Covered Entity Details

DSH140158D MERCY HOSPITAL AND MEDICAL CENTER (Terminated) - information as of 5/27/2025 2:32:39 PM

Main Details

Name

MERCY HOSPITAL AND MEDICAL CENTER

Subdivision Name

PULASKI NORTH

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140158D

Medicare Provider Number

140158

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/23/2008

Participating Start Date

7/1/2004

Participating Approval Date

4/23/2008

Last Recertification Date

8/24/2020

Termination Date
Termination Reason

7/1/2021
Site closure

Contacts

Authorizing Official

Insight Hospital and Medical Center Chicago
Baseer Tajuddin, General Counsel
(217) 377-6978

Primary Contact

Mercy Hospital and Medical Center
Steven Silverstein, Pharmacy Health System Director
(312) 567-2489

Addresses

Street Address

5525 S. PULASKI ROAD
CHICAGO, IL 60629

Billing Address

Mercy Hospital and Medical Center
2525 S. Michigan
Chicago, IL 60616

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	36-2170152-001	1730166224

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
Contract Detail	MERCY HOSPITAL & MEDICAL CENTER	DEPARTMENT OF PHARMACY SERVICES	2525 S. MICHIGAN AVENUE	CHICAGO	IL	60616-2477	08/01/2005	08/01/2005		07/01/2021	07/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140158A	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	MEDICAL SATELLITES	2600 S. MICHIGAN AVENUE	CHICAGO	IL	Terminated
DSH140158D	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	PULASKI NORTH	5525 S. PULASKI ROAD	CHICAGO	IL	Terminated
DSH140158G	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	ASHLAND	3316 S. ASHLAND AVENUE	CHICAGO	IL	Terminated
DSH140158J	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	MICHIGAN AVENUE	2930 S. MICHIGAN AVENUE	CHICAGO	IL	Terminated
DSH140158L	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	Pulaski	4321 S. Pulaski Rd.	Chicago	IL	Terminated
DSH140158M	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	Chatham	8541 S. State St.	Chicago	IL	Terminated
DSH140158N	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	Dearborn Station	47 W. Polk St.	Chicago	IL	Terminated
DSH140158P	Child	DSH	MERCY HOSPITAL AND MEDICAL CENTER	MH&MC Clinic	3753S COTTAGE GROVE AVE	CHICAGO	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	Miglio, Silia VP of Finance Mercy Hospital and Medical Center 3125672580	Tajuddin, Baseer General Counsel Insight Hospital and Medical Center Chicago 2173776978	6/3/2021 2:32 PM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/13/2021 12:00:00 AM	5/17/2021 12:17 PM
Details	State	Update	Termination Request	Active	To Be Terminated	5/17/2021 12:17 PM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/17/2021 12:17 PM
Terminations	Termination Effective Date	Update	Termination Request		5/17/2021 12:00:00 AM	5/17/2021 12:17 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	5/17/2021 12:17 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1730166224	8/24/2020 9:31 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/24/2020 9:31 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730166284 ( )		8/24/2020 9:31 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 12:40:56 PM	8/24/2020 9:31:25 AM	8/24/2020 9:31 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 4:29:38 PM	8/26/2019 12:40:56 PM	8/26/2019 12:40 PM
Contacts	Authorizing Official	Update	Change Request	Campbell, Carla Chief Patient Care Services Officer, CNO Mercy Hospital and Medical Center 3125672107	Miglio, Silia VP of Finance Mercy Hospital and Medical Center 3125672580	9/14/2018 10:42 AM
Details	Last Recertification Date	Update	Recertification	11/17/2017 2:46:48 PM	8/15/2018 4:29:38 PM	8/15/2018 4:29 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/17/2017 2:46:48 PM	11/17/2017 2:46 PM
Contacts	Authorizing Official	Insert	AO Change Request		Campbell, Carla Chief Patient Care Services Officer, CNO Mercy Hospital and Medical Center 3125672107	11/15/2017 11:13 AM
Contacts	Primary Contact	Update		Silverstein, Steven Pharmacy Health System Director 3125672489	Silverstein, Steven Pharmacy Health System Director Mercy Hospital and Medical Center 3125672489	9/29/2017 10:31 AM
Contacts	Primary Contact	Insert			Silverstein, Steven Pharmacy Health System Director 3125672489	9/6/2016 7:51 AM
Addresses	Main Address	Insert			5525 S. PULASKI ROAD CHICAGO, IL 60629	9/6/2016 7:51 AM
Addresses	Billing Address	Insert			Mercy Hospital and Medical Center 2525 S. Michigan Chicago, IL 60616	9/6/2016 7:51 AM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 11:04 AM
Medicaid Billing	NPI: Number	Insert			1730166284	4/5/2016 7:01 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/6/2015 11:07 AM
Details	Last Recertification Date	Update		8/18/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 11:07 AM
Details	Last Recertification Date	Update		8/30/2013 7:45:38 PM	8/18/2014 12:00:00 AM	8/18/2014 9:28 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 7:45:38 PM	8/30/2013 7:45 PM
Dates	Participating Approval Date	Update		4/23/2008 12:45:14 PM	4/23/2008 12:00:00 AM	3/7/2013 11:56 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 9:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	4/23/2008 12:40 PM
Medicaid Billing	Medicaid: Number	Insert			36-2170152-001	4/23/2008 12:40 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/23/2008 12:40 PM
Details	Last Recertification Date	Insert				4/23/2008 12:40 PM
Details	Grant Number	Insert				4/23/2008 12:40 PM
Details	340B ID	Insert			DSH140158D	4/23/2008 12:40 PM
Details	Is Authorizing Official EHB Data	Insert				4/23/2008 12:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/23/2008 12:40 PM
Details	Medicare Provider Number	Insert			140158	4/23/2008 12:40 PM
Details	Entity Name	Insert			MERCY HOSPITAL AND MEDICAL CENTER	4/23/2008 12:40 PM
Details	Program Code	Insert			DSH	4/23/2008 12:40 PM
Details	Entity Subname	Insert			PULASKI NORTH	4/23/2008 12:40 PM
Dates	Participating Approval Date	Insert			4/23/2008 12:45:14 PM	4/23/2008 12:40 PM
Details	State	Insert			Active	4/23/2008 12:40 PM
Dates	Registration Date	Insert			4/23/2008 12:00:00 AM	4/23/2008 12:40 PM
Dates	Signed By Date	Insert				4/23/2008 12:40 PM
Dates	Start Date	Insert			7/1/2004 12:00:00 AM	4/23/2008 12:40 PM
Terminations	Termination Comments	Insert				4/23/2008 12:40 PM
Terminations	Termination Date	Insert				4/23/2008 12:40 PM
Terminations	Termination Effective Date	Insert				4/23/2008 12:40 PM
Terminations	Termination Reason	Insert				4/23/2008 12:40 PM