Covered Entity Details

DSH140185AR MEMORIAL HOSPITAL (Active) - information as of 4/24/2025 11:10:40 PM

Main Details

Name

MEMORIAL HOSPITAL

Subdivision Name

MHE CARDIAC TESTING-PREP-LAB

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140185AR

Medicare Provider Number

140185

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/11/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/9/2024

Last Recertification Date

8/17/2024

Contacts

Authorizing Official

Christain Hospital - BJC
Susan Koesterer, VP, Chief Financial Officer
(314) 653-5715

Primary Contact

Memorial Hospital
Ryan Birk, Director of Pharmacy
(618) 606-0210

Addresses

Street Address

1404 Cross St
Shiloh, IL 62269

Billing Address

BJC Healthcare
4249 Clayton Avenue 310
St. Louis, MO 63110

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	370635502001	1982796181
MO	010638500	1982796181

Shipping Addresses

Shipping Address 1

Safecor Health, LLC
4060 Business Park Drive, Suite B
Columbus, OH 43204

Shipping Address 2

Memorial Hospital Shiloh
1404 Cross St
Shiloh, IL 62269

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
DSH140185A	Child	DSH	MEMORIAL HOSPITAL	MHE ULTRASOUND - Radiology	1404 Cross St	Shiloh	IL	Terminated
DSH140185AA	Child	DSH	MEMORIAL HOSPITAL	MHE ED - Emergency	1404 Cross St	Shiloh	IL	Active
DSH140185AB	Child	DSH	MEMORIAL HOSPITAL	MHE MOB 1 CT - CT Scan	1414 Cross St	Shiloh	IL	Terminated
DSH140185AC	Child	DSH	MEMORIAL HOSPITAL	MHB ON PAIN MGMT - Pain Management	4700 Memorial Drive	Belleville	IL	Active
DSH140185AD	Child	DSH	MEMORIAL HOSPITAL	MHBON OTHAND - Occupational Therapy	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185AE	Child	DSH	MEMORIAL HOSPITAL	MHB ON OP SP - Speech Pathology	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185AF	Child	DSH	MEMORIAL HOSPITAL	MHE MOB 2 RAD ONC - Radiology	1418 Cross St	Shiloh	IL	Active
DSH140185AG	Child	DSH	MEMORIAL HOSPITAL	MHB ON OP PT - Physical Therapy	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185AH	Child	DSH	MEMORIAL HOSPITAL	MHE Pregnancy Assessment CTR	1404 Cross St	Shiloh	IL	Active
DSH140185AJ	Child	DSH	MEMORIAL HOSPITAL	MHE AMBULATORY SURGERY-MHE - MHE AMBULATORY SURGERY-MHE	1404 Cross St	Shiloh	IL	Active
DSH140185AK	Child	DSH	MEMORIAL HOSPITAL	MHB ON CT - Cat Scan - MHB ON CT - Cat Scan	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185AL	Child	DSH	MEMORIAL HOSPITAL	MHE CT - CAT Scan - MHE CT - CAT Scan	1404 Cross St	Shiloh	IL	Terminated
DSH140185AM	Child	DSH	MEMORIAL HOSPITAL	MHE RADIOLOGY-MHE MOB - MHE RADIOLOGY-MHE MOB	1414 Cross St	Shiloh	IL	Terminated
DSH140185AN	Child	DSH	MEMORIAL HOSPITAL	MHE RADIOLOGY-GEN DIAG-MHE - MHE RADIOLOGY-GEN DIAG-MHE	1404 Cross St	Shiloh	IL	Terminated
DSH140185AP	Child	DSH	MEMORIAL HOSPITAL	MHB VAC CLIN	4600 Memorial Drive	Belleville	IL	Active
DSH140185AQ	Child	DSH	MEMORIAL HOSPITAL	Mhb Wound Care - Mhb Wound Care	4600 Memorial Drive	Belleville	IL	Active
DSH140185AR	Child	DSH	MEMORIAL HOSPITAL	MHE CARDIAC TESTING-PREP-LAB	1404 Cross St	Shiloh	IL	Active
DSH140185AS	Child	DSH	MEMORIAL HOSPITAL	MHE OB ED - Emergency - MHE OB ED - Emergency	1404 Cross St	Shiloh	IL	Active
