Covered Entity Details

DSH140150A UNIVERSITY OF ILLINOIS HOSPITAL (Terminated) - information as of 4/28/2025 1:50:31 AM

Main Details

Name

UNIVERSITY OF ILLINOIS HOSPITAL

Subdivision Name

UI HEALTH Ambulatory Care Clinics

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140150A

Medicare Provider Number

140150

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

6/24/2009

Participating Start Date

7/1/2009

Participating Approval Date

6/24/2009

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

4/1/2016
Site closure

Contacts

Authorizing Official

University of Illinois Hospital
Michael B. Zenn, Chief Executive Officer
(312) 355-5706

Primary Contact

Andrew Donnelly, Pharmacy Director
(312) 996-3671

Addresses

Street Address

1801 W. TAYLOR 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
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	376000511401
		1861431751

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	UNIV OF ILLINOIS WOOD STREET	PCC PHARMA	840 S WOOD ST RM 163 M/C 884	CHICAGO	IL	60612-4325	09/01/2009	09/01/2009		04/01/2016	01/26/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140150A	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UI HEALTH Ambulatory Care Clinics	1801 W. TAYLOR STREET	CHICAGO	IL	Terminated
DSH140150AA	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Psychiatry Clinic	1747 W. Roosevelt Rd., 1st Fl. Suite 160A	Chicago	IL	Active
DSH140150AB	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Psychiatry Clinic - Adult	912 S. Wood Street	Chicago	IL	Active
DSH140150AC	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Renal Dialysis Center	1859 W. Taylor Street	Chicago	IL	Active
DSH140150AD	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Arthritis & Kidney Clinic	1801 W. Taylor St. Suite 3-D	Chicago	IL	Active
DSH140150AE	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - HEART CENTER AT ROOSEVELT	1640 W ROOSEVELT RD	CHICAGO	IL	Active
DSH140150AF	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center/Family Center for Infectious Disease	1801 W. Taylor St., Suite 3	Chicago	IL	Active
DSH140150AG	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Lions Eye Institute	1905 West Taylor Street, First Floor	Chicago	IL	Active
DSH140150AH	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Radiology	1009 S. Wood St.	Chicago	IL	Active
DSH140150AJ	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Pre-Post Op APEC Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AK	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Ophthalmology Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AL	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB GI Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AM	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Anesthesia	1009 S. Wood St.	Chicago	IL	Active
DSH140150AN	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Perioperative Services	1009 S. Wood St.	Chicago	IL	Active
DSH140150AP	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB GI Diagnostic Svcs	1009 S. Wood St.	Chicago	IL	Active
DSH140150AQ	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Urology Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150B	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Liver Clinic	1801 W. Taylor St., Suite 1B	Chicago	IL	Active
DSH140150C	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Nutrition & Wellness Center	1801 W. Taylor St., Suite 1-C	Chicago	IL	Active
DSH140150D	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Therapeutic Infusion Services	1801 W. Taylor St., Suite 1-E	Chicago	IL	Active
DSH140150E	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Orthopedic Clinic	1801 W. Taylor St., Suite 2A	Chicago	IL	Active
DSH140150F	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Child & Youth Center	1801 W. Taylor St., Suite 2E	Chicago	IL	Active
DSH140150G	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Primary Care Plus Clinic	1801 W. Taylor St., Suite 3-AA	Chicago	IL	Active
DSH140150H	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Heart & Lung Center	1801 W. Taylor St., Suite 3-C	Chicago	IL	Active
DSH140150J	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Dermatology Clinic	1801 W. Taylor St., Suite 3-E	Chicago	IL	Active
DSH140150K	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Surgery Center	1801 W. Taylor St., Suite 3-F	Chicago	IL	Active
DSH140150L	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Center for Women's Health	1801 W. Taylor St., Suite 4-C	Chicago	IL	Active
DSH140150M	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Center for Women's Health	1801 W. Taylor Street, Suite 4-A	Chicago	IL	Active
