Covered Entity Details

DSH230165BL Ascension St. John Hospital DBA Henry Ford St. John Hospital (Active) - information as of 5/26/2025 12:55:56 AM

Main Details

Name

Ascension St. John Hospital DBA Henry Ford St. John Hospital

Subdivision Name

PREMIER FAMILY PHYSICIANS - Premier Family Physicians

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH230165BL

Medicare Provider Number

230165

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/31/2024

Last Recertification Date

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020

Addresses

Street Address

24100 LITTLE MACK
ST CLAIR SHORES, MI 48080-3247

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?
No

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
DSH230165A	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	PROFESSIONAL BUILDING #1	22151 MOROSS ROAD	DETROIT	MI	Terminated
DSH230165AA	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	St John Internal Medicine Residency Clinic/St John Hospital and Medical Center	7633 East Jefferson Ave Suite 170	Detroit	MI	Terminated
DSH230165AB	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	Romeo Plank Family Practice/St John Hospital and Medical Center	46591 Romeo Plank Road Suite 200	Macomb	MI	Terminated
DSH230165AC	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Masonic Medical Center/St John Hospital and Medical Center	21099 Masonic	St Clair Shores	MI	Active
DSH230165AD	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Internal Medicine Specialty Center/St John Hospital and Medical Center	22201 Moross Road Suite 50	Detroit	MI	Active
DSH230165AE	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Perinatology/St John Hospital and Medical Center	22151 Moross Road Suite 320	Detroit	MI	Active
DSH230165AF	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Pediatric Surgery/St John Hospital and Medical Center	22151 Moross Road Suite 209	Detroit	MI	Active
DSH230165AG	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Children's Center Clinic/St John Hospital and Medical Center	22201 Moross Road Suite 70	Detroit	MI	Active
DSH230165AH	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Rheumatology	22151 Moross, PBI, Suite 214	Detroit	MI	Active
DSH230165AJ	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	St John Podiatry Clinic	22151 Moross Road Suite 335 PB1	Detroit	MI	Terminated
DSH230165AK	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Rheumatology	17900 23 Mile Road Suite 203	Macomb Township	MI	Active
DSH230165AL	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	St John Surgery Clinic	22101 Moross Road Suite 214 PB1	Detroit	MI	Terminated
DSH230165AM	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Transplant Center	22201 Moross Road Suite 480 PB2	Detroit	MI	Active
DSH230165AN	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Hospital and Medical Center Anesthesia / Pain Management	21000 East Twelve Mile Road Suite 100	St Clair Shores	MI	Active
DSH230165AP	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	Children's Center / 23 Mile Road	17900 23 MILE RD SUITE 303	MACOMB	MI	Terminated
DSH230165AQ	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	Internal Medicine / 23 Mile Road Clinic	17900 23 Mile Road Suite 303	Macomb Township	MI	Terminated
DSH230165AR	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ROCHESTER HILLS MEDICAL ONCOLOGY CL / SJH&MC Rochester Hills Medical Oncology Clinic Suite C	1901 STAR BATT ROAD	ROCHESTER HILLS	MI	Active
DSH230165AS	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ROCHESTER HILLS INFUSION / SJH&MC Rochester Hills Infusion	1901 STAR BATT ROAD	ROCHESTER HILLS	MI	Active
DSH230165AT	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Providence Medical Center-Ralph J. Wilson Campus / St Clair Adult Medicine Specialists	17141 Kercheval Avenue	Grosse Pointe	MI	Active
DSH230165AU	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	GREAT LAKES CANCER MANAGEMENT	19229 MACK AVE STE 24	GROSSE POINTE WOODS	MI	Active
DSH230165AV	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	SJHMC- Pediatric Hematology/Oncology	19229 Mack Ave	Grosse Pointe Woods	MI	Active
