Covered Entity Details

DSH140067 SAINT FRANCIS MEDICAL CENTER (Active) - information as of 4/30/2025 10:48:37 PM

Main Details

Name

SAINT FRANCIS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140067

Medicare Provider Number

140067

Additional Details

Current Program Status

Active

Registration Date

9/5/2006

Participating Start Date

10/1/2006

Participating Approval Date

9/5/2006

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

OSF HealthCare
Sandra Salverson, SVP Pharmacy Services
(309) 624-8817

Primary Contact

OSF Healthcare
amy krantz, Manager Strategic Reimbursement
(309) 655-2865

Addresses

Street Address

530 NE GLEN OAK AVENUE
PEORIA, IL 61637

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	370662569009,370662569001,370662569401	1043260482,1164463493,1790734127,1023062312,1295785632,1942250394,1952351397,1962456764

Shipping Addresses

Shipping Address 1

OSF Healthcare System
5901 W. War Memorial Drive
Peoria, IL 61615

Shipping Address 2

Saint Francis Medical Center
530 NE Glen Oak Avenue
Peoria, IL 61637

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACRO PHARMACEUTICAL SERVICES LLC	ACRO PHARMACEUTICAL SERVICES LLC	313 HENDERSON DR	SHARON HILL	PA	19079	10/13/2016	01/01/2017	07/10/2019	07/10/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02166	3524 N UNIVERSITY	PEORIA	IL	61604	10/21/2015	01/01/2016		10/21/2015
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03181	2515 N. KNOXVILLE AVE	PEORIA	IL	61604	10/21/2015	01/01/2016	01/22/2025	01/22/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04732	2020 COURT STREET	PEKIN	IL	61554	10/21/2015	01/01/2016		10/21/2015
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05088	300 N MAIN ST	EAST PEORIA	IL	61611	10/21/2015	01/01/2016		10/21/2015
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05544	1200 E WAR MEMORIAL DR	PEORIA HEIGHTS	IL	61616	10/21/2015	01/01/2016		10/21/2015
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11493	1400 BROADWAY ST	PEKIN	IL	61554	10/21/2015	01/01/2016		10/21/2015
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	10/13/2016	01/01/2017	07/10/2019	07/10/2019
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/13/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06446	1008 W. GARFIELD ST	BARTONVILLE	IL	61607	07/12/2013	10/01/2013		07/12/2013
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06448	1101 PEORIA ST.	WASHINGTON	IL	61571	07/12/2013	10/01/2013		07/12/2013
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06452	1005 W JACKSON ST	MORTON	IL	61550	07/12/2013	10/01/2013		07/12/2013
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06453	200 NORTH MAIN STREET	EAST PEORIA	IL	61611	07/12/2013	10/01/2013		07/12/2013
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07798	3034 WEST LINCOLN	PEORIA	IL	61604	07/12/2013	10/01/2013	06/26/2021	10/08/2021
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07797	6820 NORTH PEAR TREE LANE	PEORIA	IL	61615	04/11/2014	07/01/2014		04/11/2014
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06447	9315 N. LINDBERGH DR.	PEORIA	IL	61615	04/11/2014	07/01/2014	08/02/2022	10/05/2022
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07800	2540 EAST WASHINGTON ST.	EAST PEORIA	IL	61611	04/11/2014	07/01/2014	05/20/2022	07/06/2022
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06450	603 S. FOURTH ST.	CHILLICOTHE	IL	61523	10/05/2022	01/01/2023		01/01/2023
Contract Detail	KROGER PHARMACY	#917	801 WEST LAKE STREET	PEORIA	IL	61614	04/05/2013	07/01/2013	10/31/2019	01/15/2020
Contract Detail	KROGER PHARMACY	#863	2321 W. WISCONSIN	PEORIA	IL	61603	04/05/2013	07/01/2013	01/26/2018	01/03/2019
Contract Detail	KROGER PHARMACY J918	9219 N LINDBERGH DR		PEORIA	IL	61615	04/05/2013	07/01/2013	10/31/2019	01/15/2020
Contract Detail	MEDI-PARK PHARMACY	420 NE GLEN OAK AVE STE 102	HILLCREST PLAZA	PEORIA	IL	61603-3171	12/04/2012	01/01/2013		03/28/2013
Contract Detail	ONCO360	SINA DRUG, LLC	4700 W SAM HOUSTON PKWY N STE 150	HOUSTON	TX	77041	07/15/2020	10/01/2020	01/07/2021	01/07/2021
Contract Detail	ONCOMED PHARMACEUTICAL SERVICES OF MA, L	D/B/A ONCO360	335 BEAR HILL RD STE 2100	WALTHAM	MA	02451	07/15/2020	10/01/2020	01/07/2021	01/07/2021
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	07/15/2020	10/01/2020	01/07/2021	01/07/2021
Contract Detail	OSF HOME INFUSION PHARMACY	2265 W ALTORFER DR		PEORIA	IL	61615-1807	07/09/2021	10/01/2021		10/01/2021
Contract Detail	POINTCORE INC	DBA OSF PHARMACY	1800 N KNOXVILLE AVE STE G	PEORIA	IL	61603-3028	01/07/2021	04/01/2021	09/30/2022	10/05/2022
