Covered Entity Details

DSH250069E RUSH FOUNDATION HOSPITAL (Active) - information as of 4/27/2025 12:53:26 AM

Main Details

Name

RUSH FOUNDATION HOSPITAL

Subdivision Name

Imaging Ctr Rad Diag RFHH NA09 - RUSH MOBH XRAY IMAGING CENTER

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH250069E

Medicare Provider Number

250069

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2023

Participating Start Date

1/1/2024

Participating Approval Date

11/1/2023

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Ochsner Rush Health
David Butler, Chief Financial Officer
(601) 703-3082

Primary Contact

Rush Foundation Hospital
Nicole Harmon, Director of Pharmacy
(601) 703-4952

Addresses

Street Address

1800 12th Street
Meridian, MS 39301

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
MS	00020049,09014336	1588625594,1770543399
AL	hos0069p	1770543399

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
DSH250069A	Child	DSH	RUSH FOUNDATION HOSPITAL	Rad/Diagic RFHH NA09 - RUSH MOBH XRAY BONE IMAGING CENTER	1800 12th Street	Meridian	MS	Active
DSH250069AA	Child	DSH	RUSH FOUNDATION HOSPITAL	MRI RFHH NA09 - RUSH MOBH MRI	1800 12th Street	Meridian	MS	Active
DSH250069AB	Child	DSH	RUSH FOUNDATION HOSPITAL	Int Med Prov B Clin RFHP TS04 - RUSH MOBC INTERNAL MEDICINE	1800 12th Street	Meridian	MS	Active
DSH250069AC	Child	DSH	RUSH FOUNDATION HOSPITAL	ENT Prov Clinic RFHP TS04 - RUSH MOBC OTORHINOLARYNGOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069AD	Child	DSH	RUSH FOUNDATION HOSPITAL	CardProv B Clinic RFHP TS04 - RUSH MOBC CARDIOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069B	Child	DSH	RUSH FOUNDATION HOSPITAL	Imag Ctr Ultrasound RFHH NA09 - RUSH MOBH ULTRASOUND IMAGING CENTER	1800 12th Street	Meridian	MS	Active
DSH250069C	Child	DSH	RUSH FOUNDATION HOSPITAL	Imaging Ctr Cat Scan RFHH NA09 - RUSH MOBH CT SCAN IMAGING CENTER	1800 12th Street	Meridian	MS	Active
DSH250069D	Child	DSH	RUSH FOUNDATION HOSPITAL	Imaging Ctr Mammo RFHH NA09 - RUSH MOBH MAMMOGRAPHY IMAGING CENTER	1800 12th Street	Meridian	MS	Active
DSH250069E	Child	DSH	RUSH FOUNDATION HOSPITAL	Imaging Ctr Rad Diag RFHH NA09 - RUSH MOBH XRAY IMAGING CENTER	1800 12th Street	Meridian	MS	Active
DSH250069F	Child	DSH	RUSH FOUNDATION HOSPITAL	Rad/Ultrasound RFHH NA09 - RUSH MOBH OBSTETRICS AND GYNECOLOGY ULTRASOUND	1800 12th Street	Meridian	MS	Active
DSH250069G	Child	DSH	RUSH FOUNDATION HOSPITAL	Women'S Hthcare Clin RFHH FS04 - RUSH WHCH MAMMOGRAPHY	1730 14th Street	Meridian	MS	Active
DSH250069H	Child	DSH	RUSH FOUNDATION HOSPITAL	Pain Control RFHP NA09 - RUSH ASCH PAIN MANAGEMENT	1300 18th Street	Meridian	MS	Active
DSH250069J	Child	DSH	RUSH FOUNDATION HOSPITAL	Vasc Institute Rush RFHH TS04 - RUSH MOBC VASCULAR SURGERY	1800 12th Street	Meridian	MS	Active
DSH250069K	Child	DSH	RUSH FOUNDATION HOSPITAL	Pacu (Recovery Room) RFHH NA09 - RUSH ASCH ORTHOPEDIC PACU	1300 18th Street	Meridian	MS	Active
DSH250069L	Child	DSH	RUSH FOUNDATION HOSPITAL	Operating Rooms RFHH NA09 - RUSH ASCH ORTHOPEDIC INTRA-OP	1300 18th Street	Meridian	MS	Active
DSH250069M	Child	DSH	RUSH FOUNDATION HOSPITAL	Nephrology RFHP TS04 - RUSH MOBC NEPHROLOGY	1800 12th Street	Meridian	MS	Active
DSH250069N	Child	DSH	RUSH FOUNDATION HOSPITAL	Diabeties Education RFHH NA09 - RUSH MOBC DIABETES CARE AND EDUCATION	1800 12th Street	Meridian	MS	Active
DSH250069P	Child	DSH	RUSH FOUNDATION HOSPITAL	GI Lab RFHH NA09 - RUSH ASCH ENDOSCOPY	1300 18th Street	Meridian	MS	Active
DSH250069Q	Child	DSH	RUSH FOUNDATION HOSPITAL	Neuro Prov B Clinic RFHP TS04 - RUSH MOBC NEUROLOGY	1800 12th Street	Meridian	MS	Active
DSH250069R	Child	DSH	RUSH FOUNDATION HOSPITAL	The Vein Center RFHP TS04 - RUSH MOBC VEIN CENTER	1800 12th Street	Meridian	MS	Active
DSH250069S	Child	DSH	RUSH FOUNDATION HOSPITAL	Ob/Gyn Prov B Clinic RFHP TS04 - RUSH MOBC OBSTETRICS AND GYNECOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069T	Child	DSH	RUSH FOUNDATION HOSPITAL	Pulm Prov B Clinic RFHP TS04 - RUSH MOBC PULMONOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069U	Child	DSH	RUSH FOUNDATION HOSPITAL	Rheumatology RFHP TS04 - RUSH MOBC RHEUMATOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069V	Child	DSH	RUSH FOUNDATION HOSPITAL	Audiology PB Clinic RFHH TS04 - RUSH MOBC AUDIOLOGY	1800 12th Street	Meridian	MS	Active
