Covered Entity Details

DSH520009AB Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus (Approved) - information as of 5/27/2025 2:42:34 PM

Main Details

Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Richmond Urgent Care - Urgent Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH520009AB

Medicare Provider Number

520009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/2/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/7/2025

Last Recertification Date

Contacts

Authorizing Official

Ascension Wisconsin
Michael Bergmann, President
(920) 831-8913

Primary Contact

Ascension WI
Cescilly Smith-Jenkins, 340B Program Director – Wisconsin
(414) 522-7533

Addresses

Street Address

3329 N Richmond St
Appleton, WI 54911

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
WI		1407803638

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
DSH520009A	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	Midway Surgery Center	1550 Midway Place	Menasha	WI	Active
DSH520009AA	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	Koeller Urgent Care - Urgent Care	1855 S Koeller St	Oshkosh	WI	Approved
DSH520009AB	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	Richmond Urgent Care - Urgent Care	3329 N Richmond St	Appleton	WI	Approved
DSH520009B	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	Behavioral Health Clinic	1531 S. Madison Street	Appleton	WI	Active
DSH520009C	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - CANCER CENTER	2700 W 9TH AVE	OSHKOSH	WI	Active
DSH520009D	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Emergency	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009E	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - CT	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009F	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Cardiac Catheterization	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009G	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Breast Center	2700 W. 9th Ave	OSHKOSH	WI	Active
DSH520009H	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Operating Room	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009J	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - MRI	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009K	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Recovery	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009L	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Radiology	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009M	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Anesthesiology	500 S OAKWOOD RD	OSHKOSH	WI	Active
DSH520009N	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Outpatient Behavioral Health	2700 W 9th Ave	Oshkosh	WI	Active
DSH520009P	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Wound Clinic	2700 W. 9th Ave	OSHKOSH	WI	Active
DSH520009Q	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Radiation Oncology - Radiation Oncology	2700 W. 9th Ave	Oshkosh	WI	Active
DSH520009R	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Cardiac Rehabilitation - Cardiac Rehabilitation	2700 W. 9th Ave	Oshkosh	WI	Active
DSH520009S	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Diagnostic Cardiology - Diagnostic Cardiology	500 S. Oakwood Rd	Oshkosh	WI	Active
DSH520009T	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Outpatient Procedure Area - Perioperative Care	500 S. Oakwood Rd	Oshkosh	WI	Active
DSH520009U	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Pheresis - Pheresis	500 S. Oakwood Rd	Oshkosh	WI	Terminated
DSH520009V	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Respiratory Therapy - Respiratory Therapy	500 S. Oakwood Rd	Oshkosh	WI	Active
DSH520009W	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Cardiac Nuclear Medicine - Cardiac Nuclear Medicine	500 S. Oakwood Rd	Oshkosh	WI	Active
DSH520009X	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Cardiac Ultrasound - Cardiac Ultrasound	500 S. Oakwood Rd	Oshkosh	WI	Active
DSH520009Y	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	ASCENSION NE WISCONSIN-MERCY CAMPUS - Medical Oncology - Oncology	2700 W. 9th Ave	Oshkosh	WI	Active
DSH520009Z	Child	DSH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	Neenah Urgent Care - Urgent Care	101 Main St	Neenah	WI	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Bergmann, Michael President Ascension Wisconsin 9208318913	4/7/2025 6:53 AM
Details	340B ID	Update	New Registration		DSH520009AB	4/7/2025 6:53 AM
Details	Entity Name	Update	New Registration	ASCENSION NE WISCONSIN-ST. ELIZABETH	Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus	4/7/2025 6:53 AM
Details	Entity Subname	Update	New Registration	Richmond Urgent Care	Richmond Urgent Care - Urgent Care	4/7/2025 6:53 AM
Dates	Participating Approval Date	Update	New Registration		4/7/2025 6:53:23 AM	4/7/2025 6:53 AM
Details	State	Update	New Registration	Pending	Approved	4/7/2025 6:53 AM
Dates	Signed By Date	Update	New Registration		4/3/2025 10:05:34 AM	4/7/2025 6:53 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/7/2025 6:53 AM
Addresses	Main Address	Insert	New Registration		3329 N Richmond St Appleton, WI 54911	4/2/2025 3:15 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1407803638	4/2/2025 3:15 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	4/2/2025 3:15 PM
Contacts	Primary Contact	Insert	New Registration		Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4145227533	4/2/2025 3:15 PM
Contacts	Authorizing Official	Insert	New Registration		Bergmann, Michael President Ascension Wisconsin 9208318913	4/2/2025 3:15 PM
Details	Assistance Received From Date	Insert	New Registration			4/2/2025 3:15 PM
Details	Assistance Received To Date	Insert	New Registration			4/2/2025 3:15 PM
Details	Last Recertification Date	Insert	New Registration			4/2/2025 3:15 PM
Details	Grant Number	Insert	New Registration			4/2/2025 3:15 PM
Details	340B ID	Insert	New Registration			4/2/2025 3:15 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/2/2025 3:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/2/2025 3:15 PM
Details	Medicare Provider Number	Insert	New Registration		520009	4/2/2025 3:15 PM
Details	Entity Name	Insert	New Registration		ASCENSION NE WISCONSIN-ST. ELIZABETH	4/2/2025 3:15 PM
Details	NOFO Number	Insert	New Registration			4/2/2025 3:15 PM
Details	Program Code	Insert	New Registration		DSH	4/2/2025 3:15 PM
Details	Entity Subname	Insert	New Registration		Richmond Urgent Care	4/2/2025 3:15 PM
Dates	Participating Approval Date	Insert	New Registration			4/2/2025 3:15 PM
Details	State	Insert	New Registration		Pending	4/2/2025 3:15 PM
Dates	Registration Date	Insert	New Registration		4/2/2025 3:15:08 PM	4/2/2025 3:15 PM
Dates	Signed By Date	Insert	New Registration			4/2/2025 3:15 PM
Dates	Start Date	Insert	New Registration			4/2/2025 3:15 PM
Terminations	Termination Comments	Insert	New Registration			4/2/2025 3:15 PM
Terminations	Termination Date	Insert	New Registration			4/2/2025 3:15 PM
Terminations	Termination Effective Date	Insert	New Registration			4/2/2025 3:15 PM
Terminations	Termination Reason	Insert	New Registration			4/2/2025 3:15 PM