Covered Entity Details

RRC150082-44 DEACONESS HOSPITAL (Active) - information as of 5/6/2025 11:01:26 PM

Main Details

Name

DEACONESS HOSPITAL

Subdivision Name

MTM Clinic Midtown (8070) - MTM Clinic Midtown (8070)

Type

Rural Referral Center

Rural

Yes

340B ID

RRC150082-44

Medicare Provider Number

150082

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/4/2024

Participating Start Date

4/1/2024

Participating Approval Date

1/16/2024

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Deaconess Hospital
Cheryl Wathen, Chief Financial Officer
(812) 450-3296

Primary Contact

Deaconess Hospital
Sarah Laramie, 340B Coordinator
(270) 631-2476

Addresses

Street Address

310 W Iowa St
Evansville, IN 47710

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?
No

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
RRC150082-01	Child	RRC	DEACONESS HOSPITAL	Observation Unit Gateway (7387) - Observation Unit GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-02	Child	RRC	DEACONESS HOSPITAL	Primary Care for Seniors North (9730) - Primary Care for Seniors North	4498 First Ave	Evansville	IN	Active
RRC150082-03	Child	RRC	DEACONESS HOSPITAL	Cardiovascular Short Stay Gateway (7227) - CV short stay GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-04	Child	RRC	DEACONESS HOSPITAL	Radiation Therapy Gateway (8247) - Radiation Therapy GW	4055 Gateway Blvd	Newburgh	IN	Active
RRC150082-05	Child	RRC	DEACONESS HOSPITAL	Interventional Radiology Gateway (8787) - Interventional Rad GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-06	Child	RRC	DEACONESS HOSPITAL	Observation Unit Ortho Neuro Gateway (7357) - Observation Unit Ortho Neuro GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-07	Child	RRC	DEACONESS HOSPITAL	Dialysis Gateway (7757) - Dialysis GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-08	Child	RRC	DEACONESS HOSPITAL	Chancellor Hem/Onc Gateway (8527) - Chancellor Hem/Onc GW	4055 Gateway Blvd	Newburgh	IN	Active
RRC150082-09	Child	RRC	DEACONESS HOSPITAL	Wound Care Center Midtown (8550) - Wound Care Midtown	350 West Columbia Street	Evansville	IN	Active
RRC150082-10	Child	RRC	DEACONESS HOSPITAL	Sleep Center East Columbia Midtown (8157) - Sleep Center East	7307 E. Columbia St	Evansville	IN	Active
RRC150082-11	Child	RRC	DEACONESS HOSPITAL	Cardiology Gateway (8057) - Cardiology GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-12	Child	RRC	DEACONESS HOSPITAL	Primary Care for Seniors East (9740) - Primary Care for Seniors East	1750 Oak Hill Rd	Evansville	IN	Active
RRC150082-13	Child	RRC	DEACONESS HOSPITAL	Surgery Gateway (7087) - Surgery Gateway	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-14	Child	RRC	DEACONESS HOSPITAL	Cardiology Non-invasive Gateway (8117) - Cardiology non-invasive GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-15	Child	RRC	DEACONESS HOSPITAL	Cardiac Rehab Gateway (8507) - Cardiac Rehab Gateway	4015 Gateway Blvd	Newburgh	IN	Active
RRC150082-16	Child	RRC	DEACONESS HOSPITAL	Pain Management Gateway (8677) - Pain Management GW	4015 Gateway Blvd	Newburgh	IN	Active
RRC150082-17	Child	RRC	DEACONESS HOSPITAL	Diagnostic X-Ray Gateway (8797) - Diagnostic X-Ray	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-18	Child	RRC	DEACONESS HOSPITAL	Same Day Surgery Gateway (7347) - SDS Gateway	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-19	Child	RRC	DEACONESS HOSPITAL	CT Gateway (8747) - CT Gateway	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-20	Child	RRC	DEACONESS HOSPITAL	Pain Management West (8670) - Pain Management West	4600 West Lloyd Expressway	Evansville	IN	Active
