Covered Entity Details

DSH140124 JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY (Active) - information as of 5/16/2025 11:23:25 PM

Main Details

Name

JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140124

Medicare Provider Number

140124

Additional Details

Current Program Status

Active

Registration Date

10/31/2007

Participating Start Date

1/1/1994

Participating Approval Date

10/31/2007

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Cook County Health
Pamela Cassara, Chief Financial Officer
(312) 864-5507

Primary Contact

Cook County Health & Hospitals System
CaTanya Norwood, Senior Director of Pharmacy
(312) 864-2213

Addresses

Street Address

1901 WEST HARRISON STREET
CHICAGO, IL 60612

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
UPDATED ENTITY NAME (WAS COOK COUNTY HOSP)	01/08/2010

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	366006541069,366006541075,366006541071,366006541072,366006541066,366006541063,366006541018,366006541044,366006541054,366006541019,366006541064,366006541055,366006541005,366006541083,366006541070,366006541081,366006541049,366006541073,366006541606,366006541043,366006541473	1730209545,1457385775,1023137528,1043238298,1942508460,1588612832,1649390022,1821385170,1245350040,1588781298,1861513996,1104946904,1518087428,1922127844,1861512667,1689794489,1760502439,1295855096,1497875298,1598884629,1649551938,1366073355,1750912648,1568093557,1790316784,1457982340,1295366466,1427689413,1609407691,1922639913,1457982449,1053942045,1366073256
IN	300062812,300057727,300057739,300057754,300057762,300057767,300057771,300057874,300057924,300058052,300064318,300058011,300058016,300064536,300062905,300062880,300063963,300072816	1588612832,1750912648,1366073355,1427689413,1609407691,1295366466,1922639913,1053942045,1518598507,1790316784,1366073256,1568093557,1649390022,1689794489,1023137528,1457385775,1942508460,1043238298

Shipping Addresses

Shipping Address 1

Core Center Pharmacy
2020 West Harrison Street
Chicago, IL 60612-3741

Shipping Address 2

Cook County Health Central Fill Pharmacy (formerly Oak Central Fill Pharmacy)
1901 West Harrison
Chicago, IL 60612

Shipping Address 3

Cook County Health at Blue Island Health Center
12757 Western Ave
Blue Island, IL 60406

