Covered Entity Details

DSH360008BS SOUTHERN OHIO MEDICAL CENTER (Active) - information as of 4/30/2025 10:51:11 PM

Main Details

Name

SOUTHERN OHIO MEDICAL CENTER

Subdivision Name

Respiratory Therapy - Pulmonary Function Diagnostic Testing Lab

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360008BS

Medicare Provider Number

360008

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/3/2022

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Southern Ohio Medical Center
Kara Plummer, Associate CFO, Administration
(740) 356-8880

Primary Contact

Southern Ohio Medical Center
Karen Elaine McGinnis, 340B Program Manager
(740) 356-6417

Addresses

Street Address

1735 27th Street
Waller Building, Suite 108
Portsmouth, OH 45662

Billing Address

Southern Ohio Medical Center
1248 Kinneys Lane
Portsmouth, OH 45662

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	7892571,0916512,0109697,0160273,0153224,0108488,0417059,0050732	1053342816,1457467227,1316341373,1962861047,1366816043,1386059228,1790397784,1629738679
KY	01542448,65921835,54030952,7100419190, 7100408110,7100696400,7100788700	1053342816,1457467227,1316341373,1962861047,1366816043,1386059228,1790397784,1629738679

Shipping Addresses

Shipping Address 1

Southern Ohio Medical Center
1805 27th Street
Portsmouth, OH 45662

Shipping Address 2

Southern Ohio Medical Center Warehouse
1025 Robinson Avenue
Portsmouth, OH 45662

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
DSH360008A	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC INFUSION	1121 KINNEYS LANE	PORTSMOUTH	OH	Active
DSH360008AA	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Pediatric Associates	1611 27th Street	Portsmouth	OH	Active
DSH360008AB	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Minford Family Practice	8792 State Route 335	Minford	OH	Active
DSH360008AC	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Gastroenterology Associates	1711 27th Street	Portsmouth	OH	Active
DSH360008AD	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Lucasville Family Practice	10 Thomas Hollow Road	Lucasville	OH	Active
DSH360008AE	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Heart and Vascular Associates	1711 27th Street	Portsmouth	OH	Active
DSH360008AF	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	ENT Associates	1611 27th Street	Portsmouth	OH	Active
DSH360008AG	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wound Healing Center	1745 27th Street	Portsmouth	OH	Active
DSH360008AH	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	FAMILY MEDICINE RESIDENCY CENTER	1835 OAKLAND AVENUE	PORTSMOUTH	OH	Terminated
DSH360008AJ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC WEST PORTSMOUTH FAMILY PRACTICE	15888 A US HIGHWAY 52	WEST PORTSMOUTH	OH	Active
DSH360008AK	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC ANTIARRHYTHMIC CLINIC	1711 27th Street	Portsmouth	OH	Terminated
DSH360008AL	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Sleep Medicine Associates	1735 27th Street	Portsmouth	OH	Active
DSH360008AM	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC AMBULATORY INFUSION CLINIC	1745 27th Street	Portsmouth	OH	Terminated
DSH360008AN	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC SOUTH WEBSTER FAMILY PRACTICE	110 North Jackson St	South Webster	OH	Active
DSH360008AP	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC WEST UNION PEDIATRIC ASSOCIATES	131 CIC Blvd.	West Union	OH	Active
DSH360008AQ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC OB/GYN HALDARMAN	1729 27th Street	Portsmouth	OH	Active
DSH360008AR	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC INTERNAL MEDICINE	1735 27th Street	Portsmouth	OH	Active
DSH360008AS	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Dermatology Associates	1735 27th Street	Portsmouth	OH	Terminated
DSH360008AT	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Primary Care Associates	1611 27TH STREET	Portsmouth	OH	Active
DSH360008AU	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC EASTERN FAMILY PRACTICE	1170 TILE MILL RD	BEAVER	OH	Active
DSH360008AV	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC WESTERN FAMILY PRACTICE	7959 STATE ROUTE 124	LATHAM	OH	Active
DSH360008AW	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	IRONTON FAMILY HEALTH CENTER	1005 E RING RD	IRONTON	OH	Active
DSH360008AX	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC SOUTH SHORE FAMILY PRACTICE	US 23 INDIANOLA AVE	SOUTH SHORE	KY	Active
DSH360008AY	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Breast Center - Mammography	1121 Kinneys Lane	Portsmouth	OH	Active
DSH360008AZ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Cancer Center - Medical Oncology	1121 Kinneys Lane	Portsmouth	OH	Terminated
DSH360008B	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC HOME HEALTH SERVICES	727 8TH STREET	PORTSMOUTH	OH	Terminated
DSH360008BA	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Cancer Center - Radiation Oncology	1121 Kinneys Lane	Portsmouth	OH	Active
DSH360008BB	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Health Center - Anticoagulation Clinic	8770 OHIO RIVER ROAD	WHEELERSBURG	OH	Terminated
DSH360008BC	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Waverly Family Health Center - Pediatric Associates	835 West Emmitt Avenue	Waverly	OH	Terminated
DSH360008BD	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Waverly Family Health Center - Ultrasound	835 West Emmitt Avenue	Waverly	OH	Terminated
DSH360008BE	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	West Union Family Health Center OB/GYN	90 C.I.C Boulevard	West Union	OH	Terminated
DSH360008BF	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	West Union Family Health Center Cat Scan	90 C.I.C Boulevard	West Union	OH	Terminated