Contract Detail	POINTCORE INC	DBA OSF SPECIALTY PHARMACY	5901 W WAR MEMORIAL DR SUITE 100	PEORIA	IL	61615	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/13/2020	07/01/2020	10/01/2022	10/05/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/13/2016	01/01/2017	08/31/2018	04/11/2022
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	07/15/2020	10/01/2020	07/06/2022	07/06/2022
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	07/15/2020	10/01/2020	07/06/2022	07/06/2022
Contract Detail	SINA DRUG LLC	DBA ONCO360	7125 JANES AVE STE 700	WOODRIDGE	IL	60517	07/15/2020	10/01/2020	01/07/2021	01/07/2021
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	07/15/2020	10/01/2020	07/06/2022	07/06/2022
Contract Detail	THE KROGER PHARMACY #942	3311 N STERLING AVENUE		PEORIA	IL	61604	04/05/2013	07/01/2013	10/31/2019	01/15/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/13/2020	07/01/2020	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-1028	401 RIVER ROAD		EAST PEORIA	IL	61611	04/07/2014	07/01/2014	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-1323	3315 N. UNIVERSITY STREET		PEORIA	IL	61604	04/05/2013	07/01/2013	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-1421	1980 FREEDOM PARKWAY		WASHINGTON	IL	61571	04/07/2014	07/01/2014	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-3460	8915 N ALLEN RD		PEORIA	IL	61615	04/05/2013	07/01/2013	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-5157	155 EAST COURTLAND STREET		MORTON	IL	61550	04/07/2014	07/01/2014	09/29/2023	10/09/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/13/2020	07/01/2020	09/29/2023	10/09/2023
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	04/12/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03763	1011 PEORIA ST	WASHINGTON	IL	61571-2487	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06079	4814 N SHERIDAN RD	PEORIA	IL	61614	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06408	2324 W WAR MEMORIAL DRIVE	PEORIA	IL	61614	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06604	1919 WEST PIONEER PKWY	PEORIA	IL	61615-1825	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09508	221 N WESTERN AVE	WEST PEORIA	IL	61604-5640	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09920	555 N MAIN	CANTON	IL	61520	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12367	10613 N. KNOXVILLE AVE.	PEORIA	IL	61615	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15636	221 NE GLEN OAK AVE STE A	PEORIA	IL	61636	10/21/2015	01/01/2016		10/21/2015
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21190	1150 N 5TH ST STE B	SPRINGFIELD	IL	62702	04/12/2023	07/01/2023		07/01/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/13/2020	07/01/2020	10/01/2021	10/08/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/13/2020	07/01/2020		07/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/13/2020	07/01/2020		07/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/13/2020	07/01/2020		07/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140067A	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Glen Avenue Diagnostic Center	4911 Executive Drive	Peoria	IL	Terminated
DSH140067AA	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Morton Health Center - OP Rad/Diag	435 Maxine Dr	Morton	IL	Active
DSH140067AB	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Morton Health Center - MRI	435 Maxine Dr	Morton	IL	Terminated
DSH140067AC	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Morton Health Center - SG Komen / Mammography	435 Maxine Dr	Morton	IL	Active
DSH140067AD	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Morton Health Center - Sonography	435 Maxine Dr	Morton	IL	Terminated
DSH140067AE	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Saint Francis Medical INI Rehabilitation Services - OP Rehab Service	360 Wilmor Road	Washington	IL	Terminated
DSH140067AF	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Saint Francis Medical INI Rehabilitation Services - Pediatric Dev Ctr	360 Wilmor Road	Washington	IL	Active
DSH140067AG	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Center for Health - Glen Park - DSC Imaging	5114 Glen Park Place	Peoria	IL	Active
DSH140067AH	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Center for Health - Glen Park - SG Komen / Mammography	5114 Glen Park Place	Peoria	IL	Active
DSH140067AJ	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Center for Health - Glen Park - MRI	5114 Glen Park Place	Peoria	IL	Terminated
