Covered Entity Details

CAH331321-12 ALICE HYDE MEDICAL CENTER (Active) - information as of 4/25/2025 6:36:05 PM

Main Details

Name

ALICE HYDE MEDICAL CENTER

Subdivision Name

Reddy Cancer Treatment Center - Reddy Cancer Treatment Center

Type

Critical Access Hospital

Rural

340B ID

CAH331321-12

Medicare Provider Number

331321

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

11/21/2023

Participating Start Date

11/27/2023

Participating Approval Date

11/27/2023

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Alice Hyde Medical Center/Champlain Valley Physicians Hospital
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065

Primary Contact

Alice Hyde Medical Center
Michael Sprague Dufort, Director of Pharmacy
(518) 481-2404

Addresses

Street Address

23 Fourth St
Suites 1 & 2
Malone, NY 12953

Billing Address

Alice Hyde Medical Center
133 Park St
Malone, NY 12953

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	00354114,04109459	1114954682,1568735660,1689369696

Shipping Addresses

Shipping Address 1

Alice Hyde Medical Center
133 Park St
Malone, NY 12953

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
CAH331321-01	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Dentistry - Alice Hyde Medical Center Dentistry	134 Park St	Malone	NY	Active
CAH331321-02	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Walk In Clinic - Alice Hyde Walk In Clinic	134 Park St.	Malone	NY	Active
CAH331321-03	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center OB/GYN - Alice Hyde Medical Center OB/GYN	16 Third St	Malone	NY	Active
CAH331321-04	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Urology - Alice Hyde Medical Center Urology	133 Park St	Malone	NY	Active
CAH331321-05	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center General Surgery - Alice Hyde Medical Center General Surgery	133 Park St	Malone	NY	Active
CAH331321-06	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Practices - Alice Hyde Medical Center Practices	15 Fourth Street	Malone	NY	Active
CAH331321-07	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Gastroenterology - Alice Hyde Medical Center Gastroenterology	133 Park Street	Malone	NY	Active
CAH331321-08	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Orthopedics - Alice Hyde Medical Center Orthopedics	187 Park Street	Malone	NY	Active
CAH331321-09	Child	CAH	ALICE HYDE MEDICAL CENTER	Pain Management/Pain Management & Primary Care - Pain Management/Pain Management & Primary Care	187 Park Street	Malone	NY	Active
CAH331321-10	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Practices 5 - Primary Care - Alice Hyde Medical Center Practices 5 - Primary Care	20 Fourth Street	Malone	NY	Terminated
CAH331321-11	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Endocrinology - Alice Hyde Medical Center Endocrinology	133 Park St	Malone	NY	Active
CAH331321-12	Child	CAH	ALICE HYDE MEDICAL CENTER	Reddy Cancer Treatment Center - Reddy Cancer Treatment Center	23 Fourth St	Malone	NY	Active
CAH331321-13	Child	CAH	ALICE HYDE MEDICAL CENTER	Alice Hyde Medical Center Pediatrics - Alice Hyde Medical Center Pediatrics	20 Fourth St	Malone	NY	Active
CAH331321-14	Child	CAH	ALICE HYDE MEDICAL CENTER	Malone Medical Practices - Primary Care - Malone Medical Practices - Primary Care	5 Clay Street	Malone	NY	Active
CAH331321-15	Child	CAH	ALICE HYDE MEDICAL CENTER	Leroux Health Center - Leroux Health Center	577 County Route 1	Fort Covington	NY	Active
CAH331321-16	Child	CAH	ALICE HYDE MEDICAL CENTER	Bessette Health Center - Bessette Health Center	6087 State Route 11	Chateaugay	NY	Active
CAH331321-17	Child	CAH	ALICE HYDE MEDICAL CENTER	Tower Health Center - Tower Health Center	76 North Main St	St. Regis Falls	NY	Active
CAH331321-18	Child	CAH	ALICE HYDE MEDICAL CENTER	Dwyer Health Center - Dwyer Health Center	969 State Route 11	Moira	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/15/2024 8:22 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		04109459	9/15/2024 8:22 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	9/15/2024 8:22 PM
