Covered Entity Details

DSH140053E ST. JOHNS HOSPITAL (Active) - information as of 5/13/2025 11:00:46 PM

Main Details

Name

ST. JOHNS HOSPITAL

Subdivision Name

Prairie Diagnostic Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140053E

Medicare Provider Number

140053

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/12/2013

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

HSHS
Michael Scialdone, SVP-Chief Financial Officer
(217) 492-6594

Primary Contact

HSHS St. John's Hospital
Erica Ridley, Pharmacy Manager
(217) 544-6464 Ext: 2044668

Addresses

Street Address

401 E Carpenter St
Springfield, IL 62702

Billing Address

Consolidated Services
PO Box 3646
Springfield, IL 62708

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	370661238001	1205818481

Shipping Addresses

Shipping Address 1

HSHS St. John's Hospital Pharmacy
800 East Carpenter Street
springfield, IL 62769

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
DSH140053A	Child	DSH	ST. JOHNS HOSPITAL	Home Infusion	801 E Carpenter St	Springfield	IL	Terminated
DSH140053C	Child	DSH	ST. JOHNS HOSPITAL	Women Care Mammography MOB	400 N 9th Street	Springfield	IL	Active
DSH140053D	Child	DSH	ST. JOHNS HOSPITAL	Imaging - South 6th Street	1100 E Lincolnshire Blvd	Springfield	IL	Active
DSH140053E	Child	DSH	ST. JOHNS HOSPITAL	Prairie Diagnostic Center	401 E Carpenter St	Springfield	IL	Active
DSH140053F	Child	DSH	ST. JOHNS HOSPITAL	Athleticare & Acceleration	3631 South 6th Street	Springfield	IL	Terminated
DSH140053G	Child	DSH	ST. JOHNS HOSPITAL	Rehab - SHG (West)	1603 West Washington Street	Springfield	IL	Terminated
DSH140053H	Child	DSH	ST. JOHNS HOSPITAL	Sleep Lab	1100 E Lincolnshire Blvd	Springfield	IL	Active
DSH140053J	Child	DSH	ST. JOHNS HOSPITAL	END-South 6th Street	1100 E Lincolnshire Blvd	Springfield	IL	Terminated
DSH140053K	Child	DSH	ST. JOHNS HOSPITAL	ST JOHN'S SURGERY SUITES, MONTVALE	2020 W ILES AVE	SPRINGFIELD	IL	Active
DSH140053L	Child	DSH	ST. JOHNS HOSPITAL	HSHS St. John's Hospital Infusion Center at O'Fallon - Infusion	3 St. Elizabeth's Blvd	O'Fallon	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Allen, Patty Chief Financial Officer HSHS 9208845660	Scialdone, Michael SVP-Chief Financial Officer HSHS 2174926594	5/5/2025 6:31 AM
Addresses	Billing Address	Update	Recertification	HSHS St. John's Hospital Pharmacy 800 E. Carpenter St. springfield, IL 62769	Consolidated Services PO Box 3646 Springfield, IL 62708	8/27/2024 9:08 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 9:00:31 AM	8/27/2024 9:08:35 PM	8/27/2024 9:08 PM
Contacts	Primary Contact	Update	Change Request	Strader, Brandi Director, Pharmacy HSHS St. John's Hospital 2175446464-46744	Ridley, Erica Pharmacy Manager HSHS St. John's Hospital 2175446464-2044668	8/8/2024 1:56 PM
Contacts	Authorizing Official	Update	Profile Change Request	Allen, Patty Chief Financial Officer HSHS Wisconsin 9208845660	Allen, Patty Chief Financial Officer HSHS 9208845660	8/8/2024 6:32 AM
Contacts	Authorizing Official	Update	Change Request	Fry, Matthew President & CEO HSHS St. John’s Hospital 2175446464-44572	Allen, Patty Chief Financial Officer HSHS Wisconsin 9208845660	8/7/2024 12:31 PM
Details	Last Recertification Date	Update	Recertification	9/1/2022 2:01:10 PM	9/7/2023 9:00:31 AM	9/7/2023 9:00 AM
Contacts	Authorizing Official	Update	Change Request	Paul, Allison Interim President and CEO HSHS St. John's Hospital 2177576581	Fry, Matthew President & CEO HSHS St. John’s Hospital 2175446464-44572	3/14/2023 12:34 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 2:26:28 PM	9/1/2022 2:01:10 PM	9/1/2022 2:01 PM
