Covered Entity Details

DSH380060Y Portland Adventist Medical Center dba Adventist Health Portland (Active) - information as of 5/17/2025 10:45:51 PM

Main Details

Name

Portland Adventist Medical Center dba Adventist Health Portland

Subdivision Name

Adventist Health Multispecialty Surgery - Multispecialty Surgery

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380060Y

Medicare Provider Number

380060

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/5/2023

Participating Start Date

10/1/2023

Participating Approval Date

8/1/2023

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Portland Adventist Medical Center dba Adventist Health Portland
Jason Panasuk, Finance Officer
(503) 251-6121

Primary Contact

Adventist Health Portland
Rochelle Ford, Clinical Coordinator
(503) 261-6505

Addresses

Street Address

10000 SE Main St
316
Portland, OR 97216

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
OR	158253,269070	1801887658
CA	1801887658	1801887658
ID	1801887658	1801887658
WA	158253,269070,1045716	1801887658
AK	1006442	1801887658

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
DSH380060A	Child	DSH	Adventist Medical Center-Portland	Adventist Hospice-Portland	5835 NE 122nd Ave, #135	Portland	OR	Terminated
DSH380060AA	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Infectious Disease - Infectious Disease Clinic	10201 SE Main St	Portland	OR	Active
DSH380060AB	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	ADVENTIST HEALTH PORTLAND - Gresham Station	831 NW COUNCIL DR	GRESHAM	OR	Active
DSH380060AC	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	ADVENTIST HEALTH PORTLAND - Rheumatology Clinic - Clackamas	10151 SE SUNNYSIDE RD	CLACKAMAS	OR	Approved
DSH380060AD	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	ADVENTIST HEALTH PORTLAND - AH Women's Clinic - Clackamas	10151 SE SUNNYSIDE RD	CLACKAMAS	OR	Approved
DSH380060B	Child	DSH	Adventist Medical Center-Portland	Adventist Hospice-Tillamook	1015 Third Street	Tillamook	OR	Terminated
DSH380060C	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Gresham Station Imaging	831 NW Council Drive	Gresham	OR	Active
DSH380060D	Child	DSH	Adventist Medical Center-Portland	Home Infusion Therapy	5835 NE 122nd Ave, #155	Portland	OR	Terminated
DSH380060E	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Hyperbaric Oxygen Therapy	10201 SE Main Street	Portland	OR	Active
DSH380060F	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	PORTLAND ADVENTIST MEDICAL CENTER - Cardiology Department	10000 SE MAIN ST	PORTLAND	OR	Active
DSH380060G	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	PORTLAND ADVENTIST MEDICAL CENTER - Cardiac Cathetrization Lab	10000 SE MAIN ST	PORTLAND	OR	Active
DSH380060H	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Medical Center Portland Emergency Department - Emergency Department	10123 SE Market St	Portland	OR	Active
DSH380060J	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Clackamas Primary Care - Clackamas Primary Care	10151 SE Sunnyside Rd	Clackamas	OR	Active
DSH380060K	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Lung Clinic - Lung Clinic	10201 SE Main St	Portland	OR	Active
DSH380060L	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Diabetes Clinic - Diabetes Clinic	10101 SE Main St	Portland	OR	Active
DSH380060M	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Rheumatology & Endocrine Clinic - Rheumatology & Endocrine Clinic	10101 SE Main St	Portland	OR	Active
DSH380060N	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Women's Health - AH Women's Health	10101 SE Main St	Portland	OR	Active
DSH380060P	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Sleep Clinic - Sleep Clinic	10201 SE Main St	Portland	OR	Active
DSH380060Q	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland NW Regional Heart and Vascular - Surgical Associates	10000 SE Main St	Portland	OR	Active
DSH380060R	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland NW Regional Heart & Vascular Clinic - NW Regional Heart & Vascular Clinic	10000 SE Main St	Portland	OR	Active
DSH380060S	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Parkrose Primary Care - Parkrose Primary Care	1350 NE 122nd Ave	Portland	OR	Active
DSH380060T	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	AH Portland Primary Care - AH Portland Primary Care (Cherry Park)	10201 SE Main St	Portland	OR	Active
DSH380060U	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	ADVENTIST HEALTH PORTLAND - Troutdale Primary Care	1700 SW 257TH AVE	TROUTDALE	OR	Active
DSH380060V	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Hyperbaric Oxygen Therapy and Wound care - Hyperbaric Oxygen Therapy	10201 SE Main St	Portland	OR	Terminated
DSH380060W	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Radiation Oncology - Radiation Oncology	10123 SE Market St	Portland	OR	Active
DSH380060X	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	ADVENTIST HEALTH PORTLAND - AH Damascus Primary Care	14450 SE ROYER RD	DAMASCUS	OR	Active
DSH380060Y	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Multispecialty Surgery - Multispecialty Surgery	10000 SE Main St	Portland	OR	Active
DSH380060Z	Child	DSH	Portland Adventist Medical Center dba Adventist Health Portland	Adventist Health Portland Gastroenterology - Gastroenterology	10000 SE Main St	Portland	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/19/2024 4:03:05 PM	8/19/2024 4:03 PM
Contacts	Primary Contact	Update	Group Change Request	Sedgwick, Kirsten Wallskog Director of Pharmacy Adventist Health Portland 5032516141	Ford, Rochelle Clinical Coordinator Adventist Health Portland 5032616505	6/25/2024 2:29 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (AL)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	154993105 (AZ)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (MI)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (MO)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	830105028 (MO)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (NV)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100705710A (OK)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	150007601 (TX)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (WI)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1764680 (LA)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000400991z (GA)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003120060A (GA)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000A5864 (NM)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000204005 (CO)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11699A (SC)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0380060 (TN)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q064461 (TN)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (MT)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	97904000 (FL)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801887658 (KY)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000162021 (CO)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	025470 (AZ)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0543173 (IA)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0548670 (OH)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (AL)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (AZ)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (MI)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (MO)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (NV)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (OK)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (TX)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (WI)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (LA)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (GA)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (NM)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (CO)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (IA)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (SC)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (TN)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (MT)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (FL)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (KY)		12/1/2023 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (OH)		12/1/2023 3:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3041902 (CT)		10/13/2023 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2023 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0548670	10/13/2023 11:33 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	10/13/2023 11:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (IN)		10/13/2023 11:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (IL)		10/13/2023 11:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (CT)		10/13/2023 11:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1801887658 (NE)		10/13/2023 11:33 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1801887658	10/13/2023 11:33 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/13/2023 11:33 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	25470 (AZ)		10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	543173 (IA)		10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		025470	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AZ	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0543173	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IA	10/10/2023 1:36 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300014348 (IN)		10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	930429015001 (IL)		10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10025929201 (NE)		10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		97904000	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1801887658	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000162021	10/9/2023 4:54 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	10/9/2023 4:54 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1801887658	10/9/2023 4:54 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	10/9/2023 4:54 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1801887658	10/9/2023 4:54 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	10/9/2023 4:54 PM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Primary Contact	Update	PC Change Request	DeClercque, Kevin Antibiotic stewardship pharmacist Adventist Health Portland 5032516142	Sedgwick, Kirsten Wallskog Director of Pharmacy Adventist Health Portland 5032516141	9/28/2023 8:39 AM
Contacts	Signed By	Insert	New Registration		Panasuk, Jason Finance Officer Portland Adventist Medical Center dba Adventist Health Portland 5032516121	8/1/2023 9:28 AM
Details	340B ID	Update	New Registration		DSH380060Y	8/1/2023 9:28 AM
Details	Entity Name	Update	New Registration	ADVENTIST MEDICAL CENTER-PORTLAND	Portland Adventist Medical Center dba Adventist Health Portland	8/1/2023 9:28 AM
Details	Entity Subname	Update	New Registration	Adventist Health Multispecialty Surgery	Adventist Health Multispecialty Surgery - Multispecialty Surgery	8/1/2023 9:28 AM
Dates	Participating Approval Date	Update	New Registration		8/1/2023 9:28:07 AM	8/1/2023 9:28 AM
Details	State	Update	New Registration	Pending	Approved	8/1/2023 9:28 AM
Dates	Signed By Date	Update	New Registration		7/6/2023 4:20:11 PM	8/1/2023 9:28 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	8/1/2023 9:28 AM
Addresses	Main Address	Insert	New Registration		10000 SE Main St 316 Portland, OR 97216	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		158253	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		269070	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		154993105	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		830105028	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100705710A	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		150007601	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1764680	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		158253	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		269070	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1045716	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000400991z	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003120060A	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300014348	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		930429015001	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000A5864	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1006442	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		25470	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000204005	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3041902	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		543173	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025929201	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11699A	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0380060	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q064461	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MT	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/5/2023 1:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801887658	7/5/2023 1:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	7/5/2023 1:19 PM
Contacts	Primary Contact	Insert	New Registration		DeClercque, Kevin Antibiotic stewardship pharmacist Adventist Health Portland 5032516142	7/5/2023 1:19 PM
Contacts	Authorizing Official	Insert	New Registration		Panasuk, Jason Finance Officer Portland Adventist Medical Center dba Adventist Health Portland 5032516121	7/5/2023 1:19 PM
Details	Assistance Received From Date	Insert	New Registration			7/5/2023 1:19 PM
Details	Assistance Received To Date	Insert	New Registration			7/5/2023 1:19 PM
Details	Last Recertification Date	Insert	New Registration			7/5/2023 1:19 PM
Details	Grant Number	Insert	New Registration			7/5/2023 1:19 PM
Details	340B ID	Insert	New Registration			7/5/2023 1:19 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/5/2023 1:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/5/2023 1:19 PM
Details	Medicare Provider Number	Insert	New Registration		380060	7/5/2023 1:19 PM
Details	Entity Name	Insert	New Registration		ADVENTIST MEDICAL CENTER-PORTLAND	7/5/2023 1:19 PM
Details	NOFO Number	Insert	New Registration			7/5/2023 1:19 PM
Details	Program Code	Insert	New Registration		DSH	7/5/2023 1:19 PM
Details	Entity Subname	Insert	New Registration		Adventist Health Multispecialty Surgery	7/5/2023 1:19 PM
Dates	Participating Approval Date	Insert	New Registration			7/5/2023 1:19 PM
Details	State	Insert	New Registration		Pending	7/5/2023 1:19 PM
Dates	Registration Date	Insert	New Registration		7/5/2023 1:19:43 PM	7/5/2023 1:19 PM
Dates	Signed By Date	Insert	New Registration			7/5/2023 1:19 PM
Dates	Start Date	Insert	New Registration			7/5/2023 1:19 PM
Terminations	Termination Comments	Insert	New Registration			7/5/2023 1:19 PM
Terminations	Termination Date	Insert	New Registration			7/5/2023 1:19 PM
Terminations	Termination Effective Date	Insert	New Registration			7/5/2023 1:19 PM
Terminations	Termination Reason	Insert	New Registration			7/5/2023 1:19 PM