Covered Entity Details

DSH520136T WHEATON FRANCISCAN, INC. (Terminated) - information as of 5/16/2025 11:25:48 PM

Main Details

Name

WHEATON FRANCISCAN, INC.

Subdivision Name

Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB

Type

Disproportionate Share Hospital

Rural

340B ID

DSH520136T

Medicare Provider Number

520136

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/10/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/6/2013

Last Recertification Date

8/24/2016

Termination Date
Termination Reason

10/1/2016
Site closure

Contacts

Authorizing Official

Ascension
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Primary Contact

Kenneth Shaw, Reimbursement Manager
(414) 465-3545

Addresses

Street Address

10000 WEST BLUEMOUND ROAD
WAUWATOSA, WI 53226-4321

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
WI	11024500
		1427007384

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
DSH520136AA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Surgical 6th Floor	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook CARDIAC CATHETERIZATION	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Dialysis	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Outpatient / Elmbrook Pain Center	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Emergency Dept.	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Day Surgery	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook CARDIAC DIAGNOSTIC UNIT	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook RADIATION ONCOLOGY CTR	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook ULTRASOUND	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook RADIOLOGY	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook ANESTHESIA	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AM	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Women's Health Center	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AP	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Anesthesiology	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AQ	Child	DSH	WHEATON FRANCISCAN, INC.	RADIATION ONCOLOGY CTR	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Physical Rehab Acute Services	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Nuclear Medicine	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Respiratory Care Services	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AU	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Radiology	19333 WEST NORTH AVENUE	Elmbrook	WI	Terminated
DSH520136AV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Surgery	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook MAMMOGRAPHY	19305 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AX	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook EMAC PT CLINIC	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AY	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook PNAC	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook GI Lab	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136B	Child	DSH	WHEATON FRANCISCAN, INC.	WAUWATOSA CAMPUS	201 N MAYFAIR ROAD	WAUWATOSA	WI	Terminated
DSH520136BA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Laboratory	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136BB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook MRI	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook COMPUTERIZED TOMOGRAPHY	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BD	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook-Ultrasound	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136BE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook PACU	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	St. Joseph Campus / Family and Internal Medicine	3070 N 51ST ST	MILWAUKEE	WI	Active
DSH520136BG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Brown Deer / Nuclear Medicine	9252 N. GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136BH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	BROWN DEER / CDU	9252 N. GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136BJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Urgent Care Unit	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	DAY SURGERY	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Respiratory / Pulmonary Diagnostics	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	ELECTROCARDIOLOGY / Cardiovascular Service	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BN	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Cardiac Pulmonary Rehabilitation	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BP	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	PHYSICAL THERAPY / Physical Rehab Acute	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BQ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	PHYSICAL THERAPY / Ambulatory Pain Mgmt	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	MRI / Ambulatory MRI	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	MRI / Ambulatory CT	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BT	Child	DSH	WHEATON FRANCISCAN, INC.	Radiology-Diagnostic / Radiology Admin	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136BU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Ultrasound	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Nuclear Medicine	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Ambulatory Mammography	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BY	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	ANESTHESIOLOGY / Ambulatory Anesthesia	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	RECOVERY ROOM / Post Oper Recovery Room	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136C	Child	DSH	WHEATON FRANCISCAN, INC.	BROWN DEER CAMPUS	9252 N GREEN BAY ROAD	BROWN DEER	WI	Terminated