DSH360008BG	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Waverly Family Health Center - Orthopaedic Associates	835 West Emmitt Avenue	Waverly	OH	Terminated
DSH360008BH	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	West Union Family Health Center - Orthopaedic Associates	90 C.I.C Boulevard	West Union	OH	Terminated
DSH360008BJ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Health Center - Orthopaedic Associates	8770 Ohio River Road	Wheelersburg	OH	Terminated
DSH360008BK	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Portsmouth Family Health Center - MRI	1248 Kinneys Lane	Portsmouth	OH	Terminated
DSH360008BL	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Health Center - MRI	8770 Ohio River Road	Wheelersburg	OH	Terminated
DSH360008BM	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Portsmouth Family Health Center - Cat Scan	1248 Kinneys Lane	Portsmouth	OH	Terminated
DSH360008BN	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Waverly Family Health Center - Cat Scan	835 West Emmitt Avenue	Waverly	OH	Terminated
DSH360008BP	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Health Center - Cat Scan	8770 OHIO RIVER ROAD	WHEELERSBURG	OH	Terminated
DSH360008BQ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC ORTHOPEDIC ASSOCIATES - SOMC Orthopedic Associates at SOMC Family Practice & Specialty Associates	1711 27TH STREET	PORTSMOUTH	OH	Terminated
DSH360008BR	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	NORTHWEST FAMILY PRACTICE - Northwest Clinic School	812 MOHAWK DR	MC DERMOTT	OH	Active
DSH360008BS	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Respiratory Therapy - Pulmonary Function Diagnostic Testing Lab	1735 27th Street	Portsmouth	OH	Active
DSH360008BT	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Family Practice & Specialty Associates - Greenup Clinic	1000 Ashland Drive, Suite 103	Ashland	KY	Active
DSH360008BU	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Vanceburg Family Health Center	246 Commonwealth Road	VANCEBURG	KY	Active
DSH360008BV	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC DOWNTOWN PORTSMOUTH FAMILY - Downtown Ports FP	723 8TH ST	PORTSMOUTH	OH	Active
DSH360008BW	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Endocrinology Associates - Endocrinology	1248 Kinneys Lane	Portsmouth	OH	Active
DSH360008BX	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Podiatry Associates - Podiatry Associates	1611 27th Street	Portsmouth	OH	Active
DSH360008BY	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC IRONTON FAMILY PRACTICE & SPEC - SOMC IRONTON FP & S ASSOC	1041 IRONTON HILLS DR	IRONTON	OH	Active
DSH360008BZ	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC RHEUMATOLOGY ASSOCIATES - Rheumatology Assoc	1711 27TH ST	PORTSMOUTH	OH	Active
DSH360008C	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Portsmouth Urgent Care Center	1248 Kinneys Lane	PORTSMOUTH	OH	Terminated
DSH360008CA	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC DERMATOLOGY ASSOCIATES - Dermatology	1611 27TH ST	PORTSMOUTH	OH	Active
DSH360008D	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC HOSPICE EAST CAMPUS	2201 25TH STREET	PORTSMOUTH	OH	Active
DSH360008E	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Health Center	8770 OHIO RIVER ROAD	WHEELERSBURG	OH	Active
DSH360008F	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC WHEELERSBURG REHABILITATION CENTER	613 CENTER STREET	WHEELERSBURG	OH	Terminated
DSH360008G	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC PORTSMOUTH REHABILITATION CENTER	1202 18TH STREET	PORTSMOUTH	OH	Terminated
DSH360008H	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC LUCASVILLE REHABILITATION CENTER	10617 US RT 23	LUCASVILLE	OH	Terminated
DSH360008J	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Anticoagulation Clinic	1825 Oakland Avenue	Portsmouth	OH	Active
DSH360008K	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Waverly Family Health Center	835 West Emmitt Avenue	Waverly	OH	Active
DSH360008L	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC OB/GYN Associates	1735 27th Street	Portsmouth	OH	Active
DSH360008M	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Orthopaedic Associates	1711 27th Street	Portsmouth	OH	Active
DSH360008N	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Wheelersburg Family Practice	613 Center Street	Wheelersburg	OH	Terminated
DSH360008P	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Urology Associates	1735 27th Street	Portsmouth	OH	Active
DSH360008Q	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Pulmonary & Critical Care Associates	1735 27th Street	Portsmouth	OH	Active
DSH360008R	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	West Union Family Health Center	90 C.I.C Boulevard	West Union	OH	Active
DSH360008S	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Infectious Disease	1735 27th Street	Portsmouth	OH	Active
DSH360008T	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Psychiatric Associates	1735 27th Street	Portsmouth	OH	Active
DSH360008U	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Surgical Associates	1711 27th Street	Portsmouth	OH	Active
DSH360008V	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Medical Center Psychiatric Services / Medical Center Psychiatric Services	1835 Oakland Ave	Portsmouth	OH	Terminated
DSH360008W	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Physical Medicine & Rehab	1711 27th St Suite 103B Braunlin Building	Portsmouth	OH	Terminated
DSH360008X	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Sciotoville Family Practice	5611 Gallia St.	Sciotoville	OH	Terminated
DSH360008Y	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	Portsmouth Family Health Center	1248 Kinneys Lane	Portsmouth	OH	Active
