Covered Entity Details

DSH140114G SWEDISH COVENANT HEALTH (Active) - information as of 6/1/2025 4:03:06 AM

Main Details

Name

SWEDISH COVENANT HEALTH

Subdivision Name

INFUSION / CANCER CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140114G

Medicare Provider Number

140114

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2008

Participating Start Date

10/14/2008

Participating Approval Date

10/14/2008

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Swedish Covenant Health
Jonathan Lind, Chief Operating Officer
(773) 907-1028 Ext: 1028

Primary Contact

Swedish Covenant Health
Alicia Juska, Director Pharmacy
(773) 878-8200 Ext: 5379

Addresses

Street Address

5140 N. CALIFORNIA AVENUE
G115, G600
CHICAGO, IL 60625

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
2/23/12 remove medicaid number	02/23/2012

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	362179813001, 362179813401,362179813011,362179813521,364073303002,364073303003	1831151257,1588739734,1497825855

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	SWEDISH COVENANT HEALTH	DBA GALTER MEDICAL PAVILION PHARMACY	5140 N CALIFORNIA AVE # G105	CHICAGO	IL	60625	11/04/2008	11/04/2008		12/31/2023	08/16/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140114B	Child	DSH	SWEDISH COVENANT HEALTH	WOUND CARE CLINIC	2751 W. WINNONA AVENUE, AP3 FLOOR	CHICAGO	IL	Active
DSH140114C	Child	DSH	SWEDISH COVENANT HEALTH	PAIN MANAGEMENT CLINIC	5215 N. California Ave.	CHICAGO	IL	ToBeTerminated
DSH140114D	Child	DSH	SWEDISH COVENANT HEALTH	OPERATING ROOM / ONE DAY SURGICAL PATIENTS	5140 N. CALIFORNIA AVENUE, SUITE #G200	CHICAGO	IL	Active
DSH140114E	Child	DSH	SWEDISH COVENANT HEALTH	EMERGENCY / DISCHARGE PATIENTS	5145 N. CALIFORNIA AVENUE	CHICAGO	IL	Active
DSH140114G	Child	DSH	SWEDISH COVENANT HEALTH	INFUSION / CANCER CENTER	5140 N. CALIFORNIA AVENUE	CHICAGO	IL	Active
DSH140114J	Child	DSH	Swedish Covenant Hospital	Outpatient Oncology Infusion Center Evanston	800 Austin Ave.	Evanston	IL	Terminated
DSH140114K	Child	DSH	SWEDISH COVENANT HEALTH	Ambulatory Surgery	5215 N. California Ave.	Chicago	IL	Active
DSH140114L	Child	DSH	SWEDISH COVENANT HEALTH	SWEDISH HOSPITAL INFUSION CENTER NI - Infusion Center	6450 W TOUHY AVE	NILES	IL	Active
DSH140114M	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	757 PARK AVE W	HIGHLAND PARK	IL	Active
DSH140114N	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	2650 RIDGE AVE	EVANSTON	IL	Active
DSH140114P	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology	2180 PFINGSTEN RD	GLENVIEW	IL	Active
DSH140114Q	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	120 Spalding Drive	Naperville	IL	Approved
DSH140114R	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	24600 W. 127th Street	Plainfield	IL	Approved
DSH140114S	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology and Specialty Infusion Center	3060 W Salt Creek Lane	Arlington Heights	IL	Approved
DSH140114T	Child	DSH	SWEDISH COVENANT HEALTH	Swedish Hospital - Oncology Infusion Center	177 E. Brush Hill Road	Elmhurst	IL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028-1028	5/13/2025 9:37 AM
Addresses	Main Address	Update	Change Request	5140 N. CALIFORNIA AVENUE, SUITE #G115 CHICAGO, IL 60625	5140 N. CALIFORNIA AVENUE G115, G600 CHICAGO, IL 60625	4/7/2025 6:57 AM
Details	Last Recertification Date	Update	Recertification	8/22/2023 10:39:30 AM	8/13/2024 8:43:48 AM	8/13/2024 8:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		364073303002	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		364073303003	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1588739734	6/7/2024 4:13 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1497825855	6/7/2024 4:13 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	6/7/2024 4:13 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1005928 (AK)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	24266 (AZ)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95011656 (CO)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300002997 (IN)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7279061 (MS)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	140114 (TN)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151257 (VA)		10/27/2023 10:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1831151257 (WI)		10/27/2023 10:52 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1831151257 (MS)		10/27/2023 10:52 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 10:42:09 AM	8/22/2023 10:39:30 AM	8/22/2023 10:39 AM
Details	Last Recertification Date	Update	Recertification	8/18/2021 10:42:55 AM	8/26/2022 10:42:09 AM	8/26/2022 10:42 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1831151257	4/6/2022 9:43 AM
Medicaid Billing	NPI: State	Insert	Change Request		MS	4/6/2022 9:43 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 5:52:44 PM	8/18/2021 10:42:55 AM	8/18/2021 10:42 AM