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
Contract Detail	PROVIDENT HOSPITAL OF COOK COUNTY	ATTENTION PHARMACY DEPARTMENT	500 E 51ST ST ROOM 2050	CHICAGO	IL	60615-2400	04/15/2013	07/01/2013	07/01/2019		07/09/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140124A	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Cook County Health at Blue Island Health Center (Formerly OAK FOREST HEALTH CENTER)	12757 S Western Ave.	Blue Island	IL	Active
DSH140124AA	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	COOK COUNTY - John H. Stroger, Jr. Telemedicine	1901W HARRISON ST	CHICAGO	IL	Active
DSH140124AB	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Cook County Health at Blue Island Health Center - Specialty Care - Blue Island Specialty Care	12757 S. Western Ave.	Blue Island	IL	Active
DSH140124AC	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Gynecology Tumor Clinic - Gynecology Tumor Clinic	1950 West Polk Street	Chicago	IL	Active
DSH140124AD	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Urology - Urology	1950 West Polk Street	Chicago	IL	Active
DSH140124AE	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Breast/Surgical Oncology - Surgery Oncology	1950 West Polk Street	Chicago	IL	Active
DSH140124AF	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Cancer Genetics - Cancer Genetics	1950 West Polk Street	Chicago	IL	Active
DSH140124AG	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Dermatology Pediatrics - Dermatology Pediatrics	1950 West Polk Street	Chicago	IL	Active
DSH140124AH	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Psychiatry Oncology - Psychiatry Oncology	1950 West Polk Street	Chicago	IL	Active
DSH140124AJ	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Diabetes - Diabetes	1950 West Polk Street	Chicago	IL	Active
DSH140124AK	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Hematology Clinic - Clinical Hematology	1950 West Polk Street	Chicago	IL	Active
DSH140124B	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	CORE CLINIC	2020 W Harrison St.	Chicago	IL	Active
DSH140124C	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	CHILD ADVOCACY CENTER	1240 South Damen Ave	Chicago	IL	Terminated
DSH140124D	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	MORTON EAST CLINIC	2423 South Austin Blvd	Cicero	IL	Active
DSH140124E	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	WOODY WINSTON CLINIC	650 E. Phoenix Center Drive	Phoenix	IL	Terminated
DSH140124F	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	WOODLAWN CLINIC	6337 S. Woodlawn Avenue	Chicago	IL	Terminated
DSH140124G	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Cook County Health at Arlington Heights (formerly VISTA CLINIC)	3250 N. Arlington Heights Rd.	Arlington Heights	IL	Active
DSH140124H	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	ROBBINS CLINIC	13450 S. Kedzie Avenue	Robbins	IL	Active
DSH140124J	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	PRIETO CLINIC	2424 S. Pulaski Road	Chicago	IL	Active
DSH140124K	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	NEAR SOUTH HEALTH CENTER	3525 S. Michigan Avenue	Chicago	IL	Terminated
DSH140124L	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Cook County Health at Belmont Cragin (formerly LOGAN SQUARE CLINIC)	5501 W. Fullerton Avenue	Chicago	IL	Active
DSH140124M	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	FANTUS HEALTH CENTER	1901 West Harrison Street	Chicago	IL	Terminated
DSH140124N	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	COTTAGE GROVE CLINIC	1645 Cottage Grove	Ford Heights	IL	Active
DSH140124P	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	ENGLEWOOD CLINIC	1135 W. 69th Street	Chicago	IL	Active
DSH140124Q	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Cook County Health at North Riverside (formerly known as CICERO CLINIC)	1800 S. Harlem Avenue	North Riverside	IL	Active
DSH140124R	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	AUSTIN CLINIC	4800 W. Chicago Avenue	Chicago	IL	Active
DSH140124S	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Breast/Cervical Screening	1950 West Polk Street	CHICAGO	IL	Active
DSH140124T	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Endocrinology	1950 West Polk Street	Chicago	IL	Active
DSH140124U	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Hematology/Oncology	1950 West Polk Street	Chicago	IL	Active
DSH140124V	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Infusion Center	1950 West Polk Street	CHICAGO	IL	Active
DSH140124W	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Dermatology/Oncology	1950 West Polk Street	CHICAGO	IL	Active
DSH140124X	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - Ophthalmology	1950 West Polk Street	CHICAGO	IL	Active
DSH140124Y	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	Professional Building - General Medicine Clinic (GMC)	1950 West Polk Street	CHICAGO	IL	Active