RRC150082-21	Child	RRC	DEACONESS HOSPITAL	MRI Gateway (8757) - MRI GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-22	Child	RRC	DEACONESS HOSPITAL	Ortho/Neuro SDCC Gateway (7307) - Ortho/Neuro SDCC GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-23	Child	RRC	DEACONESS HOSPITAL	Outpatient Infusion Center Gateway (7277) - Outpatient Infusion Gateway	4111 Gateway Blvd	Newburgh	IN	Active
RRC150082-24	Child	RRC	DEACONESS HOSPITAL	Endoscopy Gateway (7177) - Endoscopy	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-25	Child	RRC	DEACONESS HOSPITAL	Sleep Center West Columbia Midtown (8150) - Sleep Center West	350 West Columbia Street	Evansville	IN	Active
RRC150082-26	Child	RRC	DEACONESS HOSPITAL	Midwest Radiology OA Gateway (8717) - Midwest Radiology OA GW	10455 Orthopaedic Dr	Newburgh	IN	ToBeTerminated
RRC150082-27	Child	RRC	DEACONESS HOSPITAL	Emergency Room Gateway (7067) - Emergency room	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-28	Child	RRC	DEACONESS HOSPITAL	Post Anesthesia Care Unit Gateway (7107) - PACU Gateway	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-29	Child	RRC	DEACONESS HOSPITAL	Cross Pointe PHP (8825) - Cross Pointe PHP	445 Cross Pointe Blvd	Evansville	IN	Active
RRC150082-30	Child	RRC	DEACONESS HOSPITAL	Midwest Radiology MOB4 Gateway (8717) - Midwest Radiology MOB4 GW	4087 Gateway Blvd	Newburgh	IN	Active
RRC150082-31	Child	RRC	DEACONESS HOSPITAL	Bariatric Surgery Unit Midtown (8610) - Bariatric Surgery MT	310 W Iowa St	Evansville	IN	Active
RRC150082-32	Child	RRC	DEACONESS HOSPITAL	Ultrasound Gateway (8777) - Ultrasound GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-33	Child	RRC	DEACONESS HOSPITAL	Respiratory Services Gateway (8147) - Respiratory Services GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-34	Child	RRC	DEACONESS HOSPITAL	Women's Breast Center Midtown (8450) - Women's Breast Center MT	520 Mary St	Evansville	IN	Active
RRC150082-35	Child	RRC	DEACONESS HOSPITAL	Digestive Care and Gastroenterology Gateway (9517) - Digestive Care and Gastroenterology GW	4219 Gateway Blvd	Newburgh	IN	Active
RRC150082-36	Child	RRC	DEACONESS HOSPITAL	Procedure Center ACS Endo (7180) - Procedure Center ACS Endo	4219 Gateway Blvd	Newburgh	IN	Terminated
RRC150082-37	Child	RRC	DEACONESS HOSPITAL	Neuro Outpatient (8687) - Neuro OP Specialty Clinic Mary St	520 Mary St	Evansville	IN	Active
RRC150082-38	Child	RRC	DEACONESS HOSPITAL	Nuclear Medicine Gateway (8767) - Nuclear Medicine GW	4011 Gateway Blvd	Newburgh	IN	Active
RRC150082-39	Child	RRC	DEACONESS HOSPITAL	Family Practice Center Midtown (8260) - Family Practice Midtown	415 W. Columbia St	Evansville	IN	Active
RRC150082-40	Child	RRC	DEACONESS HOSPITAL	Weight Loss Solutions GW (8617) - Weight Loss Solutions GW (8617)	4219 Gateway Blvd.	Newburgh	IN	Active
RRC150082-41	Child	RRC	DEACONESS HOSPITAL	GI Center Radiology (8427) - GI Center Radiology (8427)	4219 Gateway Blvd.	Newburgh	IN	Active
RRC150082-42	Child	RRC	DEACONESS HOSPITAL	GI Center Endoscopy (7777) - GI Center Endoscopy (7777)	4219 Gateway Blvd.	Newburgh	IN	Active
RRC150082-43	Child	RRC	DEACONESS HOSPITAL	MTM Clinic Gateway (8070) - MTM Clinic Gateway (8070)	4209 Gateway Blvd	Newburgh	IN	Active
RRC150082-44	Child	RRC	DEACONESS HOSPITAL	MTM Clinic Midtown (8070) - MTM Clinic Midtown (8070)	310 W Iowa St	Evansville	IN	Active
RRC150082-45	Child	RRC	DEACONESS HOSPITAL	MOB4 Hem/Onc Gateway (8527) - MOB4 Hem/Onc Gateway (8527)	4099 Gateway Blvd	Newburgh	IN	Active
RRC150082-46	Child	RRC	DEACONESS HOSPITAL	DH Dermatology 4th ST (8580) - DH Dermatology 4th ST (8580)	120 SE 4th Street	Evansville	IN	Active
RRC150082-47	Child	RRC	DEACONESS HOSPITAL	DH Rheumatology 4th ST (8540) - DH Rheumatology 4th ST (8540)	120 SE 4th Street	Evansville	IN	Active
RRC150082-48	Child	RRC	DEACONESS HOSPITAL	MOB6 GI (8297) - MOB6 GI (8297)	4219 Gateway Blvd	Newburgh	IN	Active
