Covered Entity Details

RRC230019-03 ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL (Active) - information as of 4/27/2025 12:53:45 AM

Main Details

Name

ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL

Subdivision Name

Providence Pavilion Internal Medicine - Providence Pavilion Internal Medicine

Type

Rural Referral Center

Rural

Yes

340B ID

RRC230019-03

Medicare Provider Number

230019

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/2/2023

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020

Addresses

Street Address

22250 Providence Pkwy Dr
Ste 702
Southfield, MI 48075

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?
No

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
RRC230019-01	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ACADEMIC INTERNAL MEDICINE - Academic Internal Medicine	22250 PROVIDENCE DR	SOUTHFIELD	MI	Active
RRC230019-02	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	OMNI MEDICAL - Omni Medical	22250 PROVIDENCE DR	SOUTHFIELD	MI	Active
RRC230019-03	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	Providence Pavilion Internal Medicine - Providence Pavilion Internal Medicine	22250 Providence Pkwy Dr	Southfield	MI	Active
RRC230019-04	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	CONSULTANTS IN CARDIOLOGY - Consultants in Cardiology	30055 NORTHWESTERN HWY	FARMINGTON HILLS	MI	Active
RRC230019-05	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	PRIMARY CARE CENTER - Primary Care Center	30055 NORTHWESTERN HWY	FARMINGTON HILLS	MI	Active
RRC230019-06	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	PARK INTERNAL MEDICINE - Park Internal Medicine	26850 PROVIDENCE PKWY	NOVI	MI	Active
RRC230019-07	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	DEIGHTON FAMILY PRACTICE - Deighton Family Practice	22250 PROVIDENCE DR	SOUTHFIELD	MI	Active
RRC230019-08	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	PROVIDENCE MEDICAL CTR-SOUTH LYON - Providence Medical Center South Lyon	210 N LAFAYETTE ST	SOUTH LYON	MI	Active
RRC230019-09	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	DEARBORN INTERNAL MEDICINE - DEARBORN INTERNAL MEDICINE	23874 KEAN ST	DEARBORN	MI	Active
RRC230019-10	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	WEST OAKLAND INTERNISTS - Providence West Oakland Internists	44000 W 12 MILE RD	NOVI	MI	Active
RRC230019-11	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	HEART CARDIOLOGY CONSULTANTS - Heart Cardiology Consultants	1225 S LATSON RD	HOWELL	MI	Active
RRC230019-12	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Surgery 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-13	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Surgery Recovery Room 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-14	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Endoscopy GI 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-15	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Dialysis 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-16	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Pulmonary Rehab 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-17	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Respiratory Therapy 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-18	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Mother Baby Unit 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-19	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Labor and Delivery 001 NOVI LDR	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-20	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	OAKLAND FAMILY MEDICINE - Oakland Family Medicine	30055 NORTHWESTERN HWY	FARMINGTON HILLS	MI	Active
RRC230019-21	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	OAKLAND INTERNAL MEDICINE ASSOCS - Oakland Internal Medicine	1435 N MILFORD RD	MILFORD	MI	Active
RRC230019-22	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	FARMINGTON HILLS INTERNISTS - Farmington Hills Internists	30055 NORTHWESTERN HWY	FARMINGTON HILLS	MI	Active
RRC230019-23	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Computerized Tomography CT 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-24	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Interventional Radiology 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-25	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Hyperbaric Oxygen Therapy 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-26	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Emergency Department 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-27	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Observation Unit 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-28	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Observation Unit 004	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-29	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Magnetic Resonance Imaging 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-30	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Diagnostic Radiology 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-31	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Nuclear Medicine 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-32	Child	RRC	ASCENSION PROVIDENCE HOSPITAL	LIVONIA INTERNAL MEDICINE - LIVONIA INTERNAL MEDICINE	37595 7 MILE RD	LIVONIA	MI	Terminated