DSH140124Z	Child	DSH	JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	COOK COUNTY HEALTH PROFESSIONAL BLD - Professional Building - Oral Health (Dental)	1950 W POLK ST	CHICAGO	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Change Request	1740811736 (IL)		3/12/2025 1:05 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 1:32:58 PM	8/15/2024 1:26:15 PM	8/15/2024 1:26 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	366006541080 (IL)		8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1770892135 (IL)		8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1366073355	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750912648	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1568093557	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1790316784	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1740811736	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457982340	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1295366466	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1427689413	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1609407691	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922639913	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457982449	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1053942045	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1366073256	8/12/2024 7:13 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/12/2024 7:13 AM
Addresses	Shipping Address	Delete	Change Request	John H Stroger Jr Hospital BC Outpatient Pharmacy 1901 W Harrison St Room 1230A Chicago, IL 60612		3/4/2024 9:56 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 8:49:18 AM	9/6/2023 1:32:58 PM	9/6/2023 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/31/2023 4:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		300072816	3/31/2023 4:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IN	3/31/2023 4:07 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1043238298	3/31/2023 4:07 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IN	3/31/2023 4:07 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 2:47:35 PM	8/24/2022 8:49:18 AM	8/24/2022 8:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300062812	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057727	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057739	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057754	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057762	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057767	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057771	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057874	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300057924	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300058052	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300064318	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300058011	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300058016	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300064536	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300062905	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300062880	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300063963	8/24/2022 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1588612832	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750912648	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1366073355	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1427689413	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1609407691	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1295366466	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922639913	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1053942045	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1518598507	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1790316784	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1366073256	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1568093557	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649390022	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1689794489	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1023137528	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457385775	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1942508460	8/24/2022 8:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	8/24/2022 8:44 AM
Addresses	Shipping Address	Delete	Change Request	Provident Outpatient Pharmacy 500 East 51st Street Chicago, IL 60615		7/13/2022 8:18 AM
Addresses	Shipping Address	Update	Change Request	Oak Central Fill Pharmacy Oak Forest Health Center 15900 S. Cicero, F21/F22 Oak Forest, IL 60452	Cook County Health Central Fill Pharmacy (formerly Oak Central Fill Pharmacy) 1901 West Harrison Chicago, IL 60612	6/2/2022 8:59 AM
Contacts	Authorizing Official	Update	Change Request	Gibson, Andrea Maureen Interim Chief Business Officer Cook County Health 3128640953	Cassara, Pamela Chief Financial Officer Cook County Health 3128645507	11/2/2021 10:56 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 12:23:57 PM	9/7/2021 2:47:35 PM	9/7/2021 2:47 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	366006541074 (IL)		7/2/2021 10:36 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	366006541013 (IL)		7/2/2021 10:36 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	366006541007 (IL)		7/2/2021 10:36 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1336268143 (IL)		7/2/2021 10:36 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1497874325 (IL)		7/2/2021 10:36 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1396865077 (IL)		7/2/2021 10:36 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1689869802 (IL)		6/14/2021 5:02 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952510786 (IL)		6/14/2021 5:02 PM
Addresses	Shipping Address	Delete	Change Request	Oak Forest Pharmacy 15900 S. Cicero Avenue Oak Forest, IL 60452		11/18/2020 8:34 AM
