Covered Entity Details

DSH030122P BANNER GATEWAY MEDICAL CENTER (Active) - information as of 4/27/2025 1:48:48 AM

Main Details

Name

BANNER GATEWAY MEDICAL CENTER

Subdivision Name

BANNER MD ANDERSON CANCER CENTER - MD ANDERSON CANCER CENTER CLINIC - APHERSIS KIDNEY CTR-CLINIC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030122P

Medicare Provider Number

030122

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/12/2023

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Banner Gateway Medical Center
Ana Barraza, CFO
(480) 543-2277

Primary Contact

Banner Gateway Medical Center
Tanya Nacy, Pharmacy Director
(480) 543-2190

Addresses

Street Address

2946 E BANNER GATEWAY DR
GILBERT, AZ 85234-2165

Billing Address

BANNER HEALTH ACCOUNTS PAYABLE
PO BOX 2977
PHOENIX, AZ 85062

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
AZ	262489	1699884858

Shipping Addresses

Shipping Address 1

BANNER MD ANDERSON CANCER CENTER
2946 E BANNER GATEWAY DRIVE
2ND FLOOR
GILBERT, AZ 85234

Shipping Address 2

BANNER GATEWAY MEDICAL CENTER
1900 N HIGLEY RD
GILBERT, AZ 85234

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
DSH030122A	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CANCER CENTER CLINIC - AMBULATORY CARE	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122B	Child	DSH	BANNER GATEWAY MEDICAL CENTER	Banner Gateway Surgery Center Ste 100	2940 E BANNER GATEWAY DRIVE	GILBERT	AZ	Terminated
DSH030122C	Child	DSH	BANNER GATEWAY MEDICAL CENTER	Banner Gateway Occupational Health	1920 North Higley Road	Gilbert	AZ	Terminated
DSH030122D	Child	DSH	BANNER GATEWAY MEDICAL CENTER	Banner MD Anderson Outpatient Imaging Center Suite 150	2940 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122E	Child	DSH	BANNER GATEWAY MEDICAL CENTER	Banner Gateway Weight Loss Center	1920 North Higley Road, Suite 306	Gilbert	AZ	Terminated
DSH030122F	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - CT SCANNING - CT SCANNING-CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122G	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - NUCLEAR MEDICINE - NUCLEAR MEDICINE- CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122H	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - PET SCANNING - PET SCANNING- CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122J	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON- BANNER CANCER SPECIALIST CLINICS - C/P-SUPPORT SERVICES-CLINIC (ONCOLOGY)	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122K	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - WELLNESS PROGRAM - WELLNESS PROGRAMS-CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Terminated
DSH030122L	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - MRI - MRI-CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122M	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - RADIATION ONCOLOGY - RADIATION ONCOLOGY-CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122N	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON CLINIC - RADIOLOGY DIAGNOSTICS - RADIOLOGY DIAGNOSTIC-CLINIC	2946 E BANNER GATEWAY DRIVE	GILBERT	AZ	Active
DSH030122P	Child	DSH	BANNER GATEWAY MEDICAL CENTER	BANNER MD ANDERSON CANCER CENTER - MD ANDERSON CANCER CENTER CLINIC - APHERSIS KIDNEY CTR-CLINIC	2946 E BANNER GATEWAY DR	GILBERT	AZ	Active
DSH030122Q	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON - BANNER CANCER SPECIALIST CLINICS - C/P-SUPPORT SERVICES-CLINIC (CARDIO ONCOLOGY) - CARDIO ONCOLOGY	1920 N HIGLEY RD	GILBERT	AZ	Active
DSH030122R	Child	DSH	BANNER GATEWAY MEDICAL CENTER	MD ANDERSON - BANNER CANCER SPECIALIST CLINICS - C/P-SUPPORT SERVICES-CLINIC (HEMATOLOGY) - HEMATOLOGY	1920 N HIGLEY RD	GILBERT	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Update	Profile Change Request	Ziemer, Cody W Chief Financial Officer Banner Gateway Medical Center 4805432277	Ziemer, Cody W Chief Financial Officer Banner University Medical Center Phoenix 6028398507	4/3/2025 6:52 AM
Details	Last Recertification Date	Update	Recertification		8/16/2024 5:04:02 PM	8/16/2024 5:04 PM
