Covered Entity Details

DSH330203E CROUSE HOSPITAL (Active) - information as of 4/25/2025 9:23:07 PM

Main Details

Name

CROUSE HOSPITAL

Subdivision Name

CNY Medical Center- Imaging Suite 150 - Radiology Diagnostic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330203E

Medicare Provider Number

330203

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

9/8/2023

Participating Start Date

10/1/2023

Participating Approval Date

9/13/2023

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Crouse Hospital
Kevin Randall, Chief Financial Officer
(315) 470-7589

Primary Contact

Crouse Health
Dwayne Cleveland, Manager of 340B
(315) 470-3402

Addresses

Street Address

739 Irving Avenue
150
Syracuse, NY 13210

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
NY	00279396	1033107743

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
DSH330203A	Child	DSH	CROUSE HOSPITAL	PHYSICIAN'S OFFICE BUILDING SURGERY CENTER (POB)	725 IRVING AVE.	SYRACUSE	NY	Active
DSH330203B	Child	DSH	CROUSE HOSPITAL	MADISON IRVING SURGERY CENTER (MISC)	475 IRVING AVE, SUITE 500	SYRACUSE	NY	Active
DSH330203E	Child	DSH	CROUSE HOSPITAL	CNY Medical Center- Imaging Suite 150 - Radiology Diagnostic	739 Irving Avenue	Syracuse	NY	Active
DSH330203F	Child	DSH	CROUSE HOSPITAL	CROUSE HEALTH ADDICTION TREATMENT S - Addiction Treatment Services	2775 ERIE BLVD E	SYRACUSE	NY	Active
DSH330203G	Child	DSH	CROUSE HOSPITAL	CNY Medical Center- Cardiology Suite 550 - Cardiology Clinic	739 Irving Avenue	Syracuse	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/14/2024 11:48:59 PM	8/14/2024 11:48 PM
Contacts	Primary Contact	Update	Group Change Request	Rossi, Deborah Sr Financial Project Manager Crouse Hospital 3152566842	Cleveland, Dwayne Manager of 340B Crouse Health 3154703402	3/25/2024 7:22 AM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Randall, Kevin Chief Financial Officer Crouse Hospital 3154707589	9/13/2023 1:44 PM
Details	340B ID	Update	New Registration		DSH330203E	9/13/2023 1:44 PM
Details	Entity Subname	Update	New Registration	CNY Medical Center- Imaging Suite 150	CNY Medical Center- Imaging Suite 150 - Radiology Diagnostic	9/13/2023 1:44 PM
Dates	Participating Approval Date	Update	New Registration		9/13/2023 1:44:21 PM	9/13/2023 1:44 PM
Details	State	Update	New Registration	Pending	Approved	9/13/2023 1:44 PM
Dates	Signed By Date	Update	New Registration		9/8/2023 1:20:45 PM	9/13/2023 1:44 PM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	9/13/2023 1:44 PM
Addresses	Main Address	Insert	New Registration		739 Irving Avenue 150 Syracuse, NY 13210	9/8/2023 1:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	9/8/2023 1:20 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00279396	9/8/2023 1:20 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	9/8/2023 1:20 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1033107743	9/8/2023 1:20 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	9/8/2023 1:20 PM
Contacts	Authorizing Official	Insert	New Registration		Randall, Kevin Chief Financial Officer Crouse Hospital 3154707589	9/8/2023 1:20 PM
Contacts	Primary Contact	Insert	New Registration		Rossi, Deborah Sr Financial Project Manager Crouse Hospital 3152566842	9/8/2023 1:20 PM
Details	Assistance Received From Date	Insert	New Registration			9/8/2023 1:20 PM
Details	Assistance Received To Date	Insert	New Registration			9/8/2023 1:20 PM
Details	Last Recertification Date	Insert	New Registration			9/8/2023 1:20 PM
Details	Grant Number	Insert	New Registration			9/8/2023 1:20 PM
Details	340B ID	Insert	New Registration			9/8/2023 1:20 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			9/8/2023 1:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			9/8/2023 1:20 PM
Details	Medicare Provider Number	Insert	New Registration		330203	9/8/2023 1:20 PM
Details	Entity Name	Insert	New Registration		CROUSE HOSPITAL	9/8/2023 1:20 PM
Details	NOFO Number	Insert	New Registration			9/8/2023 1:20 PM
Details	Program Code	Insert	New Registration		DSH	9/8/2023 1:20 PM
Details	Entity Subname	Insert	New Registration		CNY Medical Center- Imaging Suite 150	9/8/2023 1:20 PM
Dates	Participating Approval Date	Insert	New Registration			9/8/2023 1:20 PM
Details	State	Insert	New Registration		Pending	9/8/2023 1:20 PM
Dates	Registration Date	Insert	New Registration		9/8/2023 1:20:41 PM	9/8/2023 1:20 PM
Dates	Signed By Date	Insert	New Registration			9/8/2023 1:20 PM
Dates	Start Date	Insert	New Registration			9/8/2023 1:20 PM
Terminations	Termination Comments	Insert	New Registration			9/8/2023 1:20 PM
Terminations	Termination Date	Insert	New Registration			9/8/2023 1:20 PM
Terminations	Termination Effective Date	Insert	New Registration			9/8/2023 1:20 PM
Terminations	Termination Reason	Insert	New Registration			9/8/2023 1:20 PM