Covered Entity Details

DSH170040GV UNIVERSITY OF KANSAS HOSPITAL (Active) - information as of 4/25/2025 6:32:28 PM

Main Details

Name

UNIVERSITY OF KANSAS HOSPITAL

Subdivision Name

Medical Pavilion - Interventional Radiology MP

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH170040GV

Medicare Provider Number

170040

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/4/2023

Participating Start Date

4/1/2023

Participating Approval Date

1/13/2023

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

University of Kansas Health System
Rick Couldry, Vice-President, Pharmacy and Clinical Professions
(913) 588-2301

Primary Contact

The University of Kansas Hospital
Todd Holt, Pharmacy Operations Manager
(913) 945-8291

Addresses

Street Address

2000 Olathe Blvd
Level 3
Suite F
Kansas City, KS 66160-8505

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
KS	30003935830005,30003935830010,30003935830009,30003935830035,30003935830030,30003935830039,30003935830049,30003935830003,30003935830004	1457335036,1538726880,1265921506,1962911693,1700395878,1063795896,1417245192,1093003675,1649259656
MO	600567804,600072985,600074046,600049887,600072842,600010163,606093706,600074047,010567808	1457335036,1538726880,1265921506,1962911693,1700395878,1063795896,1417245192,1093003675,1649259656