Details	Last Recertification Date	Update	Recertification		8/26/2024 7:33:29 AM	8/26/2024 7:33 AM
Addresses	Main Address	Update	Change Request	23 Fourth St Malone, NY 12953	23 Fourth St Suites 1 & 2 Malone, NY 12953	5/1/2024 2:36 PM
Details	State	Update	OPA Edit	Approved	Active	11/27/2023 2:05 PM
Dates	Start Date	Update	OPA Edit	1/1/2024 12:00:00 AM	11/27/2023 12:00:00 AM	11/27/2023 2:05 PM
Contacts	Signed By	Insert	New Registration		Kollar, Matej Vice President/Chief Financial Officer Alice Hyde Medical Center/Champlain Valley Physicians Hospital 5184818065	11/27/2023 1:51 PM
Details	340B ID	Update	New Registration		CAH331321-12	11/27/2023 1:51 PM
Details	Entity Subname	Update	New Registration	Reddy Cancer Treatment Center	Reddy Cancer Treatment Center - Reddy Cancer Treatment Center	11/27/2023 1:51 PM
Dates	Participating Approval Date	Update	New Registration		11/27/2023 1:51:52 PM	11/27/2023 1:51 PM
Details	State	Update	New Registration	Pending	Approved	11/27/2023 1:51 PM
Dates	Signed By Date	Update	New Registration		11/21/2023 2:19:27 PM	11/27/2023 1:51 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	11/27/2023 1:51 PM
Addresses	Main Address	Insert	New Registration		23 Fourth St Malone, NY 12953	11/21/2023 11:06 AM
Addresses	Billing Address	Insert	New Registration		Alice Hyde Medical Center 133 Park St Malone, NY 12953	11/21/2023 11:06 AM
Addresses	Shipping Address	Insert	New Registration		Alice Hyde Medical Center 133 Park St Malone, NY 12953	11/21/2023 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	11/21/2023 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00354114	11/21/2023 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	11/21/2023 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1114954682	11/21/2023 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	11/21/2023 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1568735660	11/21/2023 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	11/21/2023 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1689369696	11/21/2023 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		NY	11/21/2023 11:06 AM
Contacts	Authorizing Official	Insert	New Registration		Kollar, Matej Vice President/Chief Financial Officer Alice Hyde Medical Center/Champlain Valley Physicians Hospital 5184818065	11/21/2023 11:06 AM
Contacts	Primary Contact	Insert	New Registration		Dufort, Michael Sprague Director of Pharmacy Alice Hyde Medical Center 5184812404	11/21/2023 11:06 AM
Details	Assistance Received From Date	Insert	New Registration			11/21/2023 11:06 AM
Details	Assistance Received To Date	Insert	New Registration			11/21/2023 11:06 AM
Details	Last Recertification Date	Insert	New Registration			11/21/2023 11:06 AM
Details	Grant Number	Insert	New Registration			11/21/2023 11:06 AM
Details	340B ID	Insert	New Registration			11/21/2023 11:06 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			11/21/2023 11:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			11/21/2023 11:06 AM
Details	Medicare Provider Number	Insert	New Registration		331321	11/21/2023 11:06 AM
Details	Entity Name	Insert	New Registration		ALICE HYDE MEDICAL CENTER	11/21/2023 11:06 AM
Details	NOFO Number	Insert	New Registration			11/21/2023 11:06 AM
Details	Program Code	Insert	New Registration		CAH	11/21/2023 11:06 AM
Details	Entity Subname	Insert	New Registration		Reddy Cancer Treatment Center	11/21/2023 11:06 AM
Dates	Participating Approval Date	Insert	New Registration			11/21/2023 11:06 AM
Details	State	Insert	New Registration		Pending	11/21/2023 11:06 AM
Dates	Registration Date	Insert	New Registration		11/21/2023 11:06:10 AM	11/21/2023 11:06 AM
Dates	Signed By Date	Insert	New Registration			11/21/2023 11:06 AM
Dates	Start Date	Insert	New Registration			11/21/2023 11:06 AM
Terminations	Termination Comments	Insert	New Registration			11/21/2023 11:06 AM
Terminations	Termination Date	Insert	New Registration			11/21/2023 11:06 AM
Terminations	Termination Effective Date	Insert	New Registration			11/21/2023 11:06 AM
Terminations	Termination Reason	Insert	New Registration			11/21/2023 11:06 AM