Addresses	Shipping Address	Insert	Change Request		Cook County Health at Blue Island Health Center 12757 Western Ave Blue Island, IL 60406	11/18/2020 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541072	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541074	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541066	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541013	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541063	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541018	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541044	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541007	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541054	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541019	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541064	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541055	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541005	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541083	9/3/2020 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861513996	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1336268143	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104946904	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1497874325	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1518087428	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1922127844	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861512667	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1396865077	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1689794489	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760502439	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295855096	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1497875298	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1598884629	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649551938	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/3/2020 12:23 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 5:30:16 PM	9/3/2020 12:23:57 PM	9/3/2020 12:23 PM
Contacts	Authorizing Official	Update	Change Request	Akpan, Ekerete Chief Financial Officer Cook County Health & Hospitals System 3128646827	Gibson, Andrea Maureen Interim Chief Business Officer Cook County Health 3128640953	5/4/2020 1:27 PM
Details	Last Recertification Date	Update	Recertification	9/12/2018 7:12:11 PM	9/13/2019 5:30:16 PM	9/13/2019 5:30 PM
Addresses	Shipping Address	Insert	Change Request		Provident Outpatient Pharmacy 500 East 51st Street Chicago, IL 60615	4/3/2019 8:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2019 8:13 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		366006541069	4/3/2019 8:13 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2019 8:13 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1588781298	4/3/2019 8:13 AM
Contacts	Authorizing Official	Update	Change Request	Elwell, Douglas Deputy Chief Executive Officer Cook County health and Hospitals System 3128646827	Akpan, Ekerete Chief Financial Officer Cook County Health & Hospitals System 3128646827	2/8/2019 1:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1689869802	10/12/2018 6:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952510786	10/12/2018 6:11 PM
Details	Last Recertification Date	Update	Recertification	11/30/2017 10:07:19 AM	9/12/2018 7:12:11 PM	9/12/2018 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/7/2018 8:40 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		366006541043	3/7/2018 8:40 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/7/2018 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1245350040	3/7/2018 8:40 AM
Addresses	Shipping Address	Insert	Recertification		Oak Central Fill Pharmacy Oak Forest Health Center 15900 S. Cicero, F21/F22 Oak Forest, IL 60452	11/30/2017 10:07 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	366006541068 (IL)		11/30/2017 10:07 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	366006541082 (IL)		11/30/2017 10:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 10:07 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		366006541606	11/30/2017 10:07 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	11/30/2017 10:07 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1013035781 ( )		11/30/2017 10:07 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841500956 ( )		11/30/2017 10:07 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821385170	11/30/2017 10:07 AM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/30/2017 10:07:19 AM	11/30/2017 10:07 AM
Contacts	Authorizing Official	Update		Elwell, Douglas Deputy Chief Executive Officer 3128646827	Elwell, Douglas Deputy Chief Executive Officer Cook County health and Hospitals System 3128646827	10/11/2017 8:09 AM
Contacts	Primary Contact	Update		Norwood, CaTanya Senior Director of Pharmacy 3128642213	Norwood, CaTanya Senior Director of Pharmacy Cook County Health & Hospitals System 3128642213	10/10/2017 6:21 PM
Addresses	Shipping Address	Delete		Fantus Health Center Pharmacy 1901 W Harrison St Floor 3 Chicago, IL 60612		5/23/2017 9:57 AM
Addresses	Shipping Address	Delete		Fantus Health Center Refill Pharmacy 1901 W Harrison St Floor 1 Chicago, IL 60612		5/23/2017 9:57 AM
Addresses	Shipping Address	Delete		Oak Central Fill Pharmacy Oak Forest Hospital Campus 15900 S. Cicero, F21/F22 Oak Forest, IL 60452		5/23/2017 9:57 AM
