Covered Entity Details

DSH370149AC St Anthony Shawnee Hospital (Active) - information as of 6/6/2025 12:42:32 PM

Main Details

Name

St Anthony Shawnee Hospital

Subdivision Name

ST ANTHONY SHAWNEE HOSPITAL, INC - Emergency Department

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH370149AC

Medicare Provider Number

370149

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/10/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/24/2023

Last Recertification Date

8/31/2024

Contacts

Authorizing Official

- SSM ST ANTHONY HOSPITAL
Shasta Manuel, VP of Finance CFO
(405) 272-7282

Primary Contact

SSM Health
Nathan Przybysz, 340b Program Manager
(314) 989-2214

Addresses

Street Address

2401 W WRANGLER BLVD
SEMINOLE, OK 74868-1917

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
OK	100740840H,100740840A,100740840B	1134123193

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
DSH370149A	Child	DSH	St Anthony Shawnee Hospital	Operating Room	1106 W MACARTHUR STREET	SHAWNEE	OK	Active
DSH370149AA	Child	DSH	St Anthony Shawnee Hospital	ST ANTHONY SHAWNEE HOSPITAL INC - SPS Surgery Shawnee 3204	3204 MEDICAL PARK DRIVE	SHAWNEE	OK	Active
DSH370149AB	Child	DSH	St. Anthony Shawnee Hospital	ST ANTHONY SHAWNEE HOSPITAL INC - SPS Oklahoma Sports & Orthopedics Institute	3315 KETHLEY ROAD	SHAWNEE	OK	Terminated
DSH370149AC	Child	DSH	St Anthony Shawnee Hospital	ST ANTHONY SHAWNEE HOSPITAL, INC - Emergency Department	2401 W WRANGLER BLVD	SEMINOLE	OK	Active
DSH370149AD	Child	DSH	St Anthony Shawnee Hospital	Seminole CT - CT/Radiology	2401 W Wrangler Blvd	Seminole	OK	Active
DSH370149AE	Child	DSH	St Anthony Shawnee Hospital	SASH Wound Care Clinic - Wound Care	3700 N Kickapoo Ave	Shawnee	OK	Active
DSH370149AF	Child	DSH	St Anthony Shawnee Hospital	SPS Peds Express Care - Pediatrics	3315 Kethley Rd	Shawnee	OK	Active
DSH370149AG	Child	DSH	St Anthony Shawnee Hospital	SPS Shawnee Primary Care - Primary Care	3700 N Kickapoo Ave	Shawnee	OK	Active
DSH370149AH	Child	DSH	St Anthony Shawnee Hospital	SPS CARD ADA - Cardiology	3012 Arlington St	Ada	OK	Active
DSH370149AJ	Child	DSH	St Anthony Shawnee Hospital	SPS ENT Kickapoo - ENT	3700 N Kickapoo Ave	Shawnee	OK	Active
DSH370149AK	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee Family Medicine Kickapoo - Family Medicine	3700 N Kickapoo Ave	Shawnee	OK	Active
DSH370149B	Child	DSH	ST ANTHONY SHAWNEE HOSPITAL	Urgent Care Clinic	3200 Medical Park Drive	Shawnee	OK	Terminated
DSH370149C	Child	DSH	St Anthony Shawnee Hospital	ST. ANTHONY PHYSICIANS SHAWNEE FAMILY MEDICINE	3214 KETHLEY ROAD	SHAWNEE	OK	Active
DSH370149D	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Women's Health	3315 Kethley Road	Shawnee	OK	Active
DSH370149E	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Pulmonology	3315 Kethley Road	Shawnee	OK	Active
DSH370149F	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Pediatrics	3315 Kethley Road	Shawnee	OK	Active
DSH370149G	Child	DSH	St Anthony Shawnee Hospital	SSM Health Shawnee Ortho Med Park	3200 Medical Park Dr	Shawnee	OK	Active
DSH370149H	Child	DSH	St. Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Optometry	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149J	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee / Nephrology	3315 Kethley Road	Shawnee	OK	Active
DSH370149K	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee / General Surgery	3315 Kethley Road	Shawnee	OK	Active
DSH370149L	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Cardiology	3315 Kethley Road	Shawnee	OK	Active
DSH370149M	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee / Dermatology	3315 Kethley Road	Shawnee	OK	Active
DSH370149N	Child	DSH	St. Anthony Shawnee Hospital	St Anthony Physicians Shawnee / Allergy	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149P	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Internal Medicine	3315 Kethley Road	Shawnee	OK	Active
DSH370149Q	Child	DSH	St. Anthony Shawnee Hospital	ST ANTHONY PHYSICIANS FAMILY HEALTH	3204 MEDICAL PARK DR	SHAWNEE	OK	Terminated
DSH370149R	Child	DSH	St Anthony Shawnee Hospital	St. Anthony Physicians Shawnee / Urology	3315 Kethley Road	Shawnee	OK	Active
DSH370149S	Child	DSH	St. Anthony Shawnee Hospital	St Anthony Physicians Shawnee CT - SPS CT	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149T	Child	DSH	St. Anthony Shawnee Hospital	St Anthony Physicians Shawnee Radiology - SPS RADIOLOGY	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149U	Child	DSH	St. Anthony Shawnee Hospital	St Anthony Physicians Shawnee Nuclear Medicine - SPS NM	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149V	Child	DSH	St. Anthony Shawnee Hospital	St Anthony Physicians Shawnee MRI - SPS MRI	3315 Kethley Road	Shawnee	OK	Terminated
