Covered Entity Details

DSH140228K SWEDISH AMERICAN HOSPITAL (Terminated) - information as of 5/6/2025 11:10:28 PM

Main Details

Name

SWEDISH AMERICAN HOSPITAL

Subdivision Name

SwedishAmerican Medical Center Belvidere - Outpatient Health SVC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140228K

Medicare Provider Number

140228

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/14/2013

Last Recertification Date

9/6/2022

Termination Date
Termination Reason

4/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

SwedishAmerican Hospital
Patricia Ann DeWane, Vice President, Finance and Treasurer
(779) 696-4009

Primary Contact

SwedishAmerican Hospital
Tom Carey, Director of Pharmacy Services
(815) 489-4580

Addresses

Street Address

1625 South State Street
Belvidere, IL 61008

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	362222696001,362222696401	1760542732,1588093942
WI	1760542732

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140228AA	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST HEADACHE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AB	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH BREAST CENTER (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228AC	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN MEDICAL GROUP STATE-Stateline Clinic-Lab	4282 E ROCKTON RD STE 100	ROSCOE	IL	Terminated
DSH140228AD	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST ORTHO	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AE	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AF	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - SAH NEUROSURGERY	1340 CHARLES ST	ROCKFORD	IL	Terminated
DSH140228AG	Child	DSH	SWEDISH AMERICAN HOSPITAL	209 9TH ST CLINIC - UWNI SAH RKFRD VASC SURG AT SAHS	209 9TH ST	ROCKFORD	IL	Active
DSH140228AH	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST INFECTIOUS DISEASE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AJ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH DIABETES	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228AK	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH UW HEART FAILURE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AL	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN RENAISSANCE PAVILION - SAH UW HEALTH SURGERY AT SA FOURTH FL - SAH UW HEALTH SURGERY AT SA	1340 CHARLES ST	ROCKFORD	IL	Terminated
DSH140228AM	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR INFUSION (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228AN	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH NONINVASIVE CARDIOLOGY (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228AP	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR UW PROVIDERS (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228AQ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CARDIOVASCULAR AND THORACIC SURGERY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AR	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH MFM	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AS	Child	DSH	SWEDISH AMERICAN HOSPITAL	NINTH STREET CLINIC CENTER - UWNI SAH CARD PULM REHAB	209 NINTH ST	ROCKFORD	IL	Active
DSH140228AT	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH UW PEDIATRIC CARDIOLOGY	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AU	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH PEDIATRIC SPECIALITIES	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AV	Child	DSH	SWEDISH AMERICAN HOSPITAL	209 9TH ST CLINIC - UWNI SAH UWH GEN SURG AT SAHS	209 9TH ST	ROCKFORD	IL	Active
DSH140228AW	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH CLINICAL NUTRITION	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228AX	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH BREAST CTR	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AY	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST PHYSICAL THERAPY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AZ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC LAB	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BA	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC RAD	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BB	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH PAIN CLINIC (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228BC	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST NEUROLOGY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BD	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH PULMONARY MEDICINE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BE	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH UWH GEN SURG AT SAHS	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BF	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI SAH HEART CLINIC	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228BG	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC ENT	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BH	Child	DSH	SWEDISH AMERICAN HOSPITAL	VILLAGREEN CLINIC - UWNI VILLAGREEN VIEW	6861 VILLAGREEN VIEW	ROCKFORD	IL	Active
DSH140228BJ	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC PODIATRY	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BK	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC ALLERGY	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BL	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH PALLIATIVE CARE	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228BM	Child	DSH	SWEDISH AMERICAN HOSPITAL	IMMEDIATE CARE CLINIC - UWNI N MULFORD RD IMMEDIATE CARE	3775 N MULFORD RD	ROCKFORD	IL	Active
DSH140228BN	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI UROGYNECOLOGY	1253 N ALPINE RD	ROCKFORD	IL	Approved
DSH140228C	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR HEM ONC (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228D	Child	DSH	SWEDISH AMERICAN HOSPITAL	HOME HEALTH AGENCY - UWNI SAH HOME HEALTH INTERMITTENT SERVICES	2550 CHARLES ST	ROCKFORD	IL	Active
DSH140228E	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISHAMERICAN HOME HEALTH CARE	2550 CHARLES STREET	ROCKFORD	IL	Terminated
DSH140228G	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Operating Room	1625 South State Street	Belvidere	IL	Terminated
DSH140228H	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Recovery Room	1625 South State Street	Belvidere	IL	Terminated
DSH140228J	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Surgicare	1625 South State Street	Belvidere	IL	Terminated
DSH140228K	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Outpatient Health SVC	1625 South State Street	Belvidere	IL	Terminated