DSH140067AK	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Center for Health - Glen Park - Sonography	5114 Glen Park Place	Peoria	IL	Terminated
DSH140067AL	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Center for Health - Glen Park - CT	5114 Glen Park Place	Peoria	IL	Terminated
DSH140067AM	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Medical Center Physical Therapy	5009 N Glen Park Place Rd	Peoria	IL	Terminated
DSH140067AN	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Wound Healing and Hyperbaric Center	8600 North State Route 91	Peoria	IL	Active
DSH140067AP	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Medical Center-Outpatient Infusion Center/Intravenous Therapy	1310 N. Missouri Avenue	Peoria	IL	Active
DSH140067AQ	Child	DSH	SAINT FRANCIS MEDICAL CENTER	SAINT FRANCIS MEDICAL CENTER - Pediatric Diabetic Resource Center	530 NE GLEN OAK AVE	PEORIA	IL	Active
DSH140067AR	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF CENTER FOR HEALTH - PEKIN - Cardiology	3422A COURT ST	PEKIN	IL	Active
DSH140067AS	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF SAINT FRANCIS MULTIDISCIPLINARY - OSF Cancer Support Services	1001 MAIN ST	PEORIA	IL	Active
DSH140067AT	Child	DSH	SAINT FRANCIS MEDICAL CENTER	SAINT FRANCIS MEDICAL CENTER - Congenital Heart Center	420 NE GLEN OAK AVE	PEORIA	IL	Active
DSH140067AU	Child	DSH	SAINT FRANCIS MEDICAL CENTER	SAINT FRANCIS MEDICAL CENTER - Children's Pulmonary	10 Saint Clare Court	Washington	IL	Active
DSH140067AV	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF SAINT FRANCIS RADIATION ONCOLOG - OSF Radiation Oncology-Pekin	3500 COURT ST	PEKIN	IL	Active
DSH140067AW	Child	DSH	SAINT FRANCIS MEDICAL CENTER	SFMC Transplant Services - Transplant	420 N.E. Glen Oak Avenue	Peoria	IL	Active
DSH140067AX	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF SAINT FRANCIS MEDICAL CENTER OU - Sleep Lab	5405 N KNOXVILLE AVE	PEORIA	IL	Active
DSH140067AY	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF CHOI OPHTHALMOLOGY - Pediatric Opthalmology	4927 N GLEN PARK PLACE RD	PEORIA	IL	Active
DSH140067AZ	Child	DSH	SAINT FRANCIS MEDICAL CENTER	SFMC BEHAVIORAL HEALTH SERVICES - Adult Behavioral Health	617 NE GLENDALE AVE	PEORIA	IL	Active
DSH140067B	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Outpatient Rehabilitation	100 NE Randolph	Peoria	IL	Terminated
DSH140067BA	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF CHOI PLUM, ALLERGY & SLEEP - Pediatric Allergy & Pulmonology	2900 N KNOXVILLE AVE	PEORIA	IL	Active
DSH140067BB	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Saint Francis Medical Center - OSF CHOI Pediatric Clinic	420 NE Glen Oak Ave	Peoria	IL	Active
DSH140067BC	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Saint Francis Medical Center - Heart Failure Clinic	530 NE Glen Oak Ave	Peoria	IL	Active
DSH140067C	Child	DSH	SAINT FRANCIS MEDICAL CENTER	PM&R Associates	200 E Pennsylvania	Peoria	IL	Terminated
DSH140067D	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Out Patient Rehabilitation	200 E. Pennsylvania Ave	Peoria	IL	Terminated
DSH140067E	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Pekin Cancer Treatment Center	603 Thirteenth St	Pekin	IL	Terminated
DSH140067F	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Sisters Community HealthCare Center	320 E. Armstrong	Peoria	IL	Terminated
DSH140067G	Child	DSH	SAINT FRANCIS MEDICAL CENTER	Saint Clare Family Health Center	10 Saint Clare Court	Washington	IL	Active
DSH140067H	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - Pain Program	8600-8800 Rt. 91 North	Peoria	IL	Active
DSH140067J	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - Minor Plastic Surgery	8600-8800 Rt. 91 North	Peoria	IL	Active
DSH140067K	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - EKG/ Phlebotomy	8600-8800 Rt. 91 North	Peoria	IL	Active
DSH140067L	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - Diagnostic Radiology	8600-8800 Rt. 91 North	Peoria	IL	Active
DSH140067M	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - MRI	8600-8800 Rt. 91 North	Peoria	IL	Terminated
DSH140067N	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - SG Komen / Mammography	8600-8800 Rt. 91 North	Peoria	IL	Active
DSH140067P	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - Ultrasonography	8600-8800 Rt. 91 North	Peoria	IL	Terminated
DSH140067Q	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Center for Health - CT Scan	8600-8800 Rt. 91 North	Peoria	IL	Terminated
DSH140067R	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Riverplex	600 N. E. Water Street	Peoria	IL	Active