DSH520136CA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	OPERATING ROOM / Surgery Service	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136CB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WAUWATOSA OUTPATIENT CLINIC / WAUWATOSA GI	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136CC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / ICU	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wheaton Franciscan Performance Center	17000 W NORTH AVENUE	Brookfield	WI	Active
DSH520136CE	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / MRI-The Heart	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CF	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / PACU	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / WF Inc-Medical 5-South -Elmbrook	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CH	Child	DSH	WHEATON FRANCISCAN INC.	WFH - WISCONSIN HEART HOSPITAL - MI / ICU-The Heart	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / OB 4 North	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN, INC / Wound Healing	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136CM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN, INC / WOMEN'S OP CENTER/ PNAC	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136CP	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / RECOVERY ROOM	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CQ	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL - MI / MRI	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CR	Child	DSH	WHEATON FRANCISCAN INC.	WFH - BROWN DEER / SJH PHYSIATRY	9252 N GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136CS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wheaton Franciscan / Behavorial Health	3070 N. 51st Street	Milwaukee	WI	Active
DSH520136CT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Interventional Radiology - Interventional Radiology	19333 W. North Ave.	Brookfield	WI	Active
DSH520136CU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Vascular Catheterization - Vascular Catheterization	201 N. Mayfair Rd.	Wauwatosa	WI	Active
DSH520136CV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	St. Joseph Campus / Professional Office Building (POB) OB/GYN - OB/GYN	3070 N. 51st St.	Milwaukee	WI	Terminated
DSH520136CW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Cardiac Rehabilitation - Cardiac Rehabilitation	19333 West North Avenue	Brookfield	WI	Terminated
DSH520136CX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Observation - Elmbrook Acute Rehab - Rehabilitation	19333 West North Avenue	Brookfield	WI	Terminated
DSH520136CY	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Observation - Wauwatosa Pulmonary Rehab - Pulmonary Rehabilitation	201 N. Mayfair Rd.	Wauwatosa	WI	Terminated
DSH520136CZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Vascular Lab - Vascular	10101 South 27th Street	Franklin	WI	Active
DSH520136D	Child	DSH	WHEATON FRANCISCAN, INC.	MIDWEST SPINE & ORTHOPEDIC HOSPITAL/WISCONSIN HEART HOSPITAL CAMPUS	10000 W BLUE MOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136DA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Computerized Tomography - Computerized Tomography	10101 South 27th Street	Franklin	WI	Active
DSH520136DB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Interventional Radiology - Radiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Nuclear Medicine - Nuclear Medicine	10101 South 27th Street	Franklin	WI	Active
DSH520136DD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Mammography - Mammography	10101 South 27th Street	Franklin	WI	Active
DSH520136DE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Cardiac Catheterization - Cardiac Catheterization	10101 South 27th Street	Franklin	WI	Active
DSH520136DF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Respiratory Care Services - Respiratory Care	10101 South 27th Street	Franklin	WI	Active
DSH520136DG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Rawson Radiology - Radiology	7400 West Rawson Avenue	Franklin	WI	Active
DSH520136DH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Ultrasound - Ultrasound	10101 South 27th Street	Franklin	WI	Active
DSH520136DJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Rehab Services - Rehabilitation	10101 South 27th Street	Franklin	WI	Terminated
DSH520136DK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Day Surgery - Surgery	10101 South 27th Street	Franklin	WI	Active
DSH520136DL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Cardiac Diagnostic Unit - Cardiac Diagnostics	10101 South 27th Street	Franklin	WI	Active
DSH520136DM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Anesthesia - Anesthesiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DN	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Outpatient Services - Infusion Services	10101 South 27th Street	Franklin	WI	Active
DSH520136DP	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Emergency Department - Emergency	10101 South 27th Street	Franklin	WI	Active
DSH520136DQ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Radiology - Radiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin MRI - Magnetic Resonance Imaging	10101 South 27th Street	Franklin	WI	Active
DSH520136DS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Surgery - Surgery	10101 South 27th Street	Franklin	WI	Active
DSH520136DT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Center for Digestive Health - Gastroenterology	10101 South 27th Street	Franklin	WI	Active
DSH520136DU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Vascular Venous Access - Vascular Access	10101 South 27th Street	Franklin	WI	Terminated
DSH520136DV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Critical Care/ICU - Critical Care	10101 South 27th Street	Franklin	WI	Active
DSH520136DW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin PACU - Recovery Room	10101 South 27th Street	Franklin	WI	Active
