Covered Entity Details

RRC100307-03 ST. VINCENTS MEDICAL CENTER SOUTHSID (Terminated) - information as of 5/24/2025 12:35:20 AM

Main Details

Name

ST. VINCENTS MEDICAL CENTER SOUTHSID

Subdivision Name

Riverside Endocrinology - Endocrinology

Type

Rural Referral Center

Rural

Yes

340B ID

RRC100307-03

Medicare Provider Number

100307

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/4/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/15/2024

Last Recertification Date

8/19/2024

Termination Date
Termination Reason

4/1/2025
Other

Contacts

Authorizing Official

Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206

Primary Contact

Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859

Addresses

Street Address

3 Shircliff Way
Suite 527
Jacksonville, FL 32204

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
FL	0103730-00	1396926747

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
RRC100307-01	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	MAYO CLINIC CANCER CENTER - Oncology	2 SHIRCLIFF WAY	JACKSONVILLE	FL	Terminated
RRC100307-02	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	ST. VINCENT'S EMERGENCY ROOM - Emergency (FSED)	9820 HUTCHINSON PARK DR	JACKSONVILLE	FL	Terminated
RRC100307-03	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	Riverside Endocrinology - Endocrinology	3 Shircliff Way	Jacksonville	FL	Terminated
RRC100307-04	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	RIVERSIDE RHEUMATOLOGY - Rheumatology	3 SHIRCLIFF WAY	JACKSONVILLE	FL	Terminated
RRC100307-05	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	ORANGE PARK RHEUMATOLOGY - Rheumatology	2300 PARK AVE	ORANGE PARK	FL	Terminated
RRC100307-06	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	Pulmonology Southside - Pulmonology	4203 Belfort Road	Jacksonville	FL	Terminated
RRC100307-07	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	PULMONARY CLAY - PULMONOLOGY	1658 ST VINCENTS WAY	MIDDLEBURG	FL	Terminated
RRC100307-08	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	Southside Endocrinology - Endocrinology	4203 Belfort Road	Jacksonville	FL	Terminated
RRC100307-09	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	PULMONARY RIVERSIDE - Pulmonology	3 SHIRCLIFF WAY	JACKSONVILLE	FL	Terminated
RRC100307-10	Child	RRC	ST. VINCENTS MEDICAL CENTER SOUTHSID	Southside Rheumatology - Rheumatology	4203 Belfort Road	Jacksonville	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/15/2025 12:00:00 AM	1/15/2025 7:37 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/15/2025 7:37 AM
Terminations	Termination Comments	Update	Termination Request		I am converting this hospital from an RRC to a DSH-type. I am requesting the RRC termination to coincide with the DSH activation of 1-15-25. Note: I am using the PHE form for the early start-date of the RRC	1/15/2025 7:37 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	1/15/2025 7:37 AM
Terminations	Termination Effective Date	Update	Termination Request		1/15/2025 12:00:00 AM	1/15/2025 7:37 AM
Terminations	Termination Reason	Update	Termination Request		Other	1/15/2025 7:37 AM
Details	Last Recertification Date	Update	Recertification		8/19/2024 4:20:11 PM	8/19/2024 4:20 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	2/15/2024 1:58 PM
Details	340B ID	Update	New Registration		RRC100307-03	2/15/2024 1:58 PM
Details	Entity Name	Update	New Registration	ASCENSION ST. VINCENTS SOUTHSIDE HO	ST. VINCENTS MEDICAL CENTER SOUTHSID	2/15/2024 1:58 PM
Details	Entity Subname	Update	New Registration	Riverside Endocrinology	Riverside Endocrinology - Endocrinology	2/15/2024 1:58 PM
Dates	Participating Approval Date	Update	New Registration		2/15/2024 1:58:12 PM	2/15/2024 1:58 PM
Details	State	Update	New Registration	Pending	Approved	2/15/2024 1:58 PM
Dates	Signed By Date	Update	New Registration		1/10/2024 4:43:07 PM	2/15/2024 1:58 PM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	2/15/2024 1:58 PM
Addresses	Main Address	Insert	New Registration		3 Shircliff Way Suite 527 Jacksonville, FL 32204	1/4/2024 11:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2024 11:47 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0103730-00	1/4/2024 11:47 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/4/2024 11:47 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396926747	1/4/2024 11:47 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	1/4/2024 11:47 PM
Contacts	Primary Contact	Insert	New Registration		Russo, Troy 340B Coordinator Sacred Heart Health System, Inc. 8504162859	1/4/2024 11:47 PM
Contacts	Authorizing Official	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	1/4/2024 11:47 PM
Details	Assistance Received From Date	Insert	New Registration			1/4/2024 11:47 PM
Details	Assistance Received To Date	Insert	New Registration			1/4/2024 11:47 PM
Details	Last Recertification Date	Insert	New Registration			1/4/2024 11:47 PM
Details	Grant Number	Insert	New Registration			1/4/2024 11:47 PM
Details	340B ID	Insert	New Registration			1/4/2024 11:47 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/4/2024 11:47 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/4/2024 11:47 PM
Details	Medicare Provider Number	Insert	New Registration		100307	1/4/2024 11:47 PM
Details	Entity Name	Insert	New Registration		ASCENSION ST. VINCENTS SOUTHSIDE HO	1/4/2024 11:47 PM
Details	NOFO Number	Insert	New Registration			1/4/2024 11:47 PM
Details	Program Code	Insert	New Registration		RRC	1/4/2024 11:47 PM
Details	Entity Subname	Insert	New Registration		Riverside Endocrinology	1/4/2024 11:47 PM
Dates	Participating Approval Date	Insert	New Registration			1/4/2024 11:47 PM
Details	State	Insert	New Registration		Pending	1/4/2024 11:47 PM
Dates	Registration Date	Insert	New Registration		1/4/2024 11:47:00 PM	1/4/2024 11:47 PM
Dates	Signed By Date	Insert	New Registration			1/4/2024 11:47 PM
Dates	Start Date	Insert	New Registration			1/4/2024 11:47 PM
Terminations	Termination Comments	Insert	New Registration			1/4/2024 11:47 PM
Terminations	Termination Date	Insert	New Registration			1/4/2024 11:47 PM
Terminations	Termination Effective Date	Insert	New Registration			1/4/2024 11:47 PM
Terminations	Termination Reason	Insert	New Registration			1/4/2024 11:47 PM