DSH360008Z	Child	DSH	SOUTHERN OHIO MEDICAL CENTER	SOMC Neurology & Physical Medicine Associates	1711 27th Street	Portsmouth	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0109697	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0160273	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0153224	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0108488	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0417059	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0050732	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		54030952	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		7100419190	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		7100408110	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		7100696400	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		7100788700	11/26/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316341373	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1962861047	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1366816043	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1386059228	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1790397784	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1629738679	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1316341373	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1962861047	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1366816043	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1386059228	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1790397784	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1629738679	11/26/2024 8:30 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	11/26/2024 8:30 AM
Addresses	Shipping Address	Insert	Group Change Request		Southern Ohio Medical Center Warehouse 1025 Robinson Avenue Portsmouth, OH 45662	10/16/2024 9:47 AM
Details	Last Recertification Date	Update	Recertification	8/28/2023 8:58:06 AM	8/26/2024 11:02:49 AM	8/26/2024 11:02 AM
Addresses	Shipping Address	Insert	Change Request		Southern Ohio Medical Center 1805 27th Street Portsmouth, OH 45662	10/31/2023 1:51 PM
Details	Last Recertification Date	Update	Recertification		8/28/2023 8:58:06 AM	8/28/2023 8:58 AM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Plummer, Kara Associate CFO, Administration Southern Ohio Medical Center 7403568880	11/3/2022 1:28 PM
Details	340B ID	Update	New Registration		DSH360008BS	11/3/2022 1:28 PM
Details	Entity Subname	Update	New Registration	Respiratory Therapy	Respiratory Therapy - Pulmonary Function Diagnostic Testing Lab	11/3/2022 1:28 PM
Dates	Participating Approval Date	Update	New Registration		11/3/2022 1:28:17 PM	11/3/2022 1:28 PM
Details	State	Update	New Registration	Pending	Approved	11/3/2022 1:28 PM
Dates	Signed By Date	Update	New Registration		10/15/2022 12:21:58 PM	11/3/2022 1:28 PM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/3/2022 1:28 PM
Addresses	Main Address	Insert	New Registration		1735 27th Street Waller Building, Suite 108 Portsmouth, OH 45662	10/14/2022 2:48 PM
Addresses	Billing Address	Insert	New Registration		Southern Ohio Medical Center 1248 Kinneys Lane Portsmouth, OH 45662	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7892571	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0916512	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01542448	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		65921835	10/14/2022 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	10/14/2022 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053342816	10/14/2022 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/14/2022 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457467227	10/14/2022 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/14/2022 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053342816	10/14/2022 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/14/2022 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457467227	10/14/2022 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/14/2022 2:48 PM
Contacts	Primary Contact	Insert	New Registration		McGinnis, Karen Elaine 340B Program Manager Southern Ohio Medical Center 7403566417	10/14/2022 2:48 PM
Contacts	Authorizing Official	Insert	New Registration		Plummer, Kara Associate CFO, Administration Southern Ohio Medical Center 7403568880	10/14/2022 2:48 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2022 2:48 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2022 2:48 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2022 2:48 PM
Details	Grant Number	Insert	New Registration			10/14/2022 2:48 PM
Details	340B ID	Insert	New Registration			10/14/2022 2:48 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2022 2:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2022 2:48 PM
Details	Medicare Provider Number	Insert	New Registration		360008	10/14/2022 2:48 PM
Details	Entity Name	Insert	New Registration		SOUTHERN OHIO MEDICAL CENTER	10/14/2022 2:48 PM
Details	NOFO Number	Insert	New Registration			10/14/2022 2:48 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2022 2:48 PM
Details	Entity Subname	Insert	New Registration		Respiratory Therapy	10/14/2022 2:48 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2022 2:48 PM
Details	State	Insert	New Registration		Pending	10/14/2022 2:48 PM
Dates	Registration Date	Insert	New Registration		10/14/2022 2:48:15 PM	10/14/2022 2:48 PM
Dates	Signed By Date	Insert	New Registration			10/14/2022 2:48 PM
Dates	Start Date	Insert	New Registration			10/14/2022 2:48 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2022 2:48 PM
Terminations	Termination Date	Insert	New Registration			10/14/2022 2:48 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2022 2:48 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2022 2:48 PM