DSH370149W	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee Neurology - Neurology	3315 Kethley Road, Suite 200	Shawnee	OK	Active
DSH370149X	Child	DSH	St Anthony Shawnee Hospital	St Anthony Physicians Shawnee / Endocrinology - Endocrinology	3315 Kethley Rd	Shawnee	OK	Active
DSH370149Y	Child	DSH	St Anthony Shawnee Hospital	ST ANTHONY SHAWNEE HOSPITAL INC - SPS Lab Shawnee 3315	3315 KETHLEY ROAD	SHAWNEE	OK	Active
DSH370149Z	Child	DSH	St Anthony Shawnee Hospital	ST ANTHONY SHAWNEE HOSPITAL INC - SPS Family Medicine Shawnee 3204	3204 MEDICAL PARK DRIVE	SHAWNEE	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	St. Anthony Shawnee Hospital	St Anthony Shawnee Hospital	6/5/2025 12:26 PM
Contacts	Primary Contact	Update	PC Change Request	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	Przybysz, Nathan 340b Program Manager SSM Health 3149892214	5/20/2025 11:17 AM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	Schmitt, Michelle Nicole VP Pharmacy Financial Operations SSM Health 6082946203	5/19/2025 2:43 PM
Details	Last Recertification Date	Update	Recertification		8/31/2024 2:02:46 PM	8/31/2024 2:02 PM
Contacts	Primary Contact	Update	Profile Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082946203	5/7/2024 9:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100726260B (OK)		4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100740840H	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100740840A	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100740840B	4/10/2024 6:01 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/10/2024 6:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1770794893 (OK)		4/10/2024 6:01 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134123193	4/10/2024 6:01 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/10/2024 6:01 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	10/24/2023 3:54 PM
Details	340B ID	Update	New Registration		DSH370149AC	10/24/2023 3:54 PM
Details	Entity Name	Update	New Registration	ST ANTHONY SHAWNEE HOSPITAL	St. Anthony Shawnee Hospital	10/24/2023 3:54 PM
Details	Entity Subname	Update	New Registration	ST ANTHONY SHAWNEE HOSPITAL, INC	ST ANTHONY SHAWNEE HOSPITAL, INC - Emergency Department	10/24/2023 3:54 PM
Dates	Participating Approval Date	Update	New Registration		10/24/2023 3:54:39 PM	10/24/2023 3:54 PM
Details	State	Update	New Registration	Pending	Approved	10/24/2023 3:54 PM
Dates	Signed By Date	Update	New Registration		10/11/2023 12:54:25 PM	10/24/2023 3:54 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/24/2023 3:54 PM
Addresses	Main Address	Insert	New Registration		2401 W WRANGLER BLVD SEMINOLE, OK 74868-1917	10/10/2023 3:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2023 3:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100726260B	10/10/2023 3:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/10/2023 3:38 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770794893	10/10/2023 3:38 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/10/2023 3:38 PM
Contacts	Authorizing Official	Insert	New Registration		Manuel, Shasta VP of Finance CFO - SSM ST ANTHONY HOSPITAL 4052727282	10/10/2023 3:38 PM
Contacts	Primary Contact	Insert	New Registration		Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	10/10/2023 3:38 PM
Details	Assistance Received From Date	Insert	New Registration			10/10/2023 3:38 PM
Details	Assistance Received To Date	Insert	New Registration			10/10/2023 3:38 PM
Details	Last Recertification Date	Insert	New Registration			10/10/2023 3:38 PM
Details	Grant Number	Insert	New Registration			10/10/2023 3:38 PM
Details	340B ID	Insert	New Registration			10/10/2023 3:38 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2023 3:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2023 3:38 PM
Details	Medicare Provider Number	Insert	New Registration		370149	10/10/2023 3:38 PM
Details	Entity Name	Insert	New Registration		ST ANTHONY SHAWNEE HOSPITAL	10/10/2023 3:38 PM
Details	NOFO Number	Insert	New Registration			10/10/2023 3:38 PM
Details	Program Code	Insert	New Registration		DSH	10/10/2023 3:38 PM
Details	Entity Subname	Insert	New Registration		ST ANTHONY SHAWNEE HOSPITAL, INC	10/10/2023 3:38 PM
Dates	Participating Approval Date	Insert	New Registration			10/10/2023 3:38 PM
Details	State	Insert	New Registration		Pending	10/10/2023 3:38 PM
Dates	Registration Date	Insert	New Registration		10/10/2023 3:38:26 PM	10/10/2023 3:38 PM
Dates	Signed By Date	Insert	New Registration			10/10/2023 3:38 PM
Dates	Start Date	Insert	New Registration			10/10/2023 3:38 PM
Terminations	Termination Comments	Insert	New Registration			10/10/2023 3:38 PM
Terminations	Termination Date	Insert	New Registration			10/10/2023 3:38 PM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2023 3:38 PM
Terminations	Termination Reason	Insert	New Registration			10/10/2023 3:38 PM