Covered Entity Details

DSH140114M SWEDISH COVENANT HEALTH (Active) - information as of 5/13/2025 10:47:16 PM

Main Details

Name

SWEDISH COVENANT HEALTH

Subdivision Name

Swedish Hospital - Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140114M

Medicare Provider Number

140114

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/5/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/28/2024

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Swedish Covenant Health
Jonathan Lind, Chief Operating Officer
(773) 907-1028 Ext: 1028

Primary Contact

Swedish Covenant Health
Alicia Juska, Director Pharmacy
(773) 878-8200 Ext: 5379

Addresses

Street Address

757 PARK AVE W
STE 1810
HIGHLAND PARK, IL 60035-2558

Billing Address

Swedish Covenant Health
5145 N CALIFORNIA AVE
CHICAGO, IL 60625

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	362179813001,362179813401,362179813011,362179813521,364073303002,364073303003	1831151257,1588739734,1497825855

Shipping Addresses

Shipping Address 1

Highland Park Oncology Infusion Pharmacy
Department of Swedish Hospital
757 Park Ave W
STE 3860
Highland Park, IL 60035-2556

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
DSH140114B	Child	DSH	SWEDISH COVENANT HEALTH	WOUND CARE CLINIC	2751 W. WINNONA AVENUE, AP3 FLOOR	CHICAGO	IL	Active
DSH140114C	Child	DSH	SWEDISH COVENANT HEALTH	PAIN MANAGEMENT CLINIC	5215 N. California Ave.	CHICAGO	IL	ToBeTerminated
DSH140114D	Child	DSH	SWEDISH COVENANT HEALTH	OPERATING ROOM / ONE DAY SURGICAL PATIENTS	5140 N. CALIFORNIA AVENUE, SUITE #G200	CHICAGO	IL	Active
DSH140114E	Child	DSH	SWEDISH COVENANT HEALTH	EMERGENCY / DISCHARGE PATIENTS	5145 N. CALIFORNIA AVENUE	CHICAGO	IL	Active
DSH140114G	Child	DSH	SWEDISH COVENANT HEALTH	INFUSION / CANCER CENTER	5140 N. CALIFORNIA AVENUE	CHICAGO	IL	Active
DSH140114J	Child	DSH	Swedish Covenant Hospital	Outpatient Oncology Infusion Center Evanston	800 Austin Ave.	Evanston	IL	Terminated
DSH140114K	Child	DSH	SWEDISH COVENANT HEALTH	Ambulatory Surgery	5215 N. California Ave.	Chicago	IL	Active
DSH140114L	Child	DSH	SWEDISH COVENANT HEALTH	SWEDISH HOSPITAL INFUSION CENTER NI - Infusion Center	6450 W TOUHY AVE	NILES	IL	Active
DSH140114M	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	757 PARK AVE W	HIGHLAND PARK	IL	Active
DSH140114N	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	2650 RIDGE AVE	EVANSTON	IL	Active
DSH140114P	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	2180 PFINGSTEN RD	GLENVIEW	IL	Active
DSH140114Q	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	120 Spalding Drive	Naperville	IL	Approved
DSH140114R	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	24600 W. 127th Street	Plainfield	IL	Approved
DSH140114S	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology and Specialty Infusion Center	3060 W Salt Creek Lane	Arlington Heights	IL	Approved
DSH140114T	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	177 E. Brush Hill Road	Elmhurst	IL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028-1028	5/13/2025 9:37 AM
Contacts	Signed By	Update	Change Request	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028-1028	5/13/2025 9:37 AM
Details	Last Recertification Date	Update	Recertification		8/13/2024 8:53:31 AM	8/13/2024 8:53 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		364073303002	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		364073303003	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1588739734	6/7/2024 4:13 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1497825855	6/7/2024 4:13 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Addresses	Shipping Address	Insert	Change Request		Highland Park Oncology Infusion Pharmacy Department of Swedish Hospital 757 Park Ave W STE 3860 Highland Park, IL 60035-2556	5/30/2024 7:36 AM
Contacts	Signed By	Insert	New Registration		Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	5/28/2024 11:03 AM
Details	340B ID	Update	New Registration		DSH140114M	5/28/2024 11:03 AM
Details	Entity Subname	Update	New Registration	Swedish Hospital	Swedish Hospital - Oncology	5/28/2024 11:03 AM
Dates	Participating Approval Date	Update	New Registration		5/28/2024 11:03:35 AM	5/28/2024 11:03 AM
Details	State	Update	New Registration	Pending	Approved	5/28/2024 11:03 AM
Dates	Signed By Date	Update	New Registration		5/23/2024 9:32:54 PM	5/28/2024 11:03 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	5/28/2024 11:03 AM
Addresses	Main Address	Insert	New Registration		757 PARK AVE W STE 1810 HIGHLAND PARK, IL 60035-2558	4/5/2024 2:23 PM
Addresses	Billing Address	Insert	New Registration		Swedish Covenant Health 5145 N CALIFORNIA AVE CHICAGO, IL 60625	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362179813001	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362179813401	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362179813011	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362179813521	4/5/2024 2:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2024 2:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831151257	4/5/2024 2:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2024 2:23 PM
Contacts	Primary Contact	Insert	New Registration		Juska, Alicia Director Pharmacy Swedish Covenant Health 7738788200-5379	4/5/2024 2:23 PM
Contacts	Authorizing Official	Insert	New Registration		Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	4/5/2024 2:23 PM
Details	Assistance Received From Date	Insert	New Registration			4/5/2024 2:23 PM
Details	Assistance Received To Date	Insert	New Registration			4/5/2024 2:23 PM
Details	Last Recertification Date	Insert	New Registration			4/5/2024 2:23 PM
Details	Grant Number	Insert	New Registration			4/5/2024 2:23 PM
Details	340B ID	Insert	New Registration			4/5/2024 2:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2024 2:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2024 2:23 PM
Details	Medicare Provider Number	Insert	New Registration		140114	4/5/2024 2:23 PM
Details	Entity Name	Insert	New Registration		SWEDISH COVENANT HEALTH	4/5/2024 2:23 PM
Details	NOFO Number	Insert	New Registration			4/5/2024 2:23 PM
Details	Program Code	Insert	New Registration		DSH	4/5/2024 2:23 PM
Details	Entity Subname	Insert	New Registration		Swedish Hospital	4/5/2024 2:23 PM
Dates	Participating Approval Date	Insert	New Registration			4/5/2024 2:23 PM
Details	State	Insert	New Registration		Pending	4/5/2024 2:23 PM
Dates	Registration Date	Insert	New Registration		4/5/2024 2:23:22 PM	4/5/2024 2:23 PM
Dates	Signed By Date	Insert	New Registration			4/5/2024 2:23 PM
Dates	Start Date	Insert	New Registration			4/5/2024 2:23 PM
Terminations	Termination Comments	Insert	New Registration			4/5/2024 2:23 PM
Terminations	Termination Date	Insert	New Registration			4/5/2024 2:23 PM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2024 2:23 PM
Terminations	Termination Reason	Insert	New Registration			4/5/2024 2:23 PM