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
DSH170040A	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CC-CLINIC EXAM	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040AA	Child	DSH	KANSAS UNIVERSITY HOSPITAL	Indian Creek Surgery Clinic	10730 Nall Avenue	Overland Park	KS	Terminated
DSH170040AB	Child	DSH	KANSAS UNIVERSITY HOSPITAL	MATCS ICC / MATCS - Lung Nodule	10730 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040AC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Sarcoma Exam ICC	10730 Nall Ave.	Overland Park	KS	Active
DSH170040AD	Child	DSH	KANSAS UNIVERSITY HOSPITAL	KUCC ICC-BREAST SURG EXAM	10787 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040AE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	UNIV OF KS HOSPITAL NEUROPSYCHOLOGY - Neuropsychology Services	4330 Shawnee Mission Pkwy.	Fairway	KS	Active
DSH170040AF	Child	DSH	KANSAS UNIVERSITY HOSPITAL	UNIV OF KS HOSP INDIAN CREEK CAMPUS - ICC PAIN MANAGEMENT	10720 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040AG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Periop Services ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040AH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	UNIV OF KS HOSP INDIAN CREEK CAMPUS - ICC GI ENDOSCOPY	10710 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040AJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Interventional Radiology ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040AK	Child	DSH	KANSAS UNIVERSITY HOSPITAL	UNIV OF KANSAS CANCER CENTER SOUTH - KUCC SOUTH-DIAG RADIOLOGY	1000 E 101ST TER	KANSAS CITY	MO	Terminated
DSH170040AL	Child	DSH	KANSAS UNIVERSITY HOSPITAL	SOUTH KANSAS CITY MEDICAL PAVILION - SKC Med Pav-Rad Ther	1000 E 101ST TER	KANSAS CITY	MO	Terminated
DSH170040AM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	SKC Med Pavilion Treatment	1000 E. 101st Terrace	Kansas City	MO	Active
DSH170040AN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Laboratory SKCMP	1000 E. 101st Terrace	Kansas City	MO	Active
DSH170040AP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV OPK	10787 Nall Ave.	Overland Park	KS	Active
DSH170040AQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Heart Rhythm Mgmt OPK	10787 Nall Ave.	Overland Park	KS	Active
DSH170040AR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Nuclear OPK	10787 Nall Ave.	Overland Park	KS	Active
DSH170040AS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc OPK	12200 W. 110th Street	Overland Park	KS	Active
DSH170040AT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment OPK	12200 W. 110th Street	Overland Park	KS	Active
DSH170040AU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Rad Therapy OPK	12200 W. 110th Street	Overland Park	KS	Active
DSH170040AV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Laboratory OPK	12200 W. 110th Street	Overland Park	KS	Active
DSH170040AW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV Liberty	1530 N. Church Road	Liberty	MO	Active
DSH170040AX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Nuclear Liberty	1530 N. Church Road	Liberty	MO	Active
DSH170040AY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Heart Rhythm Mgmt Liberty	1530 N. Church Road	Liberty	MO	Active
DSH170040AZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc Westwood	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040BA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Laboratory WW	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040BB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Breast Center Westwood	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040BC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	BMT EXAM Westwood	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040BD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment Westwood	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040BE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment NKC	2750 Clay Edwards Drive	North Kansas City	MO	Terminated
DSH170040BF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV LVN	3601 S. 4th St.	Leavenworth	KS	Active
DSH170040BG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Heart Rhythm Mgmt LVN	3601 S. 4th St.	Leavenworth	KS	Terminated
DSH170040BH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	UKH Cancer Rad Therapy	4001 Rainbow Blvd	Kansas City	KS	Active
DSH170040BJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CRC Lab	4350 Shawnee Mission Pkwy.	Fairway	KS	Active
DSH170040BK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Rad Therapy LS	4881 NE Goodview Circle	Lee's Summit	MO	Active
DSH170040BL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc LS	4881 NE Goodview Circle	Lee's Summit	MO	Active
DSH170040BM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment LS	4881 NE Goodview Circle	Lee's Summit	MO	Active
DSH170040BN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Laboratory LS	4881 NE Goodview Circle	Lee's Summit	MO	Active
DSH170040BP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Heart Rhythm Mgmt State Ave	5701 State Ave.	Kansas City	KS	Active
DSH170040BQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV State Ave	5701 State Ave.	Kansas City	KS	Active
DSH170040BR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Nuclear State Ave	5701 State Ave.	Kansas City	KS	Active
DSH170040BS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Laboratory KUMW	7405 RENNER RD	Shawnee	KS	Active
DSH170040BT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc KUMW	7405 RENNER RD	Shawnee	KS	Active
DSH170040BU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc North	8700 N. Green Hills Road	Kansas City	MO	Active
DSH170040BV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Laboratory North	8700 N. Green Hills Road	Kansas City	MO	Active