DSH140185AT	Child	DSH	MEMORIAL HOSPITAL	MHE CARDIAC CATH LAB	1404 Cross St	Shiloh	IL	Active
DSH140185AU	Child	DSH	MEMORIAL HOSPITAL	Memorial Belleville Cancer Infusion Center (Alton) - Infusion	4 Memorial Drive Suite 132	Alton	IL	Active
DSH140185B	Child	DSH	MEMORIAL HOSPITAL	MHB MOB 2 W2 NUC MED - Radiology	4600 Memorial Drive	Belleville	IL	Active
DSH140185C	Child	DSH	MEMORIAL HOSPITAL	MHB MOB2 VSC - ELECTROCARDIOLOGY	4600 Memorial Drive	Belleville	IL	Active
DSH140185D	Child	DSH	MEMORIAL HOSPITAL	MHEMOB1 OPPT - Physical Therapy	1414 Cross St	Shiloh	IL	Terminated
DSH140185E	Child	DSH	MEMORIAL HOSPITAL	MHB ON CT - CT Scan	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185F	Child	DSH	MEMORIAL HOSPITAL	MHE ENDOSCOPY - Endo	1404 Cross St	Shiloh	IL	Active
DSH140185G	Child	DSH	MEMORIAL HOSPITAL	MHE MOB 1 PET - Radiology	1414 Cross St	Shiloh	IL	Active
DSH140185H	Child	DSH	MEMORIAL HOSPITAL	MHE CT - CT Scan	1404 Cross St	Shiloh	IL	Terminated
DSH140185J	Child	DSH	MEMORIAL HOSPITAL	MHE OPERATING ROOM - Surgery	1404 Cross St	Shiloh	IL	Active
DSH140185K	Child	DSH	MEMORIAL HOSPITAL	MHE MOB 1 BRST HLTH CTR - Radiology	1414 Cross St	Shiloh	IL	Terminated
DSH140185L	Child	DSH	MEMORIAL HOSPITAL	MHE POSTOP PH I - Surgery	1404 Cross St	Shiloh	IL	Active
DSH140185M	Child	DSH	MEMORIAL HOSPITAL	MHE BREAST IMG - Radiology	1404 Cross St	Shiloh	IL	Terminated
DSH140185N	Child	DSH	MEMORIAL HOSPITAL	MHB ON MRI - MRI	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185P	Child	DSH	MEMORIAL HOSPITAL	MHE DIAG IMG - Radiology	1404 Cross St	Shiloh	IL	Terminated
DSH140185Q	Child	DSH	MEMORIAL HOSPITAL	MHE CARDIAC CATH LAB - ELECTROCARDIOLOGY + Vasc	1404 Cross St	Shiloh	IL	Active
DSH140185R	Child	DSH	MEMORIAL HOSPITAL	MHB ON DIAG IMG - Radiology	4700 Memorial Drive	Belleville	IL	Terminated
DSH140185S	Child	DSH	MEMORIAL HOSPITAL	MHE RESPIRATORY - Respiratory	1404 Cross St	Shiloh	IL	Active
DSH140185T	Child	DSH	MEMORIAL HOSPITAL	MHB 7HLSLEEP - ELECTROENCEPHALOGRAPHY	310 North Seven Hills Road	O'Fallon	IL	Terminated
DSH140185U	Child	DSH	MEMORIAL HOSPITAL	MHB MOB 2 OP CARD TEST	4600 Memorial Drive	Belleville	IL	Active
DSH140185V	Child	DSH	MEMORIAL HOSPITAL	MHE MRI - MRI	1404 Cross St	Shiloh	IL	Terminated
DSH140185W	Child	DSH	MEMORIAL HOSPITAL	MHB GERO PSY - Clinic	4319 Memorial Drive	Belleville	IL	Active
DSH140185X	Child	DSH	MEMORIAL HOSPITAL	MHB COL LAB - Lab	200 Admiral Trost Road	Columbia	IL	Terminated
DSH140185Y	Child	DSH	MEMORIAL HOSPITAL	MHE CARDIAC TESTING - ELECTROCARDIOLOGY	1404 Cross St	Shiloh	IL	Terminated
DSH140185Z	Child	DSH	MEMORIAL HOSPITAL	MHE NUC MED - Radiology	1404 Cross St	Shiloh	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/17/2024 1:05:43 PM	8/17/2024 1:05 PM
Details	Entity Subname	Update	Recertification	MHE CARDIAC TESTING-PREP-LAB - MHE CARDIAC TESTING-PREP-LAB	MHE CARDIAC TESTING-PREP-LAB	8/17/2024 1:05 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Koesterer, Susan VP, Chief Financial Officer Christain Hospital - BJC 3146535715	5/9/2024 4:08 PM
Details	340B ID	Update	New Registration		DSH140185AR	5/9/2024 4:08 PM
Details	Entity Subname	Update	New Registration	MHE CARDIAC TESTING-PREP-LAB	MHE CARDIAC TESTING-PREP-LAB - MHE CARDIAC TESTING-PREP-LAB	5/9/2024 4:08 PM
