Covered Entity Details

DSH260065AN MERCY HOSPITAL SPRINGFIELD (Active) - information as of 6/12/2025 6:03:29 AM

Main Details

Name

MERCY HOSPITAL SPRINGFIELD

Subdivision Name

Springfield Cancer and Hematology - Hematology and Oncology Mercy CH Chub O Reilly Cancer Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH260065AN

Medicare Provider Number

260065

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/7/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/4/2025

Last Recertification Date

Contacts

Authorizing Official

Mercy Hospital Springfield
William J Roberts, Vice President Finance
(417) 820-7363

Primary Contact

Mercy Shared Services
Mike Loftus, Director-Hospital Pharmacy
(417) 820-3487

Addresses

Street Address

2055 S Fremont Ave
2
Springfield, MO 65804-2206

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?
Yes

State	Medicaid Number	NPI Number
MO	010135408	1578504056
KS	30003903950002	1578504056
AR	107971105	1578504056

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
DSH260065A	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOME INFUSION SPRINGFIELD	2115 S FREMONT	SPRINGFIELD	MO	Terminated
DSH260065AA	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - PACU	3050 E RIVER BLUFF BLVD	OZARK	MO	Terminated
DSH260065AB	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD - Hospice	1235 E CHEROKEE	SPRINGFIELD	MO	Terminated
DSH260065AC	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Mercy Gastrointestinal Endoscopy	2115 S FREMONT	Springfield	MO	Active
DSH260065AD	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY RADIATION ONCOLOGY - SPRG RADIATION ONCOLOGY CANCER CENTER	2055 S FREMONT AVENUE	SPRINGFIELD	MO	Active
DSH260065AE	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Imaging National Building - SPRG CT National	3045 S. National Avenue	Springfield	MO	Active
DSH260065AF	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY BREAST CENTER - SPRG BREAST CANCER CENTER	2055 S FREMONT AVENUE	SPRINGFIELD	MO	Active
DSH260065AG	Child	DSH	MERCY HOSPITAL SPRINGFIELD	CARDIOLOGY - ECHOCARDIOLOGY WHITESIDE	2115 S FREMONT	Springfield	MO	Terminated
DSH260065AH	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Imaging National Building - SPRG MRI NATIONAL	3045 S. National Avenue	Springfield	MO	Active
DSH260065AJ	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD - Health Styles	1325 E CHEROKEE ST	SPRINGFIELD	MO	Active
DSH260065AK	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD - SPRG Oncology Infusion Branson	448 STATE HIGHWAY 248	BRANSON	MO	Active
DSH260065AL	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY NATIONAL - Mercy Advanced Outpatient Care National	3045 S NATIONAL AVE	SPRINGFIELD	MO	Active
DSH260065AM	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD - Endocrinology SGC	3231 S NATIONAL AVE	SPRINGFIELD	MO	Active
DSH260065AN	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Springfield Cancer and Hematology - Hematology and Oncology Mercy CH Chub O Reilly Cancer Center	2055 S Fremont Ave	Springfield	MO	Active
DSH260065AP	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD - Pediatric Endocrinology and Diabetes	1965 S FREMONT AVE	SPRINGFIELD	MO	Active
DSH260065C	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Mercy Oncology Infusion Center-Springfield	2055 S Fremont Ave	SPRINGFIELD	MO	Active
DSH260065D	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Mercy Pain Procedures	2230 S. Glenstone	Springfield	MO	Active
DSH260065E	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Surgery Center Mercy Montclair	3045 S National	Springfield	MO	Active
DSH260065F	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ONCOLOGY INFUSION CENTER / Mercy Clinic Women's Oncology	2055 S FREMONT AVE	SPRINGFIELD	MO	Terminated
DSH260065G	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY SPINE CENTER & PAIN MANAGM	1229 E SEMINOLE ST	SPRINGFIELD	MO	Terminated
DSH260065H	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY SURGERY CENTER / Mercy Surgery Center - Springfield	1229 E SEMINOLE ST	SPRINGFIELD	MO	Active
DSH260065J	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE / Ortho Hospital/preprocedure phase ll	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065K	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE / Ortho Hospital- periop preadmit services	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065L	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE / Ortho Hospital- PACU routine	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065M	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE / Ortho Hospital-Operating Room	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065N	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY HOSPITAL SPRINGFIELD PAIN MGM / Mercy Headache Management	2230 S GLENSTONE AVE	SPRINGFIELD	MO	Terminated