DSH170040BW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Rad Therapy North	8700 N. Green Hills Road	Kansas City	MO	Active
DSH170040BX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment North	8700 N. Green Hills Road	Kansas City	MO	Active
DSH170040BY	Child	DSH	KANSAS UNIVERSITY HOSPITAL	UNIV OF KANSAS CANCER CENTER WEST - KUCC WEST-CLIN TRT	8919 PARALLEL PKWY 326	KANSAS CITY	KS	Terminated
DSH170040BZ	Child	DSH	KANSAS UNIVERSITY HOSPITAL	UNIV OF KANSAS CANCER CENTER WEST - KUCC WEST-LAB	8919 PARALLEL PKWY 326	KANSAS CITY	KS	Terminated
DSH170040C	Child	DSH	KANSAS UNIVERSITY HOSPITAL	KUCC WEST-EXAM	8919 Parallel Parkway	Kansas City	KS	Terminated
DSH170040CA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc AHS	One Arrowhead Drive	Kansas City	MO	Active
DSH170040CB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040CC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	IP Phlebotomy Main Campus	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040CD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	MEDICAL PAVILION - MOB RADIOLOGY-SPORTS MED	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040CE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040CF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Specialty Clinic	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040CG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CA7 Neurosurgery & Surg Onc	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CA6 Neuro & ENT Progrsv Cr	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CA5 ICU	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pre/Post Operative ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040CL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	INDIAN CREEK CAMPUS - SPINE CENTER	10730 Nall Ave.	Overland Park	KS	Active
DSH170040CM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CA 11 Medical Oncology	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Operating Room CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040CQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Interventional Radiology CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	MEDICAL PAVILION - ADDICTIONS TREATMENT CENTER	3901 Rainbow Blvd	Kansas City	KS	Active
DSH170040CS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pre/Post Operative CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040CV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Rad Therapy ICC	10730 Nall Ave	Overland Park	KS	Active
DSH170040CW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Laboratory ICC	10710 Nall Ave.	Overland Park	KS	Active
DSH170040CX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Pediatric Allergy PV	7301 Mission Road	Prairie Village	KS	Active
DSH170040CY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Surgery Bariatric CMP	10700 Nall Ave.	Overland Park	KS	Active
DSH170040CZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Infusion Center CA	3825 Cambridge St.	Kansas City	KS	Active
DSH170040DA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ENT General CMP	10787 Nall Ave.	Overland Park	KS	Active
DSH170040DB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	SKC Med Pavilion Family Phys	1000 E. 101st Terrace	Kansas City	MO	Active
DSH170040DC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics Behav Health PV	7301 Mission Rd	PRAIRIE VILLAGE	KS	Terminated
DSH170040DD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Plastic Surgery ICC	10777 Nall Ave.	Overland Park	KS	Active
DSH170040DE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	PRAIRIE VILLAGE - Ped Gen Clinic	7301 Mission Road	Prairie Village	KS	Active
DSH170040DF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics General PV	7301 Mission Road	Prairie Village	KS	Active
DSH170040DG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Westwood Int Med	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040DH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Westwood Urgent Care	2650 SHAWNEE MISSION PKWY	WESTWOOD	KS	Terminated
DSH170040DJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC KUMW Urgent Care	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040DK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	PRAIRIE VILLAGE - Resident Peds Gen Clinic	7301 Mission Rd	PRAIRIE VILLAGE	KS	Terminated
DSH170040DL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	KUMW Therapy	7405 Renner Rd	SHAWNEE	KS	Active
DSH170040DM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC KUMW Int Med	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040DN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn PV	7301 Mission Road	Prairie Village	KS	Active
DSH170040DP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Med Plaza Int Med	10787 Nall Ave.	Overland Park	KS	Active
DSH170040DQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC KUMW Family Practice	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040DR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics Cardiology PV	7301 Mission Road	Prairie Village	KS	Active
DSH170040DS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Creekwood Urgent Care	6420 N. Prospect Ave.	Gladstone	MO	Active
DSH170040DT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Creekwood Family Care	6420 N. Prospect Ave.	Gladstone	MO	Active
DSH170040DU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	NORTH KANSAS CITY - NKC Neurosurg Clinic	2790 Clay Edwards Dr	NORTH KANSAS CITY	MO	Terminated
DSH170040DV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Grand Blvd FM	1403 Grand Blvd.	Kansas City	MO	Active
DSH170040DW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Prairie Village Family Med	7301 Mission Road	Prairie Village	KS	Active
