Covered Entity Details

PED143300-59 Ann & Robert H. Lurie Children's Hospital of Chicago (Active) - information as of 6/5/2025 4:53:57 PM

Main Details

Name

Ann & Robert H. Lurie Children's Hospital of Chicago

Subdivision Name

LURIE CHILDRENS OUTPATIENT CENTER - 103119 HOSP - Uptown - Behavior and Development

Type

Children's Hospital

Rural

340B ID

PED143300-59

Medicare Provider Number

143300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/15/2024

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Ann & Robert H. Lurie Children's Hospital of Chicago
Brian Stahulak, Chief Nursing Officer
(312) 227-4622

Primary Contact

Ann & Robert H Lurie Children's Hospital of Chicago
Jenny Elhadary, VP Clinical Services
(312) 227-4161

Addresses

Street Address

4867 N BROADWAY ST
CHICAGO, IL 60640-3603

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
IL	362170833	1235234535

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
PED143300-02	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103030 HOSP - CLK/DEM - Embedded Mental Health Providers/Child Abuse	467 W. Deming Place	CHICAGO	IL	Active
PED143300-03	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102210 HOSP - SKO - Cardiology Diagnostic	3722 TOUHY AVE	SKOKIE	IL	Active
PED143300-04	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102204 HOSP - WST - Cardiology	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-05	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDREN'S SURGERY CENTER - 102191 HOSP - NB - Operating Room	1121 TECHNY RD	NORTHBROOK	IL	Active
PED143300-06	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102190 HOSP - WST - Operating Room	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-07	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102220/102202 HOSP - CLK/DEM - Cardiac Exercise Lab/ECG	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-08	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102293/102263 HOSP - WST - Ultrasound/Radiology	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-09	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102292/102262 HOSP - NB - Ultrasound/Radiology	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-10	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102297/102265 HOSP - SKO - Ultrasound/Radiology	3722 TOUHY AVE	SKOKIE	IL	Active
PED143300-11	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102291/102261 HOSP - CLK/DEM - Ultrasound/ Radiology	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-12	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103053 HOSP - CLK/DEM - Urodynamics	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-13	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103101 HOSP - NB - Immediate Care	1131 TECHNY RD	NORTHBROOK	IL	Terminated
PED143300-14	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102283 HOSP - NB - MRI Scanning	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-15	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102281 HOSP - CLK/DEM - MRI Scanning	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-16	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102282 HOSP - WST - MRI Scanning	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-17	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102295 HOSP - NWC - Ultrasound	880 W CENTRAL RD	ARLINGTON HEIGHTS	IL	Active
PED143300-18	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103113 HOSP - WST - Psych Services	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-19	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102207 HOSP - NWC - Cardiology Diagnostic	880 W CENTRAL RD	ARLINGTON HEIGHTS	IL	Active
PED143300-20	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102205 HOSP - NB - Cardiology Diagnostic	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-21	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102222 HOSP - LF Pulmonary Function Test	900 N WESTMORELAND RD	LAKE FOREST	IL	Active
PED143300-22	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102224 HOSP - NWC - Pulmonary Function Test	880 W CENTRAL RD	ARLINGTON HEIGHTS	IL	Active
PED143300-23	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102223 HOSP - NB - Pulmonary Function Test	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-24	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103115/ 102121 Dayton - Psych Services	1440 N DAYTON ST	CHICAGO	IL	Active