Contacts	Authorizing Official	Update	Change Request	King, Patricia Vice President Legal Affairs Swedish Covenant Hospital 7739898811	Lind, Jonathan Chief Operating Officer Swedish Covenant Health 7739071028	10/6/2020 2:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362179813011	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362179813521	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1005928	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		24266	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		95011656	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300002997	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7279061	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		140114	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1831151257	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1831151257	9/11/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2020 5:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831151257	9/11/2020 5:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 5:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1831151257 ( )		9/11/2020 5:52 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 11:13:13 AM	9/11/2020 5:52:44 PM	9/11/2020 5:52 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 4:50:29 PM	8/27/2019 11:13:13 AM	8/27/2019 11:13 AM
Contacts	Primary Contact	Update	Change Request	Patel, Ramesh Director Pharmacy Swedish Covenant Hospital 7738788200-5379	Juska, Alicia Director Pharmacy Swedish Covenant Health 7738788200-5379	4/19/2019 9:09 AM
Details	Entity Name	Update	Change Request	SWEDISH COVENANT HOSPITAL	SWEDISH COVENANT HEALTH	4/11/2019 2:06 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 12:31:52 PM	8/23/2018 4:50:29 PM	8/23/2018 4:50 PM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/29/2017 12:31:52 PM	11/29/2017 12:31 PM
Contacts	Primary Contact	Update	Recertification	Patel, Ramesh Director Pharmacy 7738788200-5379	Patel, Ramesh Director Pharmacy Swedish Covenant Hospital 7738788200-5379	11/29/2017 12:28 PM
Contacts	Authorizing Official	Update		King, Patricia Vice President Legal Affairs 7739898811	King, Patricia Vice President Legal Affairs Swedish Covenant Hospital 7739898811	10/11/2017 12:04 PM
Contacts	Authorizing Official	Update		KRUGEL, GARY SR VP OPERATIONS AND CFO 7739891075	King, Patricia Vice President Legal Affairs 7739898811	4/20/2017 3:34 PM
Contacts	Primary Contact	Insert			Patel, Ramesh Director Pharmacy 7738788200-5379	2/14/2017 8:39 PM
Addresses	Main Address	Insert			5140 N. CALIFORNIA AVENUE, SUITE #G115 CHICAGO, IL 60625	8/19/2016 11:32 AM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/19/2016 12:00:00 AM	8/19/2016 11:32 AM
Medicaid Billing	Medicaid: Number	Update		364073303002	362179813001, 362179813401	8/25/2015 8:41 AM
Medicaid Billing	NPI: Number	Update		1588739734	1831151257	8/25/2015 8:41 AM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 8:41 AM
Details	Last Recertification Date	Update		8/22/2013 5:37:37 AM	8/28/2014 12:00:00 AM	8/28/2014 3:46 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/22/2013 5:37:37 AM	8/22/2013 5:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/14/2013 10:15 AM
Medicaid Billing	Medicaid: Number	Insert			364073303002	2/14/2013 10:15 AM
Medicaid Billing	Medicaid: State	Insert			IL	2/14/2013 10:15 AM
Medicaid Billing	NPI: Number	Insert			1588739734	2/14/2013 10:15 AM
Contacts	Authorizing Official	Insert			KRUGEL, GARY SR VP OPERATIONS AND CFO 7739891075	2/14/2013 10:15 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 9:07 AM
Details	Comments Public	Insert			2/23/12 remove medicaid number	2/23/2012 7:26 PM
Details	Last Recertification Date	Insert				10/14/2008 2:00 PM
Details	Grant Number	Insert				10/14/2008 2:00 PM
Details	340B ID	Insert			DSH140114G	10/14/2008 2:00 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2008 2:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2008 2:00 PM
Details	Medicare Provider Number	Insert			140114	10/14/2008 2:00 PM
Details	Entity Name	Insert			SWEDISH COVENANT HOSPITAL	10/14/2008 2:00 PM
Details	Program Code	Insert			DSH	10/14/2008 2:00 PM
Details	Entity Subname	Insert			INFUSION / CANCER CENTER	10/14/2008 2:00 PM
Dates	Participating Approval Date	Insert			10/14/2008 12:00:00 AM	10/14/2008 2:00 PM
Details	State	Insert			Active	10/14/2008 2:00 PM
Dates	Registration Date	Insert			10/14/2008 12:00:00 AM	10/14/2008 2:00 PM
Dates	Signed By Date	Insert			8/4/2008 12:00:00 AM	10/14/2008 2:00 PM
Dates	Start Date	Insert			10/14/2008 12:00:00 AM	10/14/2008 2:00 PM
Terminations	Termination Comments	Insert				10/14/2008 2:00 PM
Terminations	Termination Date	Insert				10/14/2008 2:00 PM
Terminations	Termination Effective Date	Insert				10/14/2008 2:00 PM
Terminations	Termination Reason	Insert				10/14/2008 2:00 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

Parent/Child

History