE 950 NORWALK, OH 44857-2723	10/12/2022 11:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/12/2022 11:11 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2781502	10/12/2022 11:11 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/12/2022 11:11 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992738959	10/12/2022 11:11 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/12/2022 11:11 AM
Contacts	Primary Contact	Insert	New Registration		Endsley, Scott VP of Finance Fisher Titus Medical Center 4196688101-2904	10/12/2022 11:11 AM
Contacts	Authorizing Official	Insert	New Registration		Burkey, MD, Brent W President Fisher-Titus Health 4406602550	10/12/2022 11:11 AM
Details	Assistance Received From Date	Insert	New Registration			10/12/2022 11:11 AM
Details	Assistance Received To Date	Insert	New Registration			10/12/2022 11:11 AM
Details	Last Recertification Date	Insert	New Registration			10/12/2022 11:11 AM
Details	Grant Number	Insert	New Registration			10/12/2022 11:11 AM
Details	340B ID	Insert	New Registration			10/12/2022 11:11 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2022 11:11 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2022 11:11 AM
Details	Medicare Provider Number	Insert	New Registration		360065	10/12/2022 11:11 AM
Details	Entity Name	Insert	New Registration		FISHER-TITUS MEDICAL CENTER	10/12/2022 11:11 AM
Details	NOFO Number	Insert	New Registration			10/12/2022 11:11 AM
Details	Program Code	Insert	New Registration		RRC	10/12/2022 11:11 AM
Details	Entity Subname	Insert	New Registration		FISHER TITUS BEHAVIORAL HEALTH	10/12/2022 11:11 AM
Dates	Participating Approval Date	Insert	New Registration			10/12/2022 11:11 AM
Details	State	Insert	New Registration		Pending	10/12/2022 11:11 AM
Dates	Registration Date	Insert	New Registration		10/12/2022 11:11:11 AM	10/12/2022 11:11 AM
Dates	Signed By Date	Insert	New Registration			10/12/2022 11:11 AM
Dates	Start Date	Insert	New Registration			10/12/2022 11:11 AM
Terminations	Termination Comments	Insert	New Registration			10/12/2022 11:11 AM
Terminations	Termination Date	Insert	New Registration			10/12/2022 11:11 AM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2022 11:11 AM
Terminations	Termination Reason	Insert	New Registration			10/12/2022 11:11 AM