DSH170040DX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ENT General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040DY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Urology General CMP	10777 Nall Ave.	Overland Park	KS	Active
DSH170040DZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics Multispecialty MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040E	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam OPK	12200 W. 110th Street	Overland Park	KS	Active
DSH170040EA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Psychiatry General CMP	10777 Nall Ave.	Overland Park	KS	Active
DSH170040EB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn UroGyn MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	INDIAN CREEK CAMPUS - ICC INFUSION CLINIC	10710 Nall Ave	OVERLAND PARK	KS	Terminated
DSH170040ED	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Surgery Pediatric MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Dermatology MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Fam Med General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Clinical Pharm MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Nephrology MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Allergy MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	MEDICAL PAVILION - Osteo Clinic	2000 Olathe Blvd	Kansas City	KS	Terminated
DSH170040EM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Infectious Disease MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Psychiatry Adult MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn MFM MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Surgery Clinic MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040ER	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040ES	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Urology General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040ET	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Gastro (GI) MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	MEDICAL PAVILION - Miller Eye & Optometry Clinic	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Pulmonary MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Medical Pavilion - OrthoSurg PT MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Endoocrinology MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OrthoSurgery General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040EZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	NeuroSurgery Brain Trauma Clin	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040F	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	SKC Med Pavilion Exam	1000 E. 101st Terrace	Kansas City	MO	Active
DSH170040FA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Gen Med MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040FB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Plastic Surgery MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040FC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	NeuroSurgery General MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040FD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Rehab Medicine MP	2000 Olathe Blvd	Kansas City	KS	Terminated
DSH170040FE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Rheumatology BH	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040FF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Ophth State Line	7400 State Line Road	Prairie Village	KS	Active
DSH170040FG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics General KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040FH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Gastro (GI) KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040FJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Anest Pain Mgmt KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040FK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Rehab Medicine KUMW	7405 RENNER RD	SHAWNEE	KS	Terminated
DSH170040FL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Psychiatry General QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040FM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Clinic Switzer	7420 Switzer Rd	Shawnee	KS	Active
DSH170040FN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	INDIAN CREEK CAMPUS - ICC SPINE/SPORTS MED RADIOLOGY	10730 Nall Ave	OVERLAND PARK	KS	Active
DSH170040FP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Heart Rhythm Mgmt Switzer	7420 Switzer Rd	Shawnee	KS	Active
DSH170040FQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Fam Med Arrowhead	One Arrowhead Drive	Kansas City	MO	Active
DSH170040FR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Urology General KUMW	7405 RENNER RD	SHAWNEE	KS	Terminated
DSH170040FS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	BMT Treatment WW	2650 Shawnee Mission Pkwy.	Westwood	KS	Active
DSH170040FT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040FU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	INDIAN CREEK CAMPUS - CV ICC-CLINIC	10710 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040FV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Dermatology KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040FW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn UroGyn QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040FX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Laboratory Quivira Spec Clinic	12000 W. 110th St.	Overland Park	KS	Active
DSH170040FY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	INDIAN CREEK CAMPUS - CV ICC-HEART RHYTHM MGMT	10710 NALL AVE	OVERLAND PARK	KS	Terminated
DSH170040FZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Ortho Surgery General KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040G	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam LS	4881 NE Goodview Circle	Lee's Summit	MO	Active