PED143300-25	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102225 HOSP - WST - Pulmonary Function Test	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-26	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103080 WST Outpatient Specialty Clinic	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-27	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103088 SKO Outpatient Specialty Clinic	3722 TOUHY AVE	SKOKIE	IL	Active
PED143300-28	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103008 CLK/DEM Endocrinology Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-29	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103085 LF Outpatient Specialty Clinic	900 N WESTMORELAND RD	LAKE FOREST	IL	Active
PED143300-30	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103025 Dayton Adolescent Medicine	1440 N DAYTON ST	CHICAGO	IL	Active
PED143300-31	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103087 NWC Outpatient Specialty Clinic	880 W CENTRAL RD	ARLINGTON HEIGHTS	IL	Active
PED143300-32	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103082 NB Outpatient Specialty Clinic	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-33	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103046 HOSP - CLK/DEM - Orthopaedic Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-34	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103052 HOSP - CLK/DEM - Urology	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-35	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103023 HOSP - CLK/DEM - Special ID Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-36	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103005 HOSP - CLK/DEM - Cardiology Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-37	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103010 HOSP - CLK/DEM - Gastroenterology Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-38	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103042 HOSP - CLK/DEM - Neurosurgery	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-39	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103028 HOSP - CLK/DEM NEPHROLOGY CLINIC	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-40	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103016 HOSP - CLK/DEM - Neurology	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-41	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103018 HOSP - CLK/DEM - Pulmonary Medicine Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-42	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103020 HOSP - CLK/DEM - Rheumatology Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-43	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103027 HOSP - CLK/DEM Genetics Clinic	467 W. Deming Place	Chicago	IL	Active
PED143300-44	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103100 HOSP - CLK/DEM - Immediate Care	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-45	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103058 HOSP - CLK/DEM - Pediatric Surgery Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-46	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103026 HOSP - CLK/DEM Dermatology Clinic	467 W. Deming Place	Chicago	IL	Active
PED143300-47	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103048 HOSP - CLK/DEM - Otolaryngology Clinic	467 W. Deming Place	Chicago	IL	Active
PED143300-48	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 104030 HOSP - CLK/DEM Medical Imaging Nursing	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-49	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103044 HOSP - CLK/DEM - Ophthalmology Clinic	467 W. Deming Place	Chicago	IL	Active
PED143300-50	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103003 HOSP - CLK/DEM - Allergy	467 W. Deming Place	Chicago	IL	Active
PED143300-51	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103029 HOSP - CLK/DEM Behavior and Development	467 W. Deming Place	Chicago	IL	Active
PED143300-52	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103050 HOSP - CLK/DEM - Plastic Surgery Clinic	467 W. Deming Place	Chicago	IL	Active
PED143300-53	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103111 - HOSP - CLK/DEM - Psych Services	467 W. Deming Place	Chicago	IL	Active
PED143300-54	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103091 HOSP - Dayton - Outpatient Services	1440 N DAYTON ST	CHICAGO	IL	Active
PED143300-55	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102165 HOSP - WST - Neurology Lab (EEG)	2301 ENTERPRISE DR	WESTCHESTER	IL	Active
PED143300-56	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103112 HOSP - NB - Psych Services	1131 TECHNY RD	NORTHBROOK	IL	Active