RRC150082-49	Child	RRC	DEACONESS HOSPITAL	DH MOB6 PEDS GI (8377) - DH MOB6 PEDS GI (8377)	4219 Gateway Blvd	Newburgh	IN	Approved
RRC150082-50	Child	RRC	DEACONESS HOSPITAL	GW SDCCE Surgery (7137) - GW SDCCE Surgery (7137)	4011 Gateway Blvd	Newburgh	IN	Approved
RRC150082-51	Child	RRC	DEACONESS HOSPITAL	DH MOB6 GI QUICK CARE (8277) - DH MOB6 GI QUICK CARE (8277)	4219 Gateway Blvd	Newburgh	IN	Approved
RRC150082-52	Child	RRC	DEACONESS HOSPITAL	DH MOB6 OSTOMY CARE (8550) - DH MOB6 OSTOMY CARE (8550)	4219 Gateway Blvd.	Newburgh	IN	Approved
RRC150082-53	Child	RRC	DEACONESS HOSPITAL	OP INFUSION CENTER MOB6 (7247) - OP INFUSION CENTER MOB6 (7247)	4219 Gateway Blvd	Newburgh	IN	Approved
RRC150082-54	Child	RRC	DEACONESS HOSPITAL	MH MOB4 SURG ONC (8627) - MH MOB4 SURG ONC (8627)	4099 Gateway Blvd	Newburgh	IN	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/14/2024 8:08:47 AM	8/14/2024 8:08 AM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Wathen, Cheryl Chief Financial Officer Deaconess Hospital 8124503296	1/16/2024 9:36 AM
Details	340B ID	Update	New Registration		RRC150082-44	1/16/2024 9:36 AM
Details	Entity Subname	Update	New Registration	MTM Clinic Midtown (8070)	MTM Clinic Midtown (8070) - MTM Clinic Midtown (8070)	1/16/2024 9:36 AM
Dates	Participating Approval Date	Update	New Registration		1/16/2024 9:36:40 AM	1/16/2024 9:36 AM
Details	State	Update	New Registration	Pending	Approved	1/16/2024 9:36 AM
Dates	Signed By Date	Update	New Registration		1/4/2024 1:25:13 PM	1/16/2024 9:36 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	1/16/2024 9:36 AM
Contacts	Primary Contact	Update	Profile Change Request	Laramie, Sarah 340B Coordinator Deaconess Hospital 2708277164	Laramie, Sarah 340B Coordinator Deaconess Hospital 2706312476	1/4/2024 12:24 PM
Addresses	Main Address	Insert	New Registration		310 W Iowa St Evansville, IN 47710	1/4/2024 12:15 PM
Contacts	Authorizing Official	Insert	New Registration		Wathen, Cheryl Chief Financial Officer Deaconess Hospital 8124503296	1/4/2024 12:15 PM
Contacts	Primary Contact	Insert	New Registration		Laramie, Sarah 340B Coordinator Deaconess Hospital 2708277164	1/4/2024 12:15 PM
Details	Assistance Received From Date	Insert	New Registration			1/4/2024 12:15 PM
Details	Assistance Received To Date	Insert	New Registration			1/4/2024 12:15 PM
Details	Last Recertification Date	Insert	New Registration			1/4/2024 12:15 PM
Details	Grant Number	Insert	New Registration			1/4/2024 12:15 PM
Details	340B ID	Insert	New Registration			1/4/2024 12:15 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/4/2024 12:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/4/2024 12:15 PM
Details	Medicare Provider Number	Insert	New Registration		150082	1/4/2024 12:15 PM
Details	Entity Name	Insert	New Registration		DEACONESS HOSPITAL	1/4/2024 12:15 PM
Details	NOFO Number	Insert	New Registration			1/4/2024 12:15 PM
Details	Program Code	Insert	New Registration		RRC	1/4/2024 12:15 PM
Details	Entity Subname	Insert	New Registration		MTM Clinic Midtown (8070)	1/4/2024 12:15 PM
Dates	Participating Approval Date	Insert	New Registration			1/4/2024 12:15 PM
Details	State	Insert	New Registration		Pending	1/4/2024 12:15 PM
Dates	Registration Date	Insert	New Registration		1/4/2024 12:15:08 PM	1/4/2024 12:15 PM
Dates	Signed By Date	Insert	New Registration			1/4/2024 12:15 PM
Dates	Start Date	Insert	New Registration			1/4/2024 12:15 PM
Terminations	Termination Comments	Insert	New Registration			1/4/2024 12:15 PM
Terminations	Termination Date	Insert	New Registration			1/4/2024 12:15 PM
Terminations	Termination Effective Date	Insert	New Registration			1/4/2024 12:15 PM
Terminations	Termination Reason	Insert	New Registration			1/4/2024 12:15 PM