Covered Entity Details

RRC140046-34 SSM HEALTH GOOD SAMARITAN HOSPITAL (Approved) - information as of 5/15/2025 5:05:11 AM

Main Details

Name

SSM HEALTH GOOD SAMARITAN HOSPITAL

Subdivision Name

Behavioral Health Clinic - MV Behavioral Health

Type

Rural Referral Center

Rural

Yes

340B ID

RRC140046-34

Medicare Provider Number

140046

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/5/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/5/2025

Last Recertification Date

Contacts

Authorizing Official

SSM Health
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219

Primary Contact

SSM Health
Holly Herring, Director, 340B Center of Excellence
(580) 512-7188

Addresses

Street Address

2 Good Samaritan Way
410
Mt. Vernon, IL 62864

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
IL	430653587002,430653587402	1043270424,1316282163,1487758801,1609897339

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
RRC140046-01	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Good Samaritan Neurology	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
RRC140046-02	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	CardioPulmonary Rehab / Electrocardiology	2 Good Samaritan Way suite 220	Mt. Vernon	IL	Terminated
RRC140046-03	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Speech Therapy	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
RRC140046-04	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Occupational Therapy	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
RRC140046-05	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Physical Therapy	2 Good Samaritan Way	Mt Vernon	IL	Terminated
RRC140046-06	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Wound Healing Center	4106 S. Water Tower Place	Mt Vernon	IL	Approved
RRC140046-07	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Laboratory	4117 Veterans Memorial Drive	Mt. Vernon	IL	Terminated
RRC140046-08	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Diagnostics MRI	4117 Veterans Memorial Drive	Mt. Vernon	IL	Terminated
RRC140046-09	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Offsite Imaging / Diagnostics	501 DuQuoin St	Benton	IL	Terminated
RRC140046-10	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	Mammography	4117 Veterans Memorial Drive	Mt. Vernon	IL	Terminated
RRC140046-11	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Nephrology	2 Good Samaritan Way, Suite 420	Mt Vernon	IL	Approved
RRC140046-12	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS Mt Vernon ENT	2 Good Samaritan Way, Suite 420	Mt Vernon	IL	Terminated
RRC140046-13	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - GI	2 Good Samaritan Way, Suite 420	Mt Vernon	IL	Approved
RRC140046-14	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Heart and Vascular	2 Good Samaritan Way, Suite 220	Mt Vernon	IL	Approved
RRC140046-15	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS Mt Vernon Pediatrics	4103 South Water Tower Place	Mt Vernon	IL	Terminated
RRC140046-16	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS Mt Vernon Primary Care	4103 South Water Tower Place	Mt Vernon	IL	Terminated
RRC140046-17	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Oncology	4117 Veterans Memorial Drive	Mount Vernon	IL	Approved
RRC140046-18	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Oncology Infusion	4117 Veterans Memorial Drive	Mount Vernon	IL	Approved
RRC140046-19	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Pulmonary Care	2 Good Samaritan Way, Suite 420	Mount Vernon	IL	Approved
RRC140046-20	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Endocrinology 2GS	2 Good Samaritan Way, suite 420	Mount Vernon	IL	Approved
RRC140046-21	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Weight Management	5 Good Samaritan Way	Mt. Vernon	IL	Approved
RRC140046-22	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS Geriatrics - Geriatrics	#2 GOOD SAMARITAN WAY SUITE 420	Mount Vernon	IL	Terminated
RRC140046-23	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS Palliative Care - Palliative Care	#2 GOOD SAMARITAN WAY SUITE 420	Mount Vernon	IL	Terminated
RRC140046-24	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Medical Plaza Vascular Surgery	2 Good Samaritan Way	Mount Vernon	IL	Approved
RRC140046-25	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS - Physical Medicine and Rehab	2 GOOD SAMARITAN WAY	MOUNT VERNON	IL	Terminated