DSH140228L	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Anesthesia	1625 South State Street	Belvidere	IL	Terminated
DSH140228M	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD DR (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228N	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH INFUSION ROOM (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228P	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH ED (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228Q	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH HYPERBARIC	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228R	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH WOUND CARE	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228S	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Regional Cancer Center / CT	3535 N BELL SCHOOL RD	ROCKFORD	IL	Terminated
DSH140228T	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR RAD ONC (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228U	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH SLEEP CLINIC (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228V	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN MEDICAL CENTER BELVIDERE / Pulmonary Function	1625 S STATE ST	BELVIDERE	IL	Terminated
DSH140228W	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RESPIRATORY THERAPY (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228X	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH ANTICOAGULATION CLINIC (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228Y	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD MRI (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228Z	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD CT (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/1/2023 12:00:00 AM	1/18/2023 1:45 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/18/2023 1:45 PM
Terminations	Termination Date	Update	Termination Request		4/1/2023 12:00:00 AM	1/18/2023 1:45 PM
Terminations	Termination Effective Date	Update	Termination Request		1/1/2023 12:00:00 AM	1/18/2023 1:45 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/18/2023 1:45 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 10:20:40 AM	9/6/2022 4:21:18 PM	9/6/2022 4:21 PM
Contacts	Authorizing Official	Update	AO Change Request	DeWane, Patricia A. Vice President, Finance and Treasurer Swedish American Hospital 7796964727	DeWane, Patricia Ann Vice President, Finance and Treasurer SwedishAmerican Hospital 7796964009	8/26/2022 9:03 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 12:49:37 PM	8/17/2021 10:20:40 AM	8/17/2021 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 12:49 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1760542732	8/26/2020 12:49 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/26/2020 12:49 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 12:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1588093942	8/26/2020 12:49 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/26/2020 12:49 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:16:21 PM	8/26/2020 12:49:37 PM	8/26/2020 12:49 PM
Details	Last Recertification Date	Update	Recertification	8/31/2018 1:19:04 PM	8/26/2019 6:16:21 PM	8/26/2019 6:16 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 12:17:38 PM	8/31/2018 1:19:04 PM	8/31/2018 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/10/2017 12:17:38 PM	11/10/2017 12:17 PM
Contacts	Primary Contact	Update	Recertification	Carey, Tom Director of Pharmacy Services 8154894580	Carey, Tom Director of Pharmacy Services SwedishAmerican Hospital 8154894580	11/10/2017 11:45 AM
Contacts	Authorizing Official	Update		DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	DeWane, Patricia A. Vice President, Finance and Treasurer Swedish American Hospital 7796964727	11/6/2017 3:00 PM
Contacts	Authorizing Official	Insert			DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	3/20/2017 3:30 PM
Contacts	Primary Contact	Insert			Carey, Tom Director of Pharmacy Services 8154894580	2/24/2017 2:17 PM
Addresses	Main Address	Insert			1625 South State Street Belvidere, IL 61008	2/24/2017 2:17 PM
Contacts	Signed By	Insert			HARING, DON CFO 8159684400	2/24/2017 2:17 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 5:41 PM
Details	Last Recertification Date	Update		8/25/2014 12:00:00 AM	8/14/2015 12:00:00 AM	8/14/2015 4:28 PM
Details	Last Recertification Date	Update		9/10/2013 8:17:07 PM	8/25/2014 12:00:00 AM	8/25/2014 7:21 AM
Details	Last Recertification Date	Update			9/10/2013 8:17:07 PM	9/10/2013 8:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/12/2013 6:24 AM
Medicaid Billing	Medicaid: Number	Insert			362222696001	8/12/2013 6:24 AM
Medicaid Billing	Medicaid: State	Insert			IL	8/12/2013 6:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/12/2013 6:24 AM
Medicaid Billing	Medicaid: Number	Insert			362222696401	8/12/2013 6:24 AM
Medicaid Billing	Medicaid: State	Insert			IL	8/12/2013 6:24 AM
Medicaid Billing	NPI: Number	Insert			1760542732	8/12/2013 6:24 AM
Details	340B ID	Update		ISDR-DSH140228K	DSH140228K	5/14/2013 2:28 PM
Dates	Participating Approval Date	Update			5/14/2013 12:00:00 AM	5/14/2013 2:28 PM
Details	State	Update		Pending	Active	5/14/2013 2:28 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/14/2013 2:28 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISDR-DSH140228K	5/13/2013 12:38 PM
Details	Last Recertification Date	Insert				4/12/2013 12:57 PM
Details	Grant Number	Insert				4/12/2013 12:57 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 12:57 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 12:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 12:57 PM
Details	Medicare Provider Number	Insert			140228	4/12/2013 12:57 PM
Details	Entity Name	Insert			SWEDISH AMERICAN HOSPITAL	4/12/2013 12:57 PM
Details	Program Code	Insert			DSH	4/12/2013 12:57 PM
Details	Entity Subname	Insert			SwedishAmerican Medical Center Belvidere - Outpatient Health SVC	4/12/2013 12:57 PM
Dates	Participating Approval Date	Insert				4/12/2013 12:57 PM
Details	State	Insert			Pending	4/12/2013 12:57 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 12:57 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 12:57 PM
Dates	Start Date	Insert				4/12/2013 12:57 PM
Terminations	Termination Comments	Insert				4/12/2013 12:57 PM
Terminations	Termination Date	Insert				4/12/2013 12:57 PM
Terminations	Termination Effective Date	Insert				4/12/2013 12:57 PM
Terminations	Termination Reason	Insert				4/12/2013 12:57 PM