DSH140067S	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Riverplex	600 N. E. Water Street	Peoria	IL	Terminated
DSH140067T	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Heart Hospital N Knoxville Cath and Lab Diagnostic Services - SG Komen / Mammography	5405 N. Knoxville Avenue	Peoria	IL	Terminated
DSH140067U	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Heart Hospital N Knoxville Cath and Lab Diagnostic Services - Sonography	5405 N. Knoxville Avenue	Peoria	IL	Terminated
DSH140067V	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Heart Hospital Diagnostic Center - Echocardiography - HCM	610 Park Avenue	Pekin	IL	Terminated
DSH140067W	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Heart Hospital Diagnostic Center - Stress Testing - HCM	610 Park Avenue	Pekin	IL	Active
DSH140067X	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Heart Hospital Diagnostic Center - Nuclear Medicine-HCM	610 Park Avenue	Pekin	IL	Terminated
DSH140067Y	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Heart Hospital Diagnostic Center - Sonography-HCM	610 Park Avenue	Pekin	IL	Terminated
DSH140067Z	Child	DSH	SAINT FRANCIS MEDICAL CENTER	OSF Saint Francis Radiation Oncology	8948 N. Wood Sage Road	Peoria	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Recertification	530 NE GLEN OAK AVENUE PEORIA, IL 61637-0002	530 NE GLEN OAK AVENUE PEORIA, IL 61637	9/3/2024 8:51 AM
Addresses	Shipping Address	Delete	Recertification	Saint Francis Medical Center 530 NE Glen Oak Avenue Peoria, IL 61637-0002		9/3/2024 8:51 AM
Addresses	Shipping Address	Insert	Recertification		Saint Francis Medical Center 530 NE Glen Oak Avenue Peoria, IL 61637	9/3/2024 8:51 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 11:16:34 AM	9/3/2024 8:51:07 AM	9/3/2024 8:51 AM
Contacts	Primary Contact	Update	Change Request	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	krantz, amy Manager Strategic Reimbursement OSF Healthcare 3096552865	6/27/2024 6:57 AM
Contacts	Authorizing Official	Update	Change Request	McGrew, Diane L. President OSF Healthcare 3096552850	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	6/27/2024 6:57 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 3:46:32 PM	8/31/2023 11:16:34 AM	8/31/2023 11:16 AM
Contacts	Primary Contact	Update	Group Change Request	Storm, Jerry Senior Vice President of Pharmacy Services OSF Healthcare 3096553489	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	4/25/2023 4:20 PM
Addresses	Shipping Address	Insert	Change Request		OSF Healthcare System 5901 W. War Memorial Drive Peoria, IL 61615	3/9/2023 10:41 AM
Addresses	Shipping Address	Insert	Change Request		Saint Francis Medical Center 530 NE Glen Oak Avenue Peoria, IL 61637-0002	3/9/2023 10:41 AM
Addresses	Shipping Address	Delete	Recertification	Saint Francis Medical Center 530 NE Glen Oak Ave Peoria, IL 61637-0002		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (IA)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (IA)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (IA)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (WI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (WI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (WI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (MO)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (MO)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (MO)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (MI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (MI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (MI)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (TX)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (TX)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (TX)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1043260482 (IN)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1164463493 (IN)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1790734127 (IN)		8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1023062312	8/31/2022 3:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295785632	8/31/2022 3:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942250394	8/31/2022 3:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1952351397	8/31/2022 3:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2022 3:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1962456764	8/31/2022 3:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2022 3:46 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 8:08:28 AM	8/31/2022 3:46:32 PM	8/31/2022 3:46 PM
