Covered Entity Details

DSH330194V MAIMONIDES MEDICAL CENTER (Active) - information as of 5/27/2025 11:41:26 PM

Main Details

Name

MAIMONIDES MEDICAL CENTER

Subdivision Name

Maimonides Doctors Multispecialty Pavilion - Rheumatology - Rheumatology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330194V

Medicare Provider Number

330194

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/11/2023

Participating Start Date

4/1/2023

Participating Approval Date

1/25/2023

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

Maimonides Medical Center
John Marshall, EVP MedAffair/Chair MedOfficer
(718) 283-8313

Primary Contact

Maimonides Medical Center
Yevgenia Bukher, Assistant Director, Pharmacy
(718) 283-7232

Addresses

Street Address

4813 9TH Ave - Seventh Floor
Brooklyn, NY 11220

Billing Address

Maimonides Medical Center
4802 10th Avenue
Brooklyn, NY 11219

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
NY	02998736,00243641	1093777492,1083623144
NJ	4157206	1093777492

Shipping Addresses

Shipping Address 1

Maimonides Medical Center
4802 10th Avenue
Brooklyn, NY 11219

Shipping Address 2

Maimonides Doctors Multispecialty Pavilion - Rheumatology
4813 9TH Ave - Seventh Floor
Brooklyn, NY 11220