DSH250069W	Child	DSH	RUSH FOUNDATION HOSPITAL	Diab Prov B Clinic RFHP TS04 - RUSH MOBC DIABETES MANAGEMENT	1800 12th Street	Meridian	MS	Active
DSH250069X	Child	DSH	RUSH FOUNDATION HOSPITAL	Surgery Prov B Clin RFHP TS04 - RUSH MOBC GENERAL SURGERY	1800 12th Street	Meridian	MS	Active
DSH250069Y	Child	DSH	RUSH FOUNDATION HOSPITAL	Spine/Neur ProB Clin RFHP TS04 - RUSH MOBC SPINE SERVICES	1800 12th Street	Meridian	MS	Active
DSH250069Z	Child	DSH	RUSH FOUNDATION HOSPITAL	Urology Prov B Clin RFHP TS04 - RUSH MOBC UROLOGY	1800 12th Street	Meridian	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		9/3/2024 10:11:25 AM	9/3/2024 10:11 AM
Contacts	Authorizing Official	Update	AO Change Request	Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	Butler, David Chief Financial Officer Ochsner Rush Health 6017033082	5/29/2024 6:42 AM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	11/1/2023 1:09 PM
Details	340B ID	Update	New Registration		DSH250069E	11/1/2023 1:09 PM
Details	Entity Subname	Update	New Registration	Imaging Ctr Rad Diag RFHH NA09	Imaging Ctr Rad Diag RFHH NA09 - RUSH MOBH XRAY IMAGING CENTER	11/1/2023 1:09 PM
Dates	Participating Approval Date	Update	New Registration		11/1/2023 1:09:18 PM	11/1/2023 1:09 PM
Details	State	Update	New Registration	Pending	Approved	11/1/2023 1:09 PM
Dates	Signed By Date	Update	New Registration		10/4/2023 5:33:59 PM	11/1/2023 1:09 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	11/1/2023 1:09 PM
Addresses	Main Address	Insert	New Registration		1800 12th Street Meridian, MS 39301	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00020049	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		09014336	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		hos0069p	10/4/2023 5:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/4/2023 5:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1588625594	10/4/2023 5:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/4/2023 5:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770543399	10/4/2023 5:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/4/2023 5:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770543399	10/4/2023 5:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	10/4/2023 5:33 PM
Contacts	Authorizing Official	Insert	New Registration		Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	10/4/2023 5:33 PM
Contacts	Primary Contact	Insert	New Registration		Harmon, Nicole Director of Pharmacy Rush Foundation Hospital 6017034952	10/4/2023 5:33 PM
Details	Assistance Received From Date	Insert	New Registration			10/4/2023 5:33 PM
Details	Assistance Received To Date	Insert	New Registration			10/4/2023 5:33 PM
Details	Last Recertification Date	Insert	New Registration			10/4/2023 5:33 PM
Details	Grant Number	Insert	New Registration			10/4/2023 5:33 PM
Details	340B ID	Insert	New Registration			10/4/2023 5:33 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2023 5:33 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2023 5:33 PM
Details	Medicare Provider Number	Insert	New Registration		250069	10/4/2023 5:33 PM
Details	Entity Name	Insert	New Registration		RUSH FOUNDATION HOSPITAL	10/4/2023 5:33 PM
Details	NOFO Number	Insert	New Registration			10/4/2023 5:33 PM
Details	Program Code	Insert	New Registration		DSH	10/4/2023 5:33 PM
Details	Entity Subname	Insert	New Registration		Imaging Ctr Rad Diag RFHH NA09	10/4/2023 5:33 PM
Dates	Participating Approval Date	Insert	New Registration			10/4/2023 5:33 PM
Details	State	Insert	New Registration		Pending	10/4/2023 5:33 PM
Dates	Registration Date	Insert	New Registration		10/4/2023 5:33:55 PM	10/4/2023 5:33 PM
Dates	Signed By Date	Insert	New Registration			10/4/2023 5:33 PM
Dates	Start Date	Insert	New Registration			10/4/2023 5:33 PM
Terminations	Termination Comments	Insert	New Registration			10/4/2023 5:33 PM
Terminations	Termination Date	Insert	New Registration			10/4/2023 5:33 PM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2023 5:33 PM
Terminations	Termination Reason	Insert	New Registration			10/4/2023 5:33 PM