Addresses	Main Address	Insert			1901 WEST HARRISON STREET CHICAGO, IL 60612	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			Fantus Health Center Pharmacy 1901 W Harrison St Floor 3 Chicago, IL 60612	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			Fantus Health Center Refill Pharmacy 1901 W Harrison St Floor 1 Chicago, IL 60612	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			John H Stroger Jr Hospital BC Outpatient Pharmacy 1901 W Harrison St Room 1230A Chicago, IL 60612	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			Core Center Pharmacy 2020 West Harrison Street Chicago, IL 60612-3741	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			Oak Central Fill Pharmacy Oak Forest Hospital Campus 15900 S. Cicero, F21/F22 Oak Forest, IL 60452	5/23/2017 9:57 AM
Addresses	Shipping Address	Insert			Oak Forest Pharmacy 15900 S. Cicero Avenue Oak Forest, IL 60452	5/23/2017 9:57 AM
Contacts	Primary Contact	Update		Shannon, John Jay Chief of Clinical Integration 3128645504	Norwood, CaTanya Senior Director of Pharmacy 3128642213	5/23/2017 9:57 AM
Contacts	Authorizing Official	Update		Daniels, Peter W. COO, Inpatient Services 3128645507	Elwell, Douglas Deputy Chief Executive Officer 3128646827	5/23/2017 9:57 AM
Medicaid Billing	Medicaid: Number	Update		36606541049	366006541049	5/23/2017 9:56 AM
Medicaid Billing	NPI: Number	Insert			1649390022	5/23/2017 9:56 AM
Medicaid Billing	NPI: Number	Insert			1588612832	3/3/2017 2:16 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 12:56 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/1/2015 7:13 AM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 7:13 AM
Medicaid Billing	Medicaid: State	Update		IN	IL	8/7/2015 8:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/30/2015 3:40 PM
Medicaid Billing	Medicaid: Number	Insert			36606541049	6/30/2015 3:40 PM
Medicaid Billing	Medicaid: State	Insert			IN	6/30/2015 3:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/30/2015 3:40 PM
Medicaid Billing	Medicaid: Number	Insert			366006541073	6/30/2015 3:40 PM
Medicaid Billing	Medicaid: State	Insert			IL	6/30/2015 3:40 PM
Medicaid Billing	NPI: Number	Update		1043238292	1043238298	6/30/2015 3:40 PM
Contacts	Authorizing Official	Insert			Daniels, Peter W. COO, Inpatient Services 3128645507	10/30/2014 5:06 PM
Contacts	Primary Contact	Insert			Shannon, John Jay Chief of Clinical Integration 3128645504	9/8/2014 3:31 PM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 3:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/20/2014 10:55 AM
Medicaid Billing	Medicaid: Number	Insert			366006541070	2/20/2014 10:55 AM
Medicaid Billing	Medicaid: State	Insert			IL	2/20/2014 10:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/20/2014 10:55 AM
Medicaid Billing	Medicaid: Number	Insert			366006541081	2/20/2014 10:55 AM
Medicaid Billing	Medicaid: State	Insert			IL	2/20/2014 10:55 AM
Medicaid Billing	NPI: Number	Insert			1043238292	2/20/2014 10:55 AM
Medicaid Billing	NPI: Number	Insert			1942508460	2/20/2014 10:55 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 12:00:00 AM	9/10/2013 6:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: Number	Insert			366006541071	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: State	Insert			IL	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: Number	Insert			366006541080	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: State	Insert			IL	5/24/2013 3:57 PM
Medicaid Billing	NPI: Number	Insert			1023137528	5/24/2013 3:57 PM
Medicaid Billing	NPI: Number	Insert			1770892135	5/24/2013 3:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Number	Insert			366006541075	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Number	Insert			366006541068	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Number	Insert			366006541082	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/16/2013 8:46 AM
Medicaid Billing	NPI: Number	Insert			1457385775	4/16/2013 8:46 AM
Medicaid Billing	NPI: Number	Insert			1013035781	4/16/2013 8:46 AM
Medicaid Billing	NPI: Number	Insert			1841500956	4/16/2013 8:46 AM
Medicaid Billing	Medicaid: Number	Update		36-6006541-002	366006541473	3/7/2013 4:17 PM
Medicaid Billing	NPI: Number	Insert			1730209545	3/7/2013 4:17 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:35 AM
Details	Last Recertification Date	Insert				1/8/2010 2:03 PM
Details	Grant Number	Insert				1/8/2010 2:03 PM
Details	340B ID	Insert			DSH140124	1/8/2010 2:03 PM
Details	Is Authorizing Official EHB Data	Insert				1/8/2010 2:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/8/2010 2:03 PM
Details	Medicare Provider Number	Insert			140124	1/8/2010 2:03 PM
Details	Entity Name	Insert			JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY	1/8/2010 2:03 PM
Details	Program Code	Insert			DSH	1/8/2010 2:03 PM
Details	Entity Subname	Insert				1/8/2010 2:03 PM
Dates	Participating Approval Date	Insert			10/31/2007 12:00:00 AM	1/8/2010 2:03 PM
Details	State	Insert			Active	1/8/2010 2:03 PM
Dates	Registration Date	Insert			10/31/2007 12:00:00 AM	1/8/2010 2:03 PM
Dates	Signed By Date	Insert				1/8/2010 2:03 PM
Dates	Start Date	Insert			1/1/1994 12:00:00 AM	1/8/2010 2:03 PM
Terminations	Termination Comments	Insert				1/8/2010 2:03 PM
Terminations	Termination Date	Insert				1/8/2010 2:03 PM
Terminations	Termination Effective Date	Insert				1/8/2010 2:03 PM
Terminations	Termination Reason	Insert				1/8/2010 2:03 PM
Details	Comments Public	Insert			UPDATED ENTITY NAME (WAS COOK COUNTY HOSP)	1/8/2010 2:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	10/31/2007 3:36 PM
Medicaid Billing	Medicaid: Number	Insert			36-6006541-002	10/31/2007 3:36 PM
Medicaid Billing	Medicaid: State	Insert			IL	10/31/2007 3:36 PM