Covered Entity Details

DSH140053L ST. JOHNS HOSPITAL (Active) - information as of 5/19/2025 12:57:23 AM

Main Details

Name

ST. JOHNS HOSPITAL

Subdivision Name

HSHS St. John's Hospital Infusion Center at O'Fallon - Infusion

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140053L

Medicare Provider Number

140053

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/17/2024

Last Recertification Date

Contacts

Authorizing Official

HSHS
Michael Scialdone, SVP-Chief Financial Officer
(217) 492-6594

Primary Contact

HSHS St. John's Hospital
Erica Ridley, Pharmacy Manager
(217) 544-6464 Ext: 2044668

Addresses

Street Address

3 St. Elizabeth's Blvd
O'Fallon, IL 62269

Billing Address

Consolidated Services
PO Box 3646
Springfield, IL 62708

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	370661238001	1205818481

Shipping Addresses

Shipping Address 1

ST ELIZABETHS HOSPITAL OF THE HOSP SSTRS OF 3RD ORDER OF ST.
1 St. Elizabeth's Blvd
O'Fallon, 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
DSH140053A	Child	DSH	ST. JOHNS HOSPITAL	Home Infusion	801 E Carpenter St	Springfield	IL	Terminated
DSH140053C	Child	DSH	ST. JOHNS HOSPITAL	Women Care Mammography MOB	400 N 9th Street	Springfield	IL	Active
DSH140053D	Child	DSH	ST. JOHNS HOSPITAL	Imaging - South 6th Street	1100 E Lincolnshire Blvd	Springfield	IL	Active
DSH140053E	Child	DSH	ST. JOHNS HOSPITAL	Prairie Diagnostic Center	401 E Carpenter St	Springfield	IL	Active
DSH140053F	Child	DSH	ST. JOHNS HOSPITAL	Athleticare & Acceleration	3631 South 6th Street	Springfield	IL	Terminated
DSH140053G	Child	DSH	ST. JOHNS HOSPITAL	Rehab - SHG (West)	1603 West Washington Street	Springfield	IL	Terminated
DSH140053H	Child	DSH	ST. JOHNS HOSPITAL	Sleep Lab	1100 E Lincolnshire Blvd	Springfield	IL	Active
DSH140053J	Child	DSH	ST. JOHNS HOSPITAL	END-South 6th Street	1100 E Lincolnshire Blvd	Springfield	IL	Terminated
DSH140053K	Child	DSH	ST. JOHNS HOSPITAL	ST JOHN'S SURGERY SUITES, MONTVALE	2020 W ILES AVE	SPRINGFIELD	IL	Active
DSH140053L	Child	DSH	ST. JOHNS HOSPITAL	HSHS St. John's Hospital Infusion Center at O'Fallon - Infusion	3 St. Elizabeth's Blvd	O'Fallon	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Allen, Patty Chief Financial Officer HSHS 9208845660	Scialdone, Michael SVP-Chief Financial Officer HSHS 2174926594	5/5/2025 6:31 AM
Addresses	Shipping Address	Insert	Change Request		ST ELIZABETHS HOSPITAL OF THE HOSP SSTRS OF 3RD ORDER OF ST. 1 St. Elizabeth's Blvd O'Fallon, IL 62269	1/22/2025 11:58 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Allen, Patty Chief Financial Officer HSHS 9208845660	10/17/2024 9:23 AM
Details	340B ID	Update	New Registration		DSH140053L	10/17/2024 9:23 AM
Details	Entity Subname	Update	New Registration	HSHS St. John's Hospital Infusion Center at O'Fallon	HSHS St. John's Hospital Infusion Center at O'Fallon - Infusion	10/17/2024 9:23 AM
Dates	Participating Approval Date	Update	New Registration		10/17/2024 9:23:52 AM	10/17/2024 9:23 AM
Details	State	Update	New Registration	Pending	Approved	10/17/2024 9:23 AM
Dates	Signed By Date	Update	New Registration		10/10/2024 5:09:17 PM	10/17/2024 9:23 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/17/2024 9:23 AM
Addresses	Main Address	Insert	New Registration		3 St. Elizabeth's Blvd O'Fallon, IL 62269	10/4/2024 11:38 AM
Addresses	Billing Address	Insert	New Registration		Consolidated Services PO Box 3646 Springfield, IL 62708	10/4/2024 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370661238001	10/4/2024 11:38 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1205818481	10/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/4/2024 11:38 AM
Contacts	Authorizing Official	Insert	New Registration		Allen, Patty Chief Financial Officer HSHS 9208845660	10/4/2024 11:38 AM
Contacts	Primary Contact	Insert	New Registration		Ridley, Erica Pharmacy Manager HSHS St. John's Hospital 2175446464-2044668	10/4/2024 11:38 AM
Details	Assistance Received From Date	Insert	New Registration			10/4/2024 11:38 AM
Details	Assistance Received To Date	Insert	New Registration			10/4/2024 11:38 AM
Details	Last Recertification Date	Insert	New Registration			10/4/2024 11:38 AM
Details	Grant Number	Insert	New Registration			10/4/2024 11:38 AM
Details	340B ID	Insert	New Registration			10/4/2024 11:38 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2024 11:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2024 11:38 AM
Details	Medicare Provider Number	Insert	New Registration		140053	10/4/2024 11:38 AM
Details	Entity Name	Insert	New Registration		ST. JOHNS HOSPITAL	10/4/2024 11:38 AM
Details	NOFO Number	Insert	New Registration			10/4/2024 11:38 AM
Details	Program Code	Insert	New Registration		DSH	10/4/2024 11:38 AM
Details	Entity Subname	Insert	New Registration		HSHS St. John's Hospital Infusion Center at O'Fallon	10/4/2024 11:38 AM
Dates	Participating Approval Date	Insert	New Registration			10/4/2024 11:38 AM
Details	State	Insert	New Registration		Pending	10/4/2024 11:38 AM
Dates	Registration Date	Insert	New Registration		10/4/2024 11:38:16 AM	10/4/2024 11:38 AM
Dates	Signed By Date	Insert	New Registration			10/4/2024 11:38 AM
Dates	Start Date	Insert	New Registration			10/4/2024 11:38 AM
Terminations	Termination Comments	Insert	New Registration			10/4/2024 11:38 AM
Terminations	Termination Date	Insert	New Registration			10/4/2024 11:38 AM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2024 11:38 AM
Terminations	Termination Reason	Insert	New Registration			10/4/2024 11:38 AM