Dates	Participating Approval Date	Update	New Registration		5/9/2024 4:08:03 PM	5/9/2024 4:08 PM
Details	State	Update	New Registration	Pending	Approved	5/9/2024 4:08 PM
Dates	Signed By Date	Update	New Registration		4/12/2024 8:45:09 AM	5/9/2024 4:08 PM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	5/9/2024 4:08 PM
Addresses	Main Address	Insert	New Registration		1404 Cross St Shiloh, IL 62269	4/11/2024 3:37 PM
Addresses	Billing Address	Insert	New Registration		BJC Healthcare 4249 Clayton Avenue 310 St. Louis, MO 63110	4/11/2024 3:37 PM
Addresses	Shipping Address	Insert	New Registration		Safecor Health, LLC 4060 Business Park Drive, Suite B Columbus, OH 43204	4/11/2024 3:37 PM
Addresses	Shipping Address	Insert	New Registration		Memorial Hospital Shiloh 1404 Cross St Shiloh, IL 62269	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370635502001	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010638500	4/11/2024 3:37 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/11/2024 3:37 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982796181	4/11/2024 3:37 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/11/2024 3:37 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982796181	4/11/2024 3:37 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	4/11/2024 3:37 PM
Contacts	Authorizing Official	Insert	New Registration		Koesterer, Susan VP, Chief Financial Officer Christain Hospital - BJC 3146535715	4/11/2024 3:37 PM
Contacts	Primary Contact	Insert	New Registration		Birk, Ryan Director of Pharmacy Memorial Hospital 6186060210	4/11/2024 3:37 PM
Details	Assistance Received From Date	Insert	New Registration			4/11/2024 3:37 PM
Details	Assistance Received To Date	Insert	New Registration			4/11/2024 3:37 PM
Details	Last Recertification Date	Insert	New Registration			4/11/2024 3:37 PM
Details	Grant Number	Insert	New Registration			4/11/2024 3:37 PM
Details	340B ID	Insert	New Registration			4/11/2024 3:37 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2024 3:37 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2024 3:37 PM
Details	Medicare Provider Number	Insert	New Registration		140185	4/11/2024 3:37 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HOSPITAL	4/11/2024 3:37 PM
Details	NOFO Number	Insert	New Registration			4/11/2024 3:37 PM
Details	Program Code	Insert	New Registration		DSH	4/11/2024 3:37 PM
Details	Entity Subname	Insert	New Registration		MHE CARDIAC TESTING-PREP-LAB	4/11/2024 3:37 PM
Dates	Participating Approval Date	Insert	New Registration			4/11/2024 3:37 PM
Details	State	Insert	New Registration		Pending	4/11/2024 3:37 PM
Dates	Registration Date	Insert	New Registration		4/11/2024 3:37:17 PM	4/11/2024 3:37 PM
Dates	Signed By Date	Insert	New Registration			4/11/2024 3:37 PM
Dates	Start Date	Insert	New Registration			4/11/2024 3:37 PM
Terminations	Termination Comments	Insert	New Registration			4/11/2024 3:37 PM
Terminations	Termination Date	Insert	New Registration			4/11/2024 3:37 PM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2024 3:37 PM
Terminations	Termination Reason	Insert	New Registration			4/11/2024 3:37 PM