DSH230165AW	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ST JOHN HEMATOLOGY AND ONCOLOGY/ST	19229 MACK AVE	GROSSE POINTE WOODS	MI	Active
DSH230165AX	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Gyn Oncology	19229 Mack Ave	Grosse Pointe Woods	MI	Active
DSH230165AY	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	SJHMC-VINAY MALVYIA Gynecology Oncology	22301 FOSTER WINTER DR 3	SOUTHFIELD	MI	Terminated
DSH230165AZ	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	SJHMC Macomb Township 23 Mile Campus / SJHMC Emergency Room and Urgent Care 23 Mile Road	17700 23 Mile Road Suite 150	Macomb Township	MI	Active
DSH230165B	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	PROFESSIONAL BUILDING II	22201 MOROSS ROAD	DETROIT	MI	Terminated
DSH230165BA	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	SJHMC-NEWLAND MEDICAL ASSOC NOVI - Newland Medical Associates of Novi	47601 GRAND RIVER	NOVI	MI	Active
DSH230165BB	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	NEWLAND RHEUMATOLOGY - Newland Medical Associates Rheumatology	22250 PROVIDENCE DR	SOUTHFIELD	MI	Active
DSH230165BC	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	SJHMC-NEWLAND MED ASSOC SOUTHFIELD - St. John Newland Medical Associates of Southfield	22301 FOSTER WINTER DR 2	SOUTHFIELD	MI	Active
DSH230165BD	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	SJHMC-NEWLAND MED ASS BINGHAM FARMS - Newland Medical Associates of Bingham Farms	31500 TELEGRAPH RD 225	BINGHAM FARMS	MI	Active
DSH230165BE	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	GREAT LAKES CANCER MANAGEMENT SPECI - Great Lakes Cancer Management Specialists Clinic	17900 23 MILE RD	MACOMB	MI	Active
DSH230165BF	Child	DSH	Ascension St. John Hospital	ASSOCIATES IN INTERNAL MEDICINE - Associates In Internal Medicine	18263 E 10 MILE RD STE C	ROSEVILLE	MI	Terminated
DSH230165BG	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	WOUND AND HYPERBARIC CENTER SJHMC - Wound Care	22151 MOROSS RD	DETROIT	MI	Active
DSH230165BH	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	GYNECOLOGIC ONCOLOGY - Gynecology Oncology	22301 FOSTER WINTER DR	SOUTHFIELD	MI	Active
DSH230165BJ	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	HARPER FAMILY PRACTICE - HARPER FAMILY PRACTICE	19901 E 10 MILE RD	ST CLAIR SHORES	MI	Active
DSH230165BK	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	WARREN FAMILY PHYSICIAN - Warren Family Physicians	11270 E 13 MILE RD	WARREN	MI	Active
DSH230165BL	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	PREMIER FAMILY PHYSICIANS - Premier Family Physicians	24100 LITTLE MACK	ST CLAIR SHORES	MI	Active
DSH230165BM	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ST JOHN HOSPITAL AND MEDICAL CENTER - St John Wellness FM	18303 E 10 MILE RD STE 500	ROSEVILLE	MI	Active
DSH230165C	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	VAN ELSLANDER CANCER CENTER	19229 MACK AVENUE	GROSSE POINTE WOODS	MI	Active
DSH230165D	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	INTERNAL MEDICINE CLINIC	19251 MACK AVENUE	GROSSE POINTE WOODS	MI	Active
DSH230165E	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	OUTPATIENT SURGERY CENTER / SJHMC Surgery Center	21000 TWELVE MILE ROAD	ST CLAIR SHORES	MI	Active
DSH230165F	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	OUTPATIENT SATELLITE	20952 E TWELVE MILE ROAD	ST CLAIR SHORES	MI	Terminated
DSH230165G	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	FAMILY MEDICAL CENTER OUTPATIENT SATELLITE	24911 LITTLE MACK	ST CLAIR SHORES	MI	Active
DSH230165H	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ST. JOHN HOSPITAL MACOMB TOWNSHIP CAMPUS / SJHMC 23 Mile Surgery Center	17700 23 MILE ROAD	MACOMB	MI	Active
DSH230165M	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	MEDICAL PAVILION TWO	7633 E. JEFFERSON	DETROIT	MI	Terminated
DSH230165N	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	PROFESSIONAL OFFICE BUILDING - 23 MILE	17900 23 MILE ROAD	MACOMB	MI	Active
DSH230165P	Child	DSH	Ascension St. John Hospital	ST JOHN HOSPITAL- WARREN CANCER AND INFUSION CENTER	11885 12 MILE ROAD	WARREN	MI	Terminated