DSH170040GA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV Switzer	7420 Switzer Rd	Shawnee	KS	Active
DSH170040GB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Pulmonary KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040GC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ENT Cosmetic & Plastics KUMW	7405 RENNER RD	SHAWNEE	KS	Active
DSH170040GD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Endocrine Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ObGyn MFM QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Hematology Exam MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040GG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Quivira Medical Pavilion - Int Med Dermatology Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Quivira Medical Pavilion - Int Med Pulmonary Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Corporate Medical Plaza - CMP Radiology	10787 Nall Ave.	Overland Park	KS	Active
DSH170040GK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	UKH ComKC MP Urgent Care	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040GL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Quivira Medical Pavilion - Int Med Diabetes Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Quivira Medical Pavilion - Int Med Nephrology Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Quivira Medical Pavilion - Int Med Gastroenterology Clinic QV	12000 W. 110th St.	Overland Park	KS	Active
DSH170040GP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Grand Blvd - Grand Blvd Radiology	1403 Grand Blvd.	Kansas City	MO	Active
DSH170040GQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cambridge Tower A - CA9 Hematology & BMT	3825 Cambridge St.	Kansas City	KS	Active
DSH170040GR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Medical Pavilion - Pulmonary Function Lab	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040GS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cambridge Tower A - CA Lab	3825 Cambridge St.	Kansas City	KS	Active
DSH170040GT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cambridge Tower A - CA 10 BMT/Cellular Therapies	3825 Cambridge St.	Kansas City	KS	Active
DSH170040GU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Marillac - Pediatrics Behav Health Marillac	8000 W. 127th St.	Overland Park	KS	Active
DSH170040GV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Medical Pavilion - Interventional Radiology MP	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040GW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Indian Creek Campus - CV Echo/PV Vascular Surgery	10700 Nall Ave	Overland Park	KS	Active
DSH170040GX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Indian Creek Campus - Surgery VSA Vein	10700 Nall Ave	Overland Park	KS	Active
DSH170040GY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Indian Creek Campus - Fam Med ICC	10700 Nall Ave	Overland Park	KS	Active
DSH170040GZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Indian Creek Campus - Surgery VSA Ultrasound	10700 Nall Ave	Overland Park	KS	Active
DSH170040H	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam North	8700 N. Green Hills Road	Kansas City	MO	Active
DSH170040HA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Indian Creek Campus - Surgery VSA Vascular	10700 Nall Ave	Overland Park	KS	Active
DSH170040HB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Marillac - Psychiatry Child Marillac	8000 W. 127th St.	Overland Park	KS	Active
DSH170040HC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cambridge Tower A - CA8 ICU Med/Surg	3825 Cambridge St.	Kansas City	KS	Active
DSH170040HD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cambridge Tower A - CA8 Heme	3825 Cambridge St.	Kansas City	KS	Active
DSH170040HE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Echo/PV BH - CVM MPB5 ECHOPV	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040HF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Pediatrics Behav Health MP - Peds Behav Health Clinic	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040HG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV HEART RHYTHM MGMT BH - CV Heart Rhythm	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040HH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Internal Medicine Gen Med ICC- 1st Floor - ICC Internal Medicine 1st floor	10700 Nall Ave	Overland Park	KS	Active
DSH170040HJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ComKC Grand Blvd Urgent Care - Grand Blvd Urgent Care Clinic	1403 Grand Blvd	Kansas City	MO	Active
DSH170040HK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Clinical Lab Cytogenetics - Cytogenetics Lab	11300 Corporate Ave	Lenexa	KS	Active
DSH170040HL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cardiovascular Clinic Bell Hospital - CVM MPB5 Clinic	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040HN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Laboratory CPK - Lab Corbin Park	6501 W. 135th St	Overland Park	KS	Active
DSH170040HP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Gen Med Corbin Park - Int Med Corbin Park	6501 W. 135th St	Overland Park	KS	Active
DSH170040HQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	South Clinic Therapies PT/OT - PT/OT Corbin Park	6501 W. 135th St.	Overland Park	KS	Active
DSH170040HR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CTS Clinic - CTS Clinic	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040HS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Lab Cancer Center Olathe - CC OCG Lab	15123 OMC Pkwy	Olathe	KS	Active
DSH170040HT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CC OCG CLN TRT - Cancer Treatment Olathe	15123 S OMC PKWY	OLATHE	KS	Active