Contacts	Authorizing Official	Update	Profile Change Request	Barraza, Ana CFO Banner Estrella Medical Center 4805432277	Barraza, Ana CFO Banner Gateway Medical Center 4805432277	7/12/2024 6:00 AM
Contacts	Authorizing Official	Update	Profile Change Request	Barraza, Ana CFO Banner Estrella Medical Center 6233275026	Barraza, Ana CFO Banner Estrella Medical Center 4805432277	4/11/2024 5:16 PM
Contacts	Authorizing Official	Update	AO Change Request	Ziemer, Cody W Chief Financial Officer Banner Gateway Medical Center 4805432277	Barraza, Ana CFO Banner Estrella Medical Center 6233275026	2/9/2024 9:30 AM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Ziemer, Cody W Chief Financial Officer Banner Gateway Medical Center 4805432277	10/12/2023 9:50 AM
Details	340B ID	Update	New Registration		DSH030122P	10/12/2023 9:50 AM
Details	Entity Subname	Update	New Registration	BANNER MD ANDERSON CANCER CENTER	BANNER MD ANDERSON CANCER CENTER - MD ANDERSON CANCER CENTER CLINIC - APHERSIS KIDNEY CTR-CLINIC	10/12/2023 9:50 AM
Dates	Participating Approval Date	Update	New Registration		10/12/2023 9:50:44 AM	10/12/2023 9:50 AM
Details	State	Update	New Registration	Pending	Approved	10/12/2023 9:50 AM
Dates	Signed By Date	Update	New Registration		10/11/2023 1:04:23 PM	10/12/2023 9:50 AM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/12/2023 9:50 AM
Addresses	Main Address	Insert	New Registration		2946 E BANNER GATEWAY DR GILBERT, AZ 85234-2165	10/11/2023 11:19 AM
Addresses	Billing Address	Insert	New Registration		BANNER HEALTH ACCOUNTS PAYABLE PO BOX 2977 PHOENIX, AZ 85062	10/11/2023 11:19 AM
Addresses	Shipping Address	Insert	New Registration		BANNER MD ANDERSON CANCER CENTER 2946 E BANNER GATEWAY DRIVE 2ND FLOOR GILBERT, AZ 85234	10/11/2023 11:19 AM
Addresses	Shipping Address	Insert	New Registration		BANNER GATEWAY MEDICAL CENTER 1900 N HIGLEY RD GILBERT, AZ 85234	10/11/2023 11:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2023 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		262489	10/11/2023 11:19 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/11/2023 11:19 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699884858	10/11/2023 11:19 AM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/11/2023 11:19 AM
Contacts	Primary Contact	Insert	New Registration		Nacy, Tanya Pharmacy Director Banner Gateway Medical Center 4805432190	10/11/2023 11:19 AM
Contacts	Authorizing Official	Insert	New Registration		Ziemer, Cody W Chief Financial Officer Banner Gateway Medical Center 4805432277	10/11/2023 11:19 AM
Details	Assistance Received From Date	Insert	New Registration			10/11/2023 11:19 AM
Details	Assistance Received To Date	Insert	New Registration			10/11/2023 11:19 AM
Details	Last Recertification Date	Insert	New Registration			10/11/2023 11:19 AM
Details	Grant Number	Insert	New Registration			10/11/2023 11:19 AM
Details	340B ID	Insert	New Registration			10/11/2023 11:19 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2023 11:19 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2023 11:19 AM
Details	Medicare Provider Number	Insert	New Registration		030122	10/11/2023 11:19 AM
Details	Entity Name	Insert	New Registration		BANNER GATEWAY MEDICAL CENTER	10/11/2023 11:19 AM
Details	NOFO Number	Insert	New Registration			10/11/2023 11:19 AM
Details	Program Code	Insert	New Registration		DSH	10/11/2023 11:19 AM
Details	Entity Subname	Insert	New Registration		BANNER MD ANDERSON CANCER CENTER	10/11/2023 11:19 AM
Dates	Participating Approval Date	Insert	New Registration			10/11/2023 11:19 AM
Details	State	Insert	New Registration		Pending	10/11/2023 11:19 AM
Dates	Registration Date	Insert	New Registration		10/11/2023 11:19:27 AM	10/11/2023 11:19 AM
Dates	Signed By Date	Insert	New Registration			10/11/2023 11:19 AM
Dates	Start Date	Insert	New Registration			10/11/2023 11:19 AM
Terminations	Termination Comments	Insert	New Registration			10/11/2023 11:19 AM
Terminations	Termination Date	Insert	New Registration			10/11/2023 11:19 AM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2023 11:19 AM
Terminations	Termination Reason	Insert	New Registration			10/11/2023 11:19 AM