Contacts	Authorizing Official	Update	Profile Change Request	McGrew, Diane Marie President OSF Healthcare 3096552850	McGrew, Diane L. President OSF Healthcare 3096552850	4/11/2022 5:02 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 10:37:02 AM	8/30/2021 8:08:28 AM	8/30/2021 8:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 10:37 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		370662569009	8/26/2020 10:37 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1043260482	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164463493	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/26/2020 10:37 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1790734127	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 10:37 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 10:37 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 8:23:43 AM	8/26/2020 10:37:02 AM	8/26/2020 10:37 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 10:17:36 AM	8/28/2019 8:23:43 AM	8/28/2019 8:23 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 2:53:23 PM	8/22/2018 10:17:36 AM	8/22/2018 10:17 AM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/29/2017 2:53:23 PM	11/29/2017 2:53 PM
Contacts	Primary Contact	Update	Recertification	Storm, Jerry Senior Vice President of Pharmacy Services 3096553489	Storm, Jerry Senior Vice President of Pharmacy Services OSF Healthcare 3096553489	11/29/2017 12:14 PM
Contacts	Authorizing Official	Update		McGrew, Diane Marie President 3096552850	McGrew, Diane Marie President OSF Healthcare 3096552850	11/27/2017 11:13 AM
Contacts	Primary Contact	Insert			Storm, Jerry Senior Vice President of Pharmacy Services 3096553489	6/5/2017 1:04 PM
Contacts	Authorizing Official	Update		SCHOEPLEIN, KEVIN D. CEO 3096552850	McGrew, Diane Marie President 3096552850	5/3/2017 12:12 PM
Addresses	Main Address	Insert			530 NE GLEN OAK AVENUE PEORIA, IL 61637-0002	10/13/2016 11:07 AM
Addresses	Billing Address	Insert			OSF Healthcare System PO Box 6259 Peoria, IL 61601-6259	10/13/2016 11:07 AM
Addresses	Shipping Address	Insert			Saint Francis Medical Center 530 NE Glen Oak Ave Peoria, IL 61637-0002	10/13/2016 11:07 AM
Details	Last Recertification Date	Update		8/18/2015 12:00:00 AM	8/16/2016 12:00:00 AM	8/16/2016 2:41 PM
Details	Last Recertification Date	Update		8/25/2014 12:00:00 AM	8/18/2015 12:00:00 AM	8/18/2015 7:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/19/2014 2:30 PM
Medicaid Billing	Medicaid: Number	Insert			370662569001	9/19/2014 2:30 PM
Medicaid Billing	Medicaid: State	Insert			IL	9/19/2014 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/19/2014 2:30 PM
Medicaid Billing	Medicaid: Number	Insert			370662569401	9/19/2014 2:30 PM
Medicaid Billing	Medicaid: State	Insert			IL	9/19/2014 2:30 PM
Medicaid Billing	NPI: Number	Insert			1043260482	9/19/2014 2:30 PM
Medicaid Billing	NPI: Number	Insert			1164463493	9/19/2014 2:30 PM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/25/2014 12:00:00 AM	8/25/2014 9:33 AM
Contacts	Authorizing Official	Update		MOORE, JAMES M. CEO 3096552806	SCHOEPLEIN, KEVIN D. CEO 3096552850	5/16/2014 9:24 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 12:09 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/22/2012 12:45 PM
Contacts	Authorizing Official	Insert			MOORE, JAMES M. CEO 3096552806	3/21/2007 9:04 AM
Details	Last Recertification Date	Insert				3/21/2007 9:04 AM
Details	Grant Number	Insert				3/21/2007 9:04 AM
Details	340B ID	Insert			DSH140067	3/21/2007 9:04 AM
Details	Is Authorizing Official EHB Data	Insert				3/21/2007 9:04 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/21/2007 9:04 AM
Details	Medicare Provider Number	Insert			140067	3/21/2007 9:04 AM
Details	Entity Name	Insert			SAINT FRANCIS MEDICAL CENTER	3/21/2007 9:04 AM
Details	Program Code	Insert			DSH	3/21/2007 9:04 AM
Details	Entity Subname	Insert				3/21/2007 9:04 AM
Dates	Participating Approval Date	Insert			9/5/2006 12:00:00 AM	3/21/2007 9:04 AM
Details	State	Insert			Active	3/21/2007 9:04 AM
Dates	Registration Date	Insert			9/5/2006 12:00:00 AM	3/21/2007 9:04 AM
Dates	Signed By Date	Insert			8/30/2006 12:00:00 AM	3/21/2007 9:04 AM
Dates	Start Date	Insert			10/1/2006 12:00:00 AM	3/21/2007 9:04 AM
Terminations	Termination Comments	Insert				3/21/2007 9:04 AM
Terminations	Termination Date	Insert				3/21/2007 9:04 AM
Terminations	Termination Effective Date	Insert				3/21/2007 9:04 AM
Terminations	Termination Reason	Insert				3/21/2007 9:04 AM