DSH520136DX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Medical/Surgical Nursing - Medical/Surgical Nursing	10101 South 27th Street	Franklin	WI	Active
DSH520136E	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN CANCER CARE-ELMBROOK	19333 W.NORTH AVENUE	BROOKFIELD	WI	Active
DSH520136F	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN CANCER CARE- WAUWATOSA	201 N. MAYFAIR ROAD	WAUWATOSA	WI	Active
DSH520136G	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Rehab EMH Non-Nursing	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136H	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook-Diabetes Management	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136J	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital POST OPERATIVE RECOV ROOMS	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136K	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Dialysis	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136L	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital REHAB SVC	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136M	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Emergency Dept	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136N	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Day Patients	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136Q	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Cardiac Catheterization	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136R	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Stress & Echo	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136S	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Respiratory Care Services	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136T	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136U	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital ULTRASOUND	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136V	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital NUCLEAR MEDICINE	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136W	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital RADIOLOGY	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136X	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital ICU & Telemetry	10000 West Bluemound Road	WAUWATOSA	WI	Terminated
DSH520136Y	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Surgery	10000 West Bluemound Road	WAUWATOSA	WI	Terminated
DSH520136Z	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Anesthesia	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration Ascension 4144653711	Freitag, Vanessa Vice President, Pharmacy Ascension 7158971183	1/14/2021 3:35 PM
Contacts	Authorizing Official	Update		Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration Ascension 4144653711	10/5/2017 2:03 PM
Contacts	Authorizing Official	Update		Baughman, Sharon Senior Vice President /Chief Nursing Officer 4144472719	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	9/11/2017 3:29 PM
Contacts	Primary Contact	Insert			Shaw, Kenneth Reimbursement Manager 4144653545	6/27/2017 8:01 AM
Contacts	Signed By	Insert			Sohn, Jon CFO 4144653090	5/26/2017 8:02 AM
Contacts	Authorizing Official	Insert			Baughman, Sharon Senior Vice President /Chief Nursing Officer 4144472719	5/26/2017 8:02 AM
Addresses	Main Address	Insert			10000 WEST BLUEMOUND ROAD WAUWATOSA, WI 53226-4321	8/24/2016 8:36 AM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 8:36 AM
Dates	Last Date That 340B Drugs Purchased	Update			7/9/2016 12:00:00 AM	8/24/2016 8:36 AM
Details	State	Update		Active	Terminated	8/24/2016 8:36 AM
Terminations	Termination Date	Update			10/1/2016 12:00:00 AM	8/24/2016 8:36 AM
Terminations	Termination Effective Date	Update			7/9/2016 12:00:00 AM	8/24/2016 8:36 AM
Terminations	Termination Reason	Update			Site closure	8/24/2016 8:36 AM
Details	Last Recertification Date	Update		9/5/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 1:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/5/2014 12:23 PM
Medicaid Billing	Medicaid: Number	Insert			11024500	9/5/2014 12:23 PM
Medicaid Billing	Medicaid: State	Insert			WI	9/5/2014 12:23 PM
Medicaid Billing	NPI: Number	Insert			1427007384	9/5/2014 12:23 PM
Details	Last Recertification Date	Update			9/5/2014 12:00:00 AM	9/5/2014 12:23 PM
Dates	Participating Approval Date	Update			9/6/2013 12:00:00 AM	9/6/2013 4:51 PM
Details	State	Update		Pending	Active	9/6/2013 4:51 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/6/2013 4:51 PM
Details	Entity Subname	Update		Wheaton Franciscan Inc.-Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB	9/6/2013 1:37 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH520136T	8/26/2013 2:14 PM
Details	Last Recertification Date	Insert				7/10/2013 2:59 PM
Details	Grant Number	Insert				7/10/2013 2:59 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/10/2013 2:59 PM
Details	Is Authorizing Official EHB Data	Insert				7/10/2013 2:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/10/2013 2:59 PM
Details	Medicare Provider Number	Insert			520136	7/10/2013 2:59 PM
Details	Entity Name	Insert			WHEATON FRANCISCAN, INC.	7/10/2013 2:59 PM
Details	Program Code	Insert			DSH	7/10/2013 2:59 PM
Details	Entity Subname	Insert			Wheaton Franciscan Inc.-Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB	7/10/2013 2:59 PM
Dates	Participating Approval Date	Insert				7/10/2013 2:59 PM
Details	State	Insert			Pending	7/10/2013 2:59 PM
Dates	Registration Date	Insert			7/10/2013 12:00:00 AM	7/10/2013 2:59 PM
Dates	Signed By Date	Insert			7/10/2013 12:00:00 AM	7/10/2013 2:59 PM
Dates	Start Date	Insert				7/10/2013 2:59 PM
Terminations	Termination Comments	Insert				7/10/2013 2:59 PM
Terminations	Termination Date	Insert				7/10/2013 2:59 PM
Terminations	Termination Effective Date	Insert				7/10/2013 2:59 PM
Terminations	Termination Reason	Insert				7/10/2013 2:59 PM