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
Contract Detail	MMC PHARMACY INC	948 48TH ST		BROOKLYN	NY	11219-2918	10/09/2023	01/01/2024	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330194A	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES REHABILITATION SERVICES	883 65TH STREET	BROOKLYN	NY	Active
DSH330194B	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES SLEEP DISORDER CLINIC	6405 7TH AVENUE	BROOKLYN	NY	Active
DSH330194C	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES AMBULATORY CARE CENTER	1301 57TH STREET	BROOKLYN	NY	Active
DSH330194D	Child	DSH	MAIMONIDES MEDICAL CENTER	FORT HAMILTON CLINIC TREATMENT PROGRAM	8710 FIFTH AVENUE	BROOKLYN	NY	Terminated
DSH330194E	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES ADULT/PEDIATRIC DENTAL CLINIC	4303-4305 13TH AVENUE	BROOKLYN	NY	Active
DSH330194F	Child	DSH	MAIMONIDES MEDICAL CENTER	MAPLETON CLINIC TREATMENT CENTER	1083 MCDONALD AVENUE	BROOKLYN	NY	Terminated
DSH330194G	Child	DSH	MAIMONIDES MEDICAL CENTER	9TH AVENUE WOMEN'S PRIMARY CARE CENTER	4422 9TH AVENUE	BROOKLYN	NY	Active
DSH330194H	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES FAMILY HEALTH CENTER	1401 NEWKIRK AVENUE	BROOKLYN	NY	Active
DSH330194J	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES PRIMARY HEALTH SERVICES	6323 SEVENTH AVENUE	BROOKLYN	NY	Active
DSH330194K	Child	DSH	MAIMONIDES MEDICAL CENTER	BENSONHURST CLINIC TREATMENT CENTER	8620 18TH AVENUE	BROOKLYN	NY	Terminated
DSH330194L	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES ADULT PRIMARY CARE CENTER	1250 57TH STREET	BROOKLYN	NY	Active
DSH330194M	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CANCER CENTER	6300 8TH AVENUE	BROOKLYN	NY	Active
DSH330194N	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Breast Center	745 64th Street	Brooklyn	NY	Active
DSH330194P	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CARDIOLOGY OUTPATIENT C	421 OCEAN PKWY	BROOKLYN	NY	Active
DSH330194Q	Child	DSH	MAIMONIDES MEDICAL CENTER	MAIMONIDES CARDIOLOGY OUTPATIENT CENTER	850 49TH ST	BROOKLYN	NY	Active
DSH330194R	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Cardiology	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194S	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Pediatric Specialties	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194T	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Pediatric Cardiology	4813 9TH Avenue	Brooklyn	NY	Active
DSH330194U	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Cardiothoracic Surgery - Cardiothoracic Surgery	4813 9th Avenue - Seventh Floor	Brooklyn	NY	Active
DSH330194V	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Doctors Multispecialty Pavilion - Rheumatology - Rheumatology	4813 9TH Ave - Seventh Floor	Brooklyn	NY	Active
DSH330194W	Child	DSH	MAIMONIDES MEDICAL CENTER	Maimonides Health Bay Ridge Emergency Department - Emergency Department	9036 7th Avenue	Brooklyn	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Marshall, John P Chief Medical Officer Maimonides Medical Center 7182836028	Marshall, John EVP MedAffair/Chair MedOfficer Maimonides Medical Center 7182838313	4/10/2025 10:44 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 10:29:53 AM	8/30/2024 5:19:49 AM	8/30/2024 5:19 AM
Details	Last Recertification Date	Update	Recertification		8/21/2023 10:29:53 AM	8/21/2023 10:29 AM
Contacts	Primary Contact	Update	PC Change Request	Limoncelli, Vito Associate Director Maimonides Medical Center 7182836146	Bukher, Yevgenia Assistant Director, Pharmacy Maimonides Medical Center 7182837232	7/13/2023 11:05 AM
Contacts	Authorizing Official	Update	AO Change Request	Doyle, Declan SVP, Operations and Clinical Programs Maimonides Medical Center 7182837106	Marshall, John P Chief Medical Officer Maimonides Medical Center 7182836028	7/13/2023 7:17 AM
Contacts	Primary Contact	Update	PC Change Request	Luangkamthorn, Chaicharn Assistant Director of Pharmacy, Quality Assurance Maimonides Medical Center 7182837209	Limoncelli, Vito Associate Director Maimonides Medical Center 7182836146	4/3/2023 6:53 AM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	GIBBS, KENNETH D. CEO Maimonides Medical Center 7182836575	Doyle, Declan SVP, Operations and Clinical Programs Maimonides Medical Center 7182837106	3/23/2023 4:32 PM
Contacts	Signed By	Insert	New Registration		GIBBS, KENNETH D. CEO Maimonides Medical Center 7182836575	1/25/2023 7:52 AM
Details	340B ID	Update	New Registration		DSH330194V	1/25/2023 7:52 AM
Details	Entity Subname	Update	New Registration	Maimonides Doctors Multispecialty Pavilion - Rheumatology	Maimonides Doctors Multispecialty Pavilion - Rheumatology - Rheumatology	1/25/2023 7:52 AM
Dates	Participating Approval Date	Update	New Registration		1/25/2023 7:52:59 AM	1/25/2023 7:52 AM
Details	State	Update	New Registration	Pending	Approved	1/25/2023 7:52 AM
Dates	Signed By Date	Update	New Registration		1/17/2023 1:42:20 PM	1/25/2023 7:52 AM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	1/25/2023 7:52 AM
Addresses	Main Address	Insert	New Registration		4813 9TH Ave - Seventh Floor Brooklyn, NY 11220	1/11/2023 3:49 PM
Addresses	Billing Address	Insert	New Registration		Maimonides Medical Center 4802 10th Avenue Brooklyn, NY 11219	1/11/2023 3:49 PM
Addresses	Shipping Address	Insert	New Registration		Maimonides Medical Center 4802 10th Avenue Brooklyn, NY 11219	1/11/2023 3:49 PM
Addresses	Shipping Address	Insert	New Registration		Maimonides Doctors Multispecialty Pavilion - Rheumatology 4813 9TH Ave - Seventh Floor Brooklyn, NY 11220	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02998736	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00243641	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4157206	1/11/2023 3:49 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	1/11/2023 3:49 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093777492	1/11/2023 3:49 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	1/11/2023 3:49 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083623144	1/11/2023 3:49 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	1/11/2023 3:49 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093777492	1/11/2023 3:49 PM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	1/11/2023 3:49 PM
Contacts	Authorizing Official	Insert	New Registration		GIBBS, KENNETH D. CEO Maimonides Medical Center 7182836575	1/11/2023 3:49 PM
Contacts	Primary Contact	Insert	New Registration		Luangkamthorn, Chaicharn Assistant Director of Pharmacy, Quality Assurance Maimonides Medical Center 7182837209	1/11/2023 3:49 PM
Details	Assistance Received From Date	Insert	New Registration			1/11/2023 3:49 PM
Details	Assistance Received To Date	Insert	New Registration			1/11/2023 3:49 PM
Details	Last Recertification Date	Insert	New Registration			1/11/2023 3:49 PM
Details	Grant Number	Insert	New Registration			1/11/2023 3:49 PM
Details	340B ID	Insert	New Registration			1/11/2023 3:49 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/11/2023 3:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/11/2023 3:49 PM
Details	Medicare Provider Number	Insert	New Registration		330194	1/11/2023 3:49 PM
Details	Entity Name	Insert	New Registration		MAIMONIDES MEDICAL CENTER	1/11/2023 3:49 PM
Details	NOFO Number	Insert	New Registration			1/11/2023 3:49 PM
Details	Program Code	Insert	New Registration		DSH	1/11/2023 3:49 PM
Details	Entity Subname	Insert	New Registration		Maimonides Doctors Multispecialty Pavilion - Rheumatology	1/11/2023 3:49 PM
Dates	Participating Approval Date	Insert	New Registration			1/11/2023 3:49 PM
Details	State	Insert	New Registration		Pending	1/11/2023 3:49 PM
Dates	Registration Date	Insert	New Registration		1/11/2023 3:49:11 PM	1/11/2023 3:49 PM
Dates	Signed By Date	Insert	New Registration			1/11/2023 3:49 PM
Dates	Start Date	Insert	New Registration			1/11/2023 3:49 PM
Terminations	Termination Comments	Insert	New Registration			1/11/2023 3:49 PM
Terminations	Termination Date	Insert	New Registration			1/11/2023 3:49 PM
Terminations	Termination Effective Date	Insert	New Registration			1/11/2023 3:49 PM
Terminations	Termination Reason	Insert	New Registration			1/11/2023 3:49 PM