RRC230019-33	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - PositronEmissionTomography 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-34	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Mammography 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-35	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Cardiac Cath Labs Anc 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-36	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Ultrasound 001	47601 GRAND RIVER AVE	Novi	MI	Active
RRC230019-37	Child	RRC	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	ASCENSION PROVIDENCE HOSPITAL - Anesthesiology 001	47601 GRAND RIVER AVE	Novi	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	ASCENSION PROVIDENCE HOSPITAL	ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL	3/20/2025 1:27 PM
Contacts	Primary Contact	Update	Group Change Request	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	Mansour, Alexander 340B Compliance Officer Henry Ford Hospital 2487230020	1/28/2025 9:42 AM
Addresses	Main Address	Update	Change Request	22255 Greenfield Rd Ste 280 Southfield, MI 48075	22250 Providence Pkwy Dr Ste 702 Southfield, MI 48075	10/23/2024 8:05 AM
Contacts	Authorizing Official	Update	Change Request	McCullough, Michael CFO Ascension Michigan 5867530653	Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/4/2024 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/14/2023 6:36:36 AM	8/15/2024 12:23:02 PM	8/15/2024 12:23 PM
Contacts	Primary Contact	Update	Group Change Request	Beldyga, Lyndy 340b manager Ascension Health 9899078000	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	1/10/2024 7:22 AM
Details	Last Recertification Date	Update	Recertification		8/14/2023 6:36:36 AM	8/14/2023 6:36 AM
Contacts	Primary Contact	Update	Group Change Request	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	Beldyga, Lyndy 340b manager Ascension Health 9899078000	8/3/2023 8:18 AM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	McCullough, Michael CFO Ascension Michigan 5867530653	6/5/2023 7:29 AM
Contacts	Signed By	Insert	New Registration		Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	5/2/2023 6:49 AM
Details	340B ID	Update	New Registration		RRC230019-03	5/2/2023 6:49 AM
Details	Entity Subname	Update	New Registration	Providence Pavilion Internal Medicine	Providence Pavilion Internal Medicine - Providence Pavilion Internal Medicine	5/2/2023 6:49 AM
Dates	Participating Approval Date	Update	New Registration		5/2/2023 6:49:07 AM	5/2/2023 6:49 AM
Details	State	Update	New Registration	Pending	Approved	5/2/2023 6:49 AM
Dates	Signed By Date	Update	New Registration		4/17/2023 2:56:23 PM	5/2/2023 6:49 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/2/2023 6:49 AM
Addresses	Main Address	Insert	New Registration		22255 Greenfield Rd Ste 280 Southfield, MI 48075	4/14/2023 4:12 PM
Contacts	Authorizing Official	Insert	New Registration		Winner, Douglas CFO, Acute Care Operations St John Providence 5867530662	4/14/2023 4:12 PM
Contacts	Primary Contact	Insert	New Registration		Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	4/14/2023 4:12 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2023 4:12 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2023 4:12 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2023 4:12 PM
Details	Grant Number	Insert	New Registration			4/14/2023 4:12 PM
Details	340B ID	Insert	New Registration			4/14/2023 4:12 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2023 4:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2023 4:12 PM
Details	Medicare Provider Number	Insert	New Registration		230019	4/14/2023 4:12 PM
Details	Entity Name	Insert	New Registration		ASCENSION PROVIDENCE HOSPITAL	4/14/2023 4:12 PM
Details	NOFO Number	Insert	New Registration			4/14/2023 4:12 PM
Details	Program Code	Insert	New Registration		RRC	4/14/2023 4:12 PM
Details	Entity Subname	Insert	New Registration		Providence Pavilion Internal Medicine	4/14/2023 4:12 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2023 4:12 PM
Details	State	Insert	New Registration		Pending	4/14/2023 4:12 PM
Dates	Registration Date	Insert	New Registration		4/14/2023 4:12:17 PM	4/14/2023 4:12 PM
Dates	Signed By Date	Insert	New Registration			4/14/2023 4:12 PM
Dates	Start Date	Insert	New Registration			4/14/2023 4:12 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2023 4:12 PM
Terminations	Termination Date	Insert	New Registration			4/14/2023 4:12 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2023 4:12 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2023 4:12 PM