PED143300-57	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102163 HOSP - NWC - Neurology Lab (EEG)	880 W CENTRAL RD	ARLINGTON HEIGHTS	IL	Active
PED143300-58	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102128 HOSP - Dayton - Substance Use	1440 N DAYTON ST	CHICAGO	IL	Active
PED143300-59	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS OUTPATIENT CENTER - 103119 HOSP - Uptown - Behavior and Development	4867 N BROADWAY ST	CHICAGO	IL	Active
PED143300-60	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102106 HOSP - DAYTON PSYCH ADOLESCENT MED	1440 N DAYTON ST	CHICAGO	IL	Active
PED143300-61	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102211 HOSP - CLK/DEM - Echocardiology	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-62	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDREN'S SURGERY CENTER - 103093 HOSP - NB - Outpatient Services (ASTC 1121)	1121 TECHNY RD	NORTHBROOK	IL	Active
PED143300-63	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 103034 HOSP - Clark High Consequence Infectious Diseases Clinic	2515 N CLARK ST	CHICAGO	IL	Active
PED143300-64	Child	PED	Ann & Robert H. Lurie Children's Hospital of Chicago	LURIE CHILDRENS HOSPITAL OUTPATIENT - 102222 HOSP - Clark Pulmonary Function Test	2515 N CLARK ST	CHICAGO	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/27/2024 12:38:03 PM	8/27/2024 12:38 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Stahulak, Brian Chief Nursing Officer Ann & Robert H. Lurie Children's Hospital of Chicago 3122274622	2/15/2024 5:09 PM
Details	340B ID	Update	New Registration		PED143300-59	2/15/2024 5:09 PM
Details	Entity Name	Update	New Registration	ANN & ROBERT H. LURIE CHILDRENS HOS	Ann & Robert H. Lurie Children's Hospital of Chicago	2/15/2024 5:09 PM
Details	Entity Subname	Update	New Registration	LURIE CHILDRENS OUTPATIENT CENTER	LURIE CHILDRENS OUTPATIENT CENTER - 103119 HOSP - Uptown - Behavior and Development	2/15/2024 5:09 PM
Dates	Participating Approval Date	Update	New Registration		2/15/2024 5:09:04 PM	2/15/2024 5:09 PM
Details	State	Update	New Registration	Pending	Approved	2/15/2024 5:09 PM
Dates	Signed By Date	Update	New Registration		1/14/2024 7:33:42 PM	2/15/2024 5:09 PM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	2/15/2024 5:09 PM
Addresses	Main Address	Insert	New Registration		4867 N BROADWAY ST CHICAGO, IL 60640-3603	1/13/2024 6:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2024 6:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362170833	1/13/2024 6:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/13/2024 6:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1235234535	1/13/2024 6:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	1/13/2024 6:34 PM
Contacts	Primary Contact	Insert	New Registration		Elhadary, Jenny VP Clinical Services Ann & Robert H Lurie Children's Hospital of Chicago 3122274161	1/13/2024 6:34 PM
Contacts	Authorizing Official	Insert	New Registration		Stahulak, Brian Chief Nursing Officer Ann & Robert H. Lurie Children's Hospital of Chicago 3122274622	1/13/2024 6:34 PM
Details	Assistance Received From Date	Insert	New Registration			1/13/2024 6:34 PM
Details	Assistance Received To Date	Insert	New Registration			1/13/2024 6:34 PM
Details	Last Recertification Date	Insert	New Registration			1/13/2024 6:34 PM
Details	Grant Number	Insert	New Registration			1/13/2024 6:34 PM
Details	340B ID	Insert	New Registration			1/13/2024 6:34 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2024 6:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2024 6:34 PM
Details	Medicare Provider Number	Insert	New Registration		143300	1/13/2024 6:34 PM
Details	Entity Name	Insert	New Registration		ANN & ROBERT H. LURIE CHILDRENS HOS	1/13/2024 6:34 PM
Details	NOFO Number	Insert	New Registration			1/13/2024 6:34 PM
Details	Program Code	Insert	New Registration		PED	1/13/2024 6:34 PM
Details	Entity Subname	Insert	New Registration		LURIE CHILDRENS OUTPATIENT CENTER	1/13/2024 6:34 PM
Dates	Participating Approval Date	Insert	New Registration			1/13/2024 6:34 PM
Details	State	Insert	New Registration		Pending	1/13/2024 6:34 PM
Dates	Registration Date	Insert	New Registration		1/13/2024 6:34:34 PM	1/13/2024 6:34 PM
Dates	Signed By Date	Insert	New Registration			1/13/2024 6:34 PM
Dates	Start Date	Insert	New Registration			1/13/2024 6:34 PM
Terminations	Termination Comments	Insert	New Registration			1/13/2024 6:34 PM
Terminations	Termination Date	Insert	New Registration			1/13/2024 6:34 PM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2024 6:34 PM
Terminations	Termination Reason	Insert	New Registration			1/13/2024 6:34 PM