Covered Entity Details

DSH140018J MOUNT SINAI HOSPITAL MEDICAL CENTER (Active) - information as of 6/3/2025 10:54:49 AM

Main Details

Name

MOUNT SINAI HOSPITAL MEDICAL CENTER

Subdivision Name

GI Pre-Post Op - Gastroenterology (Ogden Commons)

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140018J

Medicare Provider Number

140018

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/3/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/5/2024

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Sinai Health System
Sameer Shah, President, Mount Sinai Hospital Medical Center
(773) 257-2012

Primary Contact

Sinai Health System
Thomas Yu, System Director of Ambulatory Pharmacy Services
(773) 257-2486

Addresses

Street Address

2642 W OGDEN AVE
Chicago, IL 60608-1797

Billing Address

Mount Sinai Hospital Medical Center
2750 W 15th Place
Chicago, IL 60608-1797

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	36-1509000	1861024176

Shipping Addresses

Shipping Address 1

Mount Sinai Hospital Medical Center
2750 W 15th Place
Chicago, IL 60608-1797

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
DSH140018A	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Spasticity Clinic at Schwab	1401 S California Ave	Chicago	IL	Active
DSH140018B	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	MSH SPECIALTY CLINIC AT SCHWAB	1414 South Fairfield Avenue	Chicago	IL	Active
DSH140018C	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	HEM/ONC CLINIC @ ARCHER	6084 South Archer Avenue	Chicago	IL	Terminated
DSH140018D	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Chemotherapy	2750 W 15TH PLACE	CHICAGO	IL	Active
DSH140018E	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	MSH Specialty Clinic	2750 W 15TH PLACE	CHICAGO	IL	Active
DSH140018F	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Renal Dialysis	2642 W OGDEN AVE	CHICAGO	IL	Active
DSH140018G	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Adult OP Behavioral Health - Behavioral Health	2653 West Ogden Avenue	Chicago	IL	Active
DSH140018H	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Under the Rainbow - Behavioral Health	2750 W 15th Place	Chicago	IL	Active
DSH140018J	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI Pre-Post Op - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018K	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI At Ogden Comm - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018L	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	OR Pre-Post Op - Surgery (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018M	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Surgery at Ogden Commons - Surgery (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018N	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI Clinic Ogden - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	Shah, Sameer President, Mount Sinai Hospital Medical Center Sinai Health System 7732572012	4/9/2025 11:25 AM
Contacts	Signed By	Update	Profile Change Request	Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	Shah, Sameer President, Mount Sinai Hospital Medical Center Sinai Health System 7732572012	4/9/2025 11:25 AM
Details	Last Recertification Date	Update	Recertification		9/6/2024 11:23:20 AM	9/6/2024 11:23 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	4/5/2024 12:35 PM
Details	340B ID	Update	New Registration		DSH140018J	4/5/2024 12:35 PM
Details	Entity Subname	Update	New Registration	GI Pre-Post Op	GI Pre-Post Op - Gastroenterology (Ogden Commons)	4/5/2024 12:35 PM
Dates	Participating Approval Date	Update	New Registration		4/5/2024 12:35:18 PM	4/5/2024 12:35 PM
Details	State	Update	New Registration	Pending	Approved	4/5/2024 12:35 PM
Dates	Signed By Date	Update	New Registration		4/3/2024 3:28:15 PM	4/5/2024 12:35 PM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/5/2024 12:35 PM
Addresses	Main Address	Insert	New Registration		2642 W OGDEN AVE Chicago, IL 60608-1797	4/3/2024 3:00 PM
Addresses	Billing Address	Insert	New Registration		Mount Sinai Hospital Medical Center 2750 W 15th Place Chicago, IL 60608-1797	4/3/2024 3:00 PM
Addresses	Shipping Address	Insert	New Registration		Mount Sinai Hospital Medical Center 2750 W 15th Place Chicago, IL 60608-1797	4/3/2024 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		36-1509000	4/3/2024 3:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2024 3:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1861024176	4/3/2024 3:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/3/2024 3:00 PM
Contacts	Primary Contact	Insert	New Registration		Yu, Thomas System Director of Ambulatory Pharmacy Services Sinai Health System 7732572486	4/3/2024 3:00 PM
Contacts	Authorizing Official	Insert	New Registration		Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	4/3/2024 3:00 PM
Details	Assistance Received From Date	Insert	New Registration			4/3/2024 3:00 PM
Details	Assistance Received To Date	Insert	New Registration			4/3/2024 3:00 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2024 3:00 PM
Details	Grant Number	Insert	New Registration			4/3/2024 3:00 PM
Details	340B ID	Insert	New Registration			4/3/2024 3:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2024 3:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2024 3:00 PM
Details	Medicare Provider Number	Insert	New Registration		140018	4/3/2024 3:00 PM
Details	Entity Name	Insert	New Registration		MOUNT SINAI HOSPITAL MEDICAL CENTER	4/3/2024 3:00 PM
Details	NOFO Number	Insert	New Registration			4/3/2024 3:00 PM
Details	Program Code	Insert	New Registration		DSH	4/3/2024 3:00 PM
Details	Entity Subname	Insert	New Registration		GI Pre-Post Op	4/3/2024 3:00 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2024 3:00 PM
Details	State	Insert	New Registration		Pending	4/3/2024 3:00 PM
Dates	Registration Date	Insert	New Registration		4/3/2024 3:00:06 PM	4/3/2024 3:00 PM
Dates	Signed By Date	Insert	New Registration			4/3/2024 3:00 PM
Dates	Start Date	Insert	New Registration			4/3/2024 3:00 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2024 3:00 PM
Terminations	Termination Date	Insert	New Registration			4/3/2024 3:00 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2024 3:00 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2024 3:00 PM