DSH230165Q	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	ST. JOHN HOSPITAL & MEDICAL CENTER- WEBBER CANCER CENTER AND INFUSION CENTER	11800 E 12 MILE ROAD	WARREN	MI	Active
DSH230165R	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St. John Hospital and Medical Center-Providence Cancer Center	22301 Foster Winter Drive	Southfield	MI	Active
DSH230165S	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St John Hospital and Medical Center - Assarian Cancer Center	47601 Grand River Ave.	Novi	MI	Active
DSH230165T	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	Newland Medical Associates	31500 Telegraph	Bingham Farms	MI	Active
DSH230165U	Child	DSH	ST JOHN HOSPITAL & MEDICAL CENTER	Cornerstone Romeo Family Practice	64580 Van Dyke	Washington	MI	Terminated
DSH230165W	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	St. John Hospital and Medical Center Doctors Park	4014 River Road	East China	MI	Active
DSH230165X	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	OB GYN Clinic/St John Hospital and Medical Center	22201 Moross Road Suite 370	Detroit	MI	Active
DSH230165Y	Child	DSH	Ascension St. John Hospital DBA Henry Ford St. John Hospital	OB GYN Faculty Clinic/St John Hospital and Medical Center	22151 Moross Road Suite 313	Detroit	MI	Active
DSH230165Z	Child	DSH	Ascension St. John Hospital	Dr. Hadesman Internal Medicine/St John Hospital and Medical Center	7633 East Jefferson Ave Suite 290	Detroit	MI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	Mansour, Alexander 340B Compliance Officer Henry Ford Hospital 2487230020	1/28/2025 11:25 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Details	Entity Name	Update	Change Request	Ascension St. John Hospital	Ascension St. John Hospital DBA Henry Ford St. John Hospital	12/30/2024 7:30 AM
Contacts	Signed By	Insert	New Registration		Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/31/2024 8:28 AM
Details	340B ID	Update	New Registration		DSH230165BL	10/31/2024 8:28 AM
Details	Entity Subname	Update	New Registration	PREMIER FAMILY PHYSICIANS	PREMIER FAMILY PHYSICIANS - Premier Family Physicians	10/31/2024 8:28 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2024 8:28:15 AM	10/31/2024 8:28 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2024 8:28 AM
Dates	Signed By Date	Update	New Registration		10/28/2024 1:53:14 PM	10/31/2024 8:28 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/31/2024 8:28 AM
Addresses	Main Address	Insert	New Registration		24100 LITTLE MACK ST CLAIR SHORES, MI 48080-3247	10/14/2024 3:04 PM
Contacts	Primary Contact	Insert	New Registration		Fiser, Kelsey 340B Program Director Ascension Rx 6152225190	10/14/2024 3:04 PM
Contacts	Authorizing Official	Insert	New Registration		Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	10/14/2024 3:04 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2024 3:04 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2024 3:04 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2024 3:04 PM
Details	Grant Number	Insert	New Registration			10/14/2024 3:04 PM
Details	340B ID	Insert	New Registration			10/14/2024 3:04 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2024 3:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2024 3:04 PM
Details	Medicare Provider Number	Insert	New Registration		230165	10/14/2024 3:04 PM
Details	Entity Name	Insert	New Registration		Ascension St. John Hospital	10/14/2024 3:04 PM
Details	NOFO Number	Insert	New Registration			10/14/2024 3:04 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2024 3:04 PM
Details	Entity Subname	Insert	New Registration		PREMIER FAMILY PHYSICIANS	10/14/2024 3:04 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2024 3:04 PM
Details	State	Insert	New Registration		Pending	10/14/2024 3:04 PM
Dates	Registration Date	Insert	New Registration		10/14/2024 3:04:55 PM	10/14/2024 3:04 PM
Dates	Signed By Date	Insert	New Registration			10/14/2024 3:04 PM
Dates	Start Date	Insert	New Registration			10/14/2024 3:04 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2024 3:04 PM
Terminations	Termination Date	Insert	New Registration			10/14/2024 3:04 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2024 3:04 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2024 3:04 PM