DSH260065P	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE / Ortho Hospital Imaging	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065Q	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Mercy Clinic Imaging Services Whiteside / Nuclear Medicine Whiteside	2115 S. Fremont Suite 3100	Springfield	MO	Terminated
DSH260065R	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Mercy Clinic Cardiac, Thoracic, and Vascular Surgery / Electrocardiology Whiteside	2115 S. Fremont suite 5000	Springfield	MO	Terminated
DSH260065S	Child	DSH	MERCY HOSPITAL SPRINGFIELD	Smith Glynn Callaway Infusion Center	3231 S. National Ave suite 125	Springfield	MO	Terminated
DSH260065T	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Acute Therapy Services	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065U	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Anesthesia	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065V	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Cat Scan	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065W	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Outpatient Therapy Services	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065X	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Respiratory Therapy Services	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065Y	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - Ultrasound	3050 E RIVER BLUFF BLVD	OZARK	MO	Active
DSH260065Z	Child	DSH	MERCY HOSPITAL SPRINGFIELD	MERCY ORTHOPEDIC HOSPITAL SPRINGFIE - MRI	3050 E RIVER BLUFF BLVD	OZARK	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Roberts, William J Vice President Finance Mercy Hospital Springfield 4178207363	2/4/2025 7:47 AM
Details	340B ID	Update	New Registration		DSH260065AN	2/4/2025 7:47 AM
Details	Entity Subname	Update	New Registration	Springfield Cancer and Hematology	Springfield Cancer and Hematology - Hematology and Oncology Mercy CH Chub O Reilly Cancer Center	2/4/2025 7:47 AM
Dates	Participating Approval Date	Update	New Registration		2/4/2025 7:47:16 AM	2/4/2025 7:47 AM
Details	State	Update	New Registration	Pending	Approved	2/4/2025 7:47 AM
Dates	Signed By Date	Update	New Registration		1/8/2025 12:56:01 PM	2/4/2025 7:47 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	2/4/2025 7:47 AM
Addresses	Main Address	Insert	New Registration		2055 S Fremont Ave 2 Springfield, MO 65804-2206	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010135408	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30003903950002	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		107971105	1/7/2025 12:16 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	1/7/2025 12:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1578504056	1/7/2025 12:16 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	1/7/2025 12:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1578504056	1/7/2025 12:16 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	1/7/2025 12:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1578504056	1/7/2025 12:16 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	1/7/2025 12:16 PM
Contacts	Authorizing Official	Insert	New Registration		Roberts, William J Vice President Finance Mercy Hospital Springfield 4178207363	1/7/2025 12:16 PM
Contacts	Primary Contact	Insert	New Registration		Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	1/7/2025 12:16 PM
Details	Assistance Received From Date	Insert	New Registration			1/7/2025 12:16 PM
Details	Assistance Received To Date	Insert	New Registration			1/7/2025 12:16 PM
Details	Last Recertification Date	Insert	New Registration			1/7/2025 12:16 PM
Details	Grant Number	Insert	New Registration			1/7/2025 12:16 PM
Details	340B ID	Insert	New Registration			1/7/2025 12:16 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/7/2025 12:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/7/2025 12:16 PM
Details	Medicare Provider Number	Insert	New Registration		260065	1/7/2025 12:16 PM
Details	Entity Name	Insert	New Registration		MERCY HOSPITAL SPRINGFIELD	1/7/2025 12:16 PM
Details	NOFO Number	Insert	New Registration			1/7/2025 12:16 PM
Details	Program Code	Insert	New Registration		DSH	1/7/2025 12:16 PM
Details	Entity Subname	Insert	New Registration		Springfield Cancer and Hematology	1/7/2025 12:16 PM
Dates	Participating Approval Date	Insert	New Registration			1/7/2025 12:16 PM
Details	State	Insert	New Registration		Pending	1/7/2025 12:16 PM
Dates	Registration Date	Insert	New Registration		1/7/2025 12:16:15 PM	1/7/2025 12:16 PM
Dates	Signed By Date	Insert	New Registration			1/7/2025 12:16 PM
Dates	Start Date	Insert	New Registration			1/7/2025 12:16 PM
Terminations	Termination Comments	Insert	New Registration			1/7/2025 12:16 PM
Terminations	Termination Date	Insert	New Registration			1/7/2025 12:16 PM
Terminations	Termination Effective Date	Insert	New Registration			1/7/2025 12:16 PM
Terminations	Termination Reason	Insert	New Registration			1/7/2025 12:16 PM