NEW JERSEY DEPARTMENT OF HEALTH
DIVISION OF CERTIFICATE OF NEED AND LICENSING
Presents, pursuant to NJ.S.A. 26:2H-1 et seq.,
this

Designations:

COMMUNITY PERINATAL CENTER - INTERMEDIATE
Acute Hemodialysis
Computerize*

Cystoscopy R]
Mixed OR
MRI mobile

Sleep Center

Licensed: 10906
Effective: 04/01/2016

Expires: 03/31/2017
Issued: 03/15/2016

'
a /Wi _a—
Cathleen D. Bennett

Acting Commissioner

MUST BEPOSTED INA CONSPICUOUS PLACE IN THEFACILiTY

THIS LICENSE IS NOT TRANSFERABlSlES^TO THE ABOVE LOCATIOH ANDTERMINATES ON NOTICE BY THE DEPARTMENT

 FACILITY DATA SHEET

Llcrec

MEADOWLANDS HOSPITAL MEDICAL CENTER
Facility ID:

GENERAL ACUTE CARE HOSPITAL

License No:

Administrator Ms. FELICIA KARSOS

License Expires:

LR-10906-32016

NJ10906
10906

March 31,2016

Address 55 MEADOWLANDS PKWY

Mail To CIO:

CSZ SECAUCUS, NJ 07094

County HUDSON
Phone (201)392-3200

Medicare*

Mail Addressl

310118

MEADOWLANDS HOSPITAL MEDICAL CENTER
55 MEADOWLANDS PKWY

Mail Addrcss2

Medicaids

CSZ

Fax (201)392-3527

SECAUCUS, NJ 07094

Designations

COMMUNITY PERINATAL CENTER - INTERMEDIATE

Services Provided

1

Acute Hemodialysis

1

Computerized Tomography (CT)-Fixed

1

Cystoscopy Room

5

Mixed OR

1

MR1 mobile

1

Sleep Center

Bed Types

30 Comprehensive Rehabilitation Beds

14 Adult ICU/CCU Beds

4 Neonatal Intermediate Care Bassinets

Hospital-Based Oflsites

Licensed

138 Medical Surgical Beds

26 Pediatric Hospital Beds

22 OB/GYNBeds

# of Offsite Facilities:

Name

Pg2

4  f

 Owner-Officer/Principals

MEADOWLANDS HOSPITAL MEDICAL CENTER
GENERAL A CUTE CARE HOSPITAL

Facility ID:

NJ 10906

License*:

10906

License Expires:

March 31,2016

LR-10906-32016

Licrec#:

MHA, LLC

Profit - Corporation

ANASTASIA BURLYUK

0

PROJECTMGMT COMPLETE_MEDlCAL

PAUL DUNAEV

0

EUGENE DUNAEV

0

CAR! HOLDINGS, LLC

0

LAUREN LIPSKY

0

RIMMA LIPSKY

-

TAMARA DUNAEV

-

MIKHAIL LIPSKY

-

ELEANOR LIPSKY
NADIA LIPSKY

-

-

-

0

-

0

LEONARD LIPSKY

0

WK MEADOWLANDS LLC

NLK MGMT, LLC

0

PAVEL POGODIN

0

DANIEL POGODIN

NICHOLAS RENTAS

-

0

Pg2a

0

-

0

-

0
0

-

RICHARD Z UPSKY, MD

NIKOLE POGODIN

-

-

-

0

-

0

0
-

0

 LICENSE RENEWAL QUESTIONAIRE
MEADOWLANDS HOSPITAL MEDICAL CENTER

License* 10906

Expires: 03/31/2016

Ref#: LR-10906-32016

Please answer the following questions (attach additional sheets If necessary)

1: Haveyou or any person mentioned in thisapplication ever had an interest, directly or indirectly, inany application for health care faapproval in New Jersey, or anyotherstate, which was denied or revoked? NQ (yes/no) If yes, indicate whom and give details:

2: Do any oftheprincipals have an ownership, management oroperational interest in any other licensed health care facility in New Jersey,

or any other state?

\J£$> (yes/no) If yes, explain and give name and address of each facility:

fyJu^foiK V\o&o\-Val l_Tfl<lH

ftcuuU-Kj M^HuoR)

PqcKouCc^ Upsk\( (61%) Av\asWrQ 6SnffyL,tr (iS*A) ToJ-ya^kyGuono«*?(?\

3:Are you related to anyperson who now operates or has everoperated a health carefacility in New Jerseyor elsewhere?

nJ^S (yes/no) If yes, give name and address of facility, and full name and relationship ofrelative:

4: Have anyprincipals, owners, operators or managers ofthis facility oranyother licensed healthcare facility, in this state oranyother state,
ever been indicted for, or charged with, or havebeenfound guilty of, a criminal or administrative chargeofMedicaid/Medicare fraud,
Medicaid/Medicare abuse,or Medicaid/Medicare waste?
kid (yes/no) Ifyes, explain in detail:

5: Have anyprincipals, owners, operators or managers ofthefacility everbeenIndicted for or convicted ofa felony crime?
KlQ (yes/no) If yes, explain in details:

CERTIFICATION

The applicant certifies:

1) that all information contained in this application and attachments istrue and correct, tothebestofhis/her knowledge and
belief, and that willful misrepresentation ofthese facts maymakethe applicant subjectto civil penalties;
2) that the application has been duly authorized by the governing bodyof the applicant;
3) thatthe facility has been and will be operated inaccordance with applicable licensing requirements;
4) thatthe facility is notsuspended, debarred , or otherwise excluded for any reason from entering into the covered
transaction; and

5) that the facilityis in compliance with the requirements of Section 6032 of The Federal Deficit Reduction Act.
Nameof authorized individual completing form (print or type):

Print Name: PeWlQ K^^^
Signature:

Title: C£~Q

^tljuUti fcft/l^xn,

Date: ^JKnjdO/U
Pg3

 LICENSE RENEWAL CORRECTION FORM
PAYMENT / DATA CORRECTION / DATA UPDATE
for

MEADOWLANDS HOSPITAL MEDICAL CENTER

Facility ID: NJ10906
License Renewal #

License No: 10906

License Expires: 03/31/2016
Accreditation

LR-10906-32016

DNV

Date Returned

Method of payment

Renewal Fee S

\ 0,000

ChkorRcf*

* Inspection Fee $

0

Amt Submitted $

Address

City
Zip

Corrections to Data / Add Missing Data

SECAUCUS
07094

(201)392-3200
(201)392-3527

Mail Address 1

Edit/Update Accreditation Info as Needed.
Submit letter/cert from agency:

MEADOWLANDS HOSPITAL MEDICAL CENTER

Fax

Mail To

Y

55 MEADOWLANDS PKWY

Telephone
Email Address

Deemed

01/06/2014

* Billed in odd years

Currently in the State Database

Legal Name

Expires

Total Due $ 10,000

mail@meadowlandshospital.org
MEADOWLANDS HOSPrTAL MEDICAL CENTER

55 MEADOWLANDS PKWY

Mail Address2

Mail City

Mail Zip

SECAUCUS
07094

Attn:

Primary Person
Admin Salutation

Ms

Admin First Name

FELICIA

Admin Last Name

KARSOS

Admin Title

Licensed Owner

MHA.LLC

Address

City
ST

Zip

Basinets Type
Example:

Profit - Corporation

(Proflt-LLC, Non-Profit-LLC, Profit-Corp,
Non-Profit-Religious, Govt-State etc)

Emergency Contact: fe\_YCA&. KCk fOO S"

phone: (<^0») S°l A"3<^ 7

Emergency Email: P"/CQ^0S"<? nOCadoUjlGLOck hoSflTt£.\ , OTQ
Changes made bv:(Print)

feWo.\a fca.csos

Signature:

?**• <$0 0 3°) e) S<S~<S} 7
Date:

__ sJ-jlLu*. /sat^oPg4

<^hu l^oj l,

 Imhmc
I

meadowlands

hospital If

55 Meadowlands Parkway
Secaucus, NJ 07094
P. 201-392-3100

www.meadowlandshospital.org

February 25,2016

Janet Diaz

Office of Certificate of Need and

Healthcare Facility Licensure
State of New Jersey Department of Health
P.O. Box 358

Trenton, NJ. 08625-0358

Re: Meadowlands Hospital Medical Center License Renewal
Facility U: NJ10906/License# 10906
Dear Ms. Diaz:

Enclosed please find Meadowlands Hospital License Renewal forms and Check # 003004 in the

amount of $10,000. Please contact me directly with any questions at (201) 392-3227.
Sincerely,

)&?*a&0-^
Felicia Karsos,
Chief Executive Officer

 W

COMMENT

02/24/16

MEADOWLANDS HOSPITAL MEDICAL CENTER

TEN THOUSAND 00/100

OF

TO THE
ORDER

PAY

STATE OF NEW JERSEY

VOIO If NOT CASHED WITMIH 90 DAYS

212

55 2

.•OD3OD0M'i:0 3l!0 7&O7i:ii,B0E,1.5 tmiM-

PAY

TOTAL

"♦$10000.00

10000.0

AMOUNT

02/24/16

10000.00

0030004

CHECK
NUMBER

"$10000.00

DETACH HERE FOR YOURRECORDS

PNC Bank, N.A.

ISSUE
DATE

0.00

0.00

SECAUCUS, NJ 07094

0

NET AMOUNT

NO. 0030004
DISCOUNT

THIS CHECK HAS ACOLORED BACKGROUND AND WILL PRINT VOID IF COPIED

%5 MEADOWLANDS PARKWAY

lECAUCUS, NJ 07094

0030004

PO BOX 358

55 MEADOWLANDS PARKWAY

CHECK NUMBER

a-xium^u ")i^c10cc.

LIC#: 10906

INVOICE NUMBER

DEPARTMENT OF HEALTH

MEADOWLANDS HOSPITAL MEDICAL CENTER

CHECK DATE

01/22/16

DATE

STATE OF NEW JERSEY

-D-

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