DSH140150N	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Neurosciences Center	1801 W. Taylor St., Suite 4-E	Chicago	IL	Active
DSH140150P	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Internal Medicine Clinic	1801 W. Taylor St., Suite 3-A	Chicago	IL	Active
DSH140150Q	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Radiation Therapy	1801 W. Taylor St., Concourse	Chicago	IL	Active
DSH140150R	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Radiology MRI	1801 W. Taylor St. Suite 1-A	Chicago	IL	Active
DSH140150S	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - West Harrison Imaging Center	2242 W. Harrison St., Suite 103	Chicago	IL	Active
DSH140150T	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Mile Square Imaging Center	1220 S. Wood Street, Room 1047	Chicago	IL	Active
DSH140150U	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Telemedicine IDOC	1940 W. Taylor St., 3rd Floor	Chicago	IL	Active
DSH140150V	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Sleep Disorders Laboratory	2242 W. Harrison St., Suite 104	Chicago	IL	Active
DSH140150W	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Ophthalomology Center	1855 W. Taylor St.	Chicago	IL	Active
DSH140150X	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building / Transplant Center	1009 S. Wood Street, 2nd Floor SCB	Chicago	IL	Active
DSH140150Y	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building / Otolaryngology Clinic	1009 S. Wood Street, 6th Floor SCB	Chicago	IL	Active
DSH140150Z	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Craniofacial Center	811 S. Paulina St., Suite 161	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Zenn, Michael B. CFO University of Illinois Hospital 3129963620	Zenn, Michael B. Chief Executive Officer University of Illinois Hospital 3123555706	8/6/2021 6:29 AM
Contacts	Authorizing Official	Update		Zenn, Michael B. CFO 3129963620	Zenn, Michael B. CFO University of Illinois Hospital 3129963620	9/27/2017 11:35 AM
Contacts	Authorizing Official	Insert			Zenn, Michael B. CFO 3129963620	2/22/2017 9:59 AM
Contacts	Primary Contact	Insert			Donnelly, Andrew Pharmacy Director 3129963671	2/22/2017 9:59 AM
Addresses	Main Address	Insert			1801 W. TAYLOR STREET CHICAGO, IL 60612	1/26/2016 11:05 AM
Dates	Last Date That 340B Drugs Purchased	Update			1/22/2016 12:00:00 AM	1/26/2016 11:05 AM
Details	State	Update		Active	Terminated	1/26/2016 11:05 AM
Terminations	Termination Comments	Update			Updated database to register clinic sites separately.	1/26/2016 11:05 AM
Terminations	Termination Date	Update			4/1/2016 12:00:00 AM	1/26/2016 11:05 AM
Terminations	Termination Effective Date	Update			1/22/2016 12:00:00 AM	1/26/2016 11:05 AM
Terminations	Termination Reason	Update			Site closure	1/26/2016 11:05 AM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	9/8/2015 12:00:00 AM	9/8/2015 2:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/16/2014 9:01 AM
Medicaid Billing	Medicaid: Number	Insert			376000511401	12/16/2014 9:01 AM
Medicaid Billing	Medicaid: State	Insert			IL	12/16/2014 9:01 AM
Medicaid Billing	NPI: Number	Insert			1861431751	12/16/2014 9:01 AM
Details	Entity Subname	Update		UIC CLINICS	UI HEALTH Ambulatory Care Clinics	12/16/2014 9:01 AM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 2:24 PM
Details	Last Recertification Date	Update		9/9/2013 10:24:59 PM	9/9/2013 12:00:00 AM	8/1/2014 1:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 10:24:59 PM	9/9/2013 10:24 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 12:04 PM
Details	Last Recertification Date	Insert				6/24/2009 1:39 PM
Details	Grant Number	Insert				6/24/2009 1:39 PM
Details	340B ID	Insert			DSH140150A	6/24/2009 1:39 PM
Details	Is Authorizing Official EHB Data	Insert				6/24/2009 1:39 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/24/2009 1:39 PM
Details	Medicare Provider Number	Insert			140150	6/24/2009 1:39 PM
Details	Entity Name	Insert			UNIVERSITY OF ILLINOIS HOSPITAL	6/24/2009 1:39 PM
Details	Program Code	Insert			DSH	6/24/2009 1:39 PM
Details	Entity Subname	Insert			UIC CLINICS	6/24/2009 1:39 PM
Dates	Participating Approval Date	Insert			6/24/2009 12:00:00 AM	6/24/2009 1:39 PM
Details	State	Insert			Active	6/24/2009 1:39 PM
Dates	Registration Date	Insert			6/24/2009 12:00:00 AM	6/24/2009 1:39 PM
Dates	Signed By Date	Insert			5/18/2009 12:00:00 AM	6/24/2009 1:39 PM
Dates	Start Date	Insert			7/1/2009 12:00:00 AM	6/24/2009 1:39 PM
Terminations	Termination Comments	Insert				6/24/2009 1:39 PM
Terminations	Termination Date	Insert				6/24/2009 1:39 PM
Terminations	Termination Effective Date	Insert				6/24/2009 1:39 PM
Terminations	Termination Reason	Insert				6/24/2009 1:39 PM