RRC140046-26	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS - Medical Plaza Urology [CC - 746000]	2 Good Samaritan Way	Mount Vernon	IL	Terminated
RRC140046-27	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS - Infectious Disease	2 GOOD SAMARITAN WAY	MOUNT VERNON	IL	Terminated
RRC140046-28	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS - Endocrinology 5GS	5 GOOD SAMARITAN WAY	MOUNT VERNON	IL	Terminated
RRC140046-29	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - General Surgery	5 Good Samaritan Way	Mount Vernon	IL	Approved
RRC140046-30	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Medical Plaza Urology [CC - 746100]	2 Good Samaritan Way	Mount Vernon	IL	Approved
RRC140046-31	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - Medical Plaza Podiatry	2 Good Samaritan Way	Mount Vernon	IL	Approved
RRC140046-32	Child	RRC	GOOD SAMARITAN REGIONAL HEALTH CTR.	SMGS - Rheumatology	2 GOOD SAMARITAN WAY	MOUNT VERNON	IL	Terminated
RRC140046-34	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	Behavioral Health Clinic - MV Behavioral Health	2 Good Samaritan Way	Mt. Vernon	IL	Approved
RRC140046-35	Child	RRC	SSM HEALTH GOOD SAMARITAN HOSPITAL	Good Samaritan Infusion Centralia- Infusion - Centralia Infusion	400 North Pleasant Avenue	Centralia	IL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	5/5/2025 1:27 PM
Details	340B ID	Update	New Registration		RRC140046-34	5/5/2025 1:27 PM
Details	Entity Subname	Update	New Registration	Behavioral Health Clinic	Behavioral Health Clinic - MV Behavioral Health	5/5/2025 1:27 PM
Dates	Participating Approval Date	Update	New Registration		5/5/2025 1:27:40 PM	5/5/2025 1:27 PM
Details	State	Update	New Registration	Pending	Approved	5/5/2025 1:27 PM
Dates	Signed By Date	Update	New Registration		4/14/2025 10:23:57 AM	5/5/2025 1:27 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/5/2025 1:27 PM
Addresses	Main Address	Insert	New Registration		2 Good Samaritan Way 410 Mt. Vernon, IL 62864	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		430653587002	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		430653587402	4/5/2025 12:53 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270424	4/5/2025 12:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316282163	4/5/2025 12:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1487758801	4/5/2025 12:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609897339	4/5/2025 12:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/5/2025 12:53 PM
Contacts	Authorizing Official	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	4/5/2025 12:53 PM
Contacts	Primary Contact	Insert	New Registration		Herring, Holly Director, 340B Center of Excellence SSM Health 5805127188	4/5/2025 12:53 PM
Details	Assistance Received From Date	Insert	New Registration			4/5/2025 12:53 PM
Details	Assistance Received To Date	Insert	New Registration			4/5/2025 12:53 PM
Details	Last Recertification Date	Insert	New Registration			4/5/2025 12:53 PM
Details	Grant Number	Insert	New Registration			4/5/2025 12:53 PM
Details	340B ID	Insert	New Registration			4/5/2025 12:53 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2025 12:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2025 12:53 PM
Details	Medicare Provider Number	Insert	New Registration		140046	4/5/2025 12:53 PM
Details	Entity Name	Insert	New Registration		SSM HEALTH GOOD SAMARITAN HOSPITAL	4/5/2025 12:53 PM
Details	NOFO Number	Insert	New Registration			4/5/2025 12:53 PM
Details	Program Code	Insert	New Registration		RRC	4/5/2025 12:53 PM
Details	Entity Subname	Insert	New Registration		Behavioral Health Clinic	4/5/2025 12:53 PM
Dates	Participating Approval Date	Insert	New Registration			4/5/2025 12:53 PM
Details	State	Insert	New Registration		Pending	4/5/2025 12:53 PM
Dates	Registration Date	Insert	New Registration		4/5/2025 12:53:58 PM	4/5/2025 12:53 PM
Dates	Signed By Date	Insert	New Registration			4/5/2025 12:53 PM
Dates	Start Date	Insert	New Registration			4/5/2025 12:53 PM
Terminations	Termination Comments	Insert	New Registration			4/5/2025 12:53 PM
Terminations	Termination Date	Insert	New Registration			4/5/2025 12:53 PM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2025 12:53 PM
Terminations	Termination Reason	Insert	New Registration			4/5/2025 12:53 PM