DSH170040HU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam NKC - Briarcliff Cancer Exam	4150 N Mulberry Drive	Kansas City	MO	Active
DSH170040HV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA MAMMO - QCA Mammography	12000 W 151ST ST	OLATHE	KS	Active
DSH170040HW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA ORTHO CLINIC - QCA Ortho Cl	12000 W 151ST ST	OLATHE	KS	Active
DSH170040HX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Lab Int Med Olathe - OCB2 Lab	20805 W 151st St	Olathe	KS	Active
DSH170040HY	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	RVF IM DERMATOLOGY CL - RVF IM Dermatology Clinic	18200 W 119TH ST	OLATHE	KS	Active
DSH170040HZ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCB2 IM CL - OCB2 IM Cl (Int Med Amb Comm Olathe)	20805 W 151ST STREET	OLATHE	KS	Active
DSH170040J	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Clinic OPK	10787 Nall Ave.	Overland Park	KS	Active
DSH170040JA	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CC OCG RAD THER - Cancer Rad Therapy Olathe	15123 S OMC PKWY	OLATHE	KS	Active
DSH170040JB	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Int Med Gen Med SKC - KCMO South Gen Med Cl	1000 E. 101st Terrace	Kansas City	MO	Active
DSH170040JC	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCA2 IM RHEUM CL - OCA2 IM Rheum Cl	20375 W 151ST ST	OLATHE	KS	Active
DSH170040JD	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCA3 IM GASTRO CL - OCA3 IM Gastro CL (Int Med Gastro Comm Olathe)	20375 W 151ST ST	OLATHE	KS	Active
DSH170040JE	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA Sono - QCA Sonography	12000 W. 151st St	Olathe	KS	Active
DSH170040JF	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCA2 NEUROLOGY CL - Neurology Clinic Olathe	20375 W 151ST ST	OLATHE	KS	Active
DSH170040JG	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Lab Olathe Medical Pavilion A - OCA4 Lab- Olathe	20375 W 151st St	Olathe	KS	Active
DSH170040JH	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA UROLOGY CL - QCA Urology Cl (Urology QC)	12000 W 151ST ST	OLATHE	KS	Active
DSH170040JJ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Center for Advanced Disease - MPB4 CCM Gastro IBD	2000 Olathe Blvd	Kansas City	KS	Active
DSH170040JK	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCA2 IM PULMONARY CL - OCA2 IM Pulm Cl (Int Med Pulm Comm Olathe)	20375 W 151ST ST	OLATHE	KS	Active
DSH170040JL	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Orthosurgery PT ICC - ICD2 PT Sports Med	10730 Nall Ave	Overland Park	KS	Active
DSH170040JM	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology General QC - QCA Gen Radiology	12000 W. 151st St	Olathe	KS	Active
DSH170040JN	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA CT - QCA CT	12000 W 151ST ST	OLATHE	KS	Active
DSH170040JP	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA MRI - QCA MRI	12000 W 151ST ST	OLATHE	KS	Active
DSH170040JQ	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCA INFUSION CL - OCA2 Infusion Clinic	20375 W 151ST ST	OLATHE	KS	Active
DSH170040JR	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Psychiatry Adult MP-ICC - ICC Sports Psych	10730 Nall Ave	Overland Park	KS	Active
DSH170040JS	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA PLASTIC SURGERY CL - QCA Plastic Surgery Cl (Plastic Surgery QC)	12000 W 151ST ST	OLATHE	KS	Active
DSH170040JT	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OCB2 IM ENDO CL - OCB2 IM Endo Cl (Int Med Endocrinology Comm Olathe)	20805 W 151ST ST	OLATHE	KS	Active
DSH170040JU	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Orthosurgery Hand Therapy ICC - OCD2 Hand Therapy	10730 Nall Ave	Overland Park	KS	Active
DSH170040JV	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	QCA LAB - Laboratory QC	12000 W 151ST ST	OLATHE	KS	Active
DSH170040JW	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CC OCG EXM - Cancer Exam Olathe	15123 S OMC PKWY	OLATHE	KS	Active
DSH170040JX	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Treatment NKC - Briarcliff Treatment Area	4150 N Mulberry	Kansas City	MO	Active
DSH170040K	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Clinic Liberty	1530 N. Church Road	Liberty	MO	Active
DSH170040L	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Clinic State Ave	5701 State Ave.	Kansas City	KS	Active
DSH170040M	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cardiac Rehab OPK	10787 Nall Ave.	Overland Park	KS	Active
DSH170040N	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Radiology Multidisc W Plaza	1901 W. 47th Place	Westwood	KS	Active
DSH170040P	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Ortho & Sports Medicine ICC	10730 Nall Ave.	Overland Park	KS	Active
DSH170040Q	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CC CRC EXAM/PROC RM	4350 Shawnee Mission Pkwy.	Fairway	KS	Active
DSH170040R	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Landon Center	3599 Rainbow Blvd.	Kansas City	KS	Active
DSH170040S	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Sleep Disorders Center	4720 Rainbow Blvd.	Westwood	KS	Active
DSH170040T	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	ICC IP NURSING UNIT	10710 Nall Ave.	Overland Park	KS	Active
DSH170040U	Child	DSH	KANSAS UNIVERSITY HOSPITAL	Mid-America Cardiology/Kansas City	5501 NW 62ND TERR	KANSAS CITY	MO	Terminated
DSH170040V	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Neurology ICC	10777 Nall Ave.	Overland Park	KS	Active
DSH170040W	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Cancer Exam NKC	2750 Clay Edwards Drive	North Kansas City	MO	Terminated
DSH170040X	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	CV Clinic LVN	3601 S. 4th St.	Leavenworth	KS	Active
DSH170040Y	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	Sports Med Clinic Arrowhead	One Arrowhead Drive	Kansas City	MO	Active
DSH170040Z	Child	DSH	UNIVERSITY OF KANSAS HOSPITAL	OP Surgery State Line	7400 State Line Road	Prairie Village	KS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 10:38:13 AM	9/3/2024 2:19:03 PM	9/3/2024 2:19 PM
Contacts	Primary Contact	Update	PC Change Request	Loucks, Christopher Director of Pharmacy The University of Kansas Health System 9135881521	Holt, Todd Pharmacy Operations Manager The University of Kansas Hospital 9139458291	9/27/2023 8:59 AM
Details	Last Recertification Date	Update	Recertification		9/5/2023 10:38:13 AM	9/5/2023 10:38 AM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Couldry, Rick Vice-President, Pharmacy and Clinical Professions University of Kansas Health System 9135882301	1/13/2023 9:33 AM
Details	340B ID	Update	New Registration		DSH170040GV	1/13/2023 9:33 AM
Details	Entity Subname	Update	New Registration	Medical Pavilion	Medical Pavilion - Interventional Radiology MP	1/13/2023 9:33 AM
Dates	Participating Approval Date	Update	New Registration		1/13/2023 9:33:50 AM	1/13/2023 9:33 AM
Details	State	Update	New Registration	Pending	Approved	1/13/2023 9:33 AM
Dates	Signed By Date	Update	New Registration		1/5/2023 4:20:34 PM	1/13/2023 9:33 AM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	1/13/2023 9:33 AM
Addresses	Main Address	Insert	New Registration		2000 Olathe Blvd Level 3 Suite F Kansas City, KS 66160-8505	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830005	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830010	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830009	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830035	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830030	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830039	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830049	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830003	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003935830004	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600567804	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600072985	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600074046	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600049887	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600072842	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600010163	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		606093706	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		600074047	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010567808	1/4/2023 2:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457335036	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538726880	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265921506	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1962911693	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700395878	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063795896	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417245192	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093003675	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649259656	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457335036	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538726880	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265921506	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1962911693	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700395878	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063795896	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417245192	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093003675	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649259656	1/4/2023 2:25 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/4/2023 2:25 PM
Contacts	Authorizing Official	Insert	New Registration		Couldry, Rick Vice-President, Pharmacy and Clinical Professions University of Kansas Health System 9135882301	1/4/2023 2:25 PM
Contacts	Primary Contact	Insert	New Registration		Loucks, Christopher Director of Pharmacy The University of Kansas Health System 9135881521	1/4/2023 2:25 PM
Details	Assistance Received From Date	Insert	New Registration			1/4/2023 2:25 PM
Details	Assistance Received To Date	Insert	New Registration			1/4/2023 2:25 PM
Details	Last Recertification Date	Insert	New Registration			1/4/2023 2:25 PM
Details	Grant Number	Insert	New Registration			1/4/2023 2:25 PM
Details	340B ID	Insert	New Registration			1/4/2023 2:25 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/4/2023 2:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/4/2023 2:25 PM
Details	Medicare Provider Number	Insert	New Registration		170040	1/4/2023 2:25 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF KANSAS HOSPITAL	1/4/2023 2:25 PM
Details	NOFO Number	Insert	New Registration			1/4/2023 2:25 PM
Details	Program Code	Insert	New Registration		DSH	1/4/2023 2:25 PM
Details	Entity Subname	Insert	New Registration		Medical Pavilion	1/4/2023 2:25 PM
Dates	Participating Approval Date	Insert	New Registration			1/4/2023 2:25 PM
Details	State	Insert	New Registration		Pending	1/4/2023 2:25 PM
Dates	Registration Date	Insert	New Registration		1/4/2023 2:25:42 PM	1/4/2023 2:25 PM
Dates	Signed By Date	Insert	New Registration			1/4/2023 2:25 PM
Dates	Start Date	Insert	New Registration			1/4/2023 2:25 PM
Terminations	Termination Comments	Insert	New Registration			1/4/2023 2:25 PM
Terminations	Termination Date	Insert	New Registration			1/4/2023 2:25 PM
Terminations	Termination Effective Date	Insert	New Registration			1/4/2023 2:25 PM
Terminations	Termination Reason	Insert	New Registration			1/4/2023 2:25 PM