Contacts	Authorizing Official	Update	Change Request	Deis, Terrence G. President and Chief Executive Officer HSHS St. John's Hospital 2175446464-76255	Paul, Allison Interim President and CEO HSHS St. John's Hospital 2177576581	11/30/2021 3:10 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 2:50:32 PM	9/9/2021 2:26:28 PM	9/9/2021 2:26 PM
Contacts	Authorizing Official	Update	Change Request	Kuiper, E J President-CEO HSHS St. John's Hospital 2178144572	Deis, Terrence G. President and Chief Executive Officer HSHS St. John's Hospital 2175446464-76255	12/7/2020 4:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1205818481 ( )		8/25/2020 2:50 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1205818481	8/25/2020 2:50 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/25/2020 2:50 PM
Details	Last Recertification Date	Update	Recertification	9/12/2019 3:11:17 PM	8/25/2020 2:50:32 PM	8/25/2020 2:50 PM
Addresses	Billing Address	Insert	Recertification		HSHS St. John's Hospital Pharmacy 800 E. Carpenter St. springfield, IL 62769	9/12/2019 3:11 PM
Addresses	Shipping Address	Insert	Recertification		HSHS St. John's Hospital Pharmacy 800 East Carpenter Street springfield, IL 62769	9/12/2019 3:11 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 9:38:09 AM	9/12/2019 3:11:17 PM	9/12/2019 3:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205818481	6/26/2019 11:18 AM
Contacts	Authorizing Official	Update	Profile Change Request	Kuiper, E J President-CEO HSHS St. John's Hospital 2174647665	Kuiper, E J President-CEO HSHS St. John's Hospital 2178144572	6/17/2019 11:15 AM
Contacts	Authorizing Official	Update	Profile Change Request	Kuiper, E J President-CEO HSHS St. Mary's 2174647665	Kuiper, E J President-CEO HSHS St. John's Hospital 2174647665	6/17/2019 11:13 AM
Contacts	Authorizing Official	Update	Change Request	Lucore, Charles Chief Executive Officer HSHS St john's Hospital 2177576255	Kuiper, E J President-CEO HSHS St. Mary's 2174647665	12/21/2018 8:06 AM
Details	Last Recertification Date	Update	Recertification	11/10/2017 11:39:03 AM	8/24/2018 9:38:09 AM	8/24/2018 9:38 AM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/10/2017 11:39:03 AM	11/10/2017 11:39 AM
Contacts	Authorizing Official	Update		Lucore, Charles Chief Executive Officer 2177576255	Lucore, Charles Chief Executive Officer HSHS St john's Hospital 2177576255	10/10/2017 9:30 AM
Contacts	Primary Contact	Update		Strader, Brandi Director, Pharmacy 2175446464-46744	Strader, Brandi Director, Pharmacy HSHS St. John's Hospital 2175446464-46744	10/3/2017 10:02 PM
Contacts	Signed By	Insert			Schumacher, Larry INTERIM PRESIDENT AND CEO 2175446464-44572	5/10/2017 3:32 PM
Contacts	Primary Contact	Update		Reeder, Abigail Director, Pharmacy 2175446464-48514	Strader, Brandi Director, Pharmacy 2175446464-46744	5/10/2017 3:32 PM
Contacts	Authorizing Official	Update		Olejniczak, Dave Chieef Operating Officer 2177576256	Lucore, Charles Chief Executive Officer 2177576255	5/10/2017 3:32 PM
Addresses	Main Address	Insert			401 E Carpenter St Springfield, IL 62702	5/10/2017 3:31 PM
Contacts	Primary Contact	Insert			Reeder, Abigail Director, Pharmacy 2175446464-48514	8/15/2016 12:24 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 12:24 PM
Contacts	Authorizing Official	Insert			Olejniczak, Dave Chieef Operating Officer 2177576256	8/5/2015 8:38 AM
Details	Last Recertification Date	Update		8/12/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 8:38 AM
Details	Last Recertification Date	Update			8/12/2014 12:00:00 AM	8/12/2014 11:32 AM
Details	340B ID	Update		ISJMDSH140053E	DSH140053E	9/12/2013 10:02 AM
Dates	Participating Approval Date	Update			9/12/2013 12:00:00 AM	9/12/2013 10:02 AM
Details	State	Update		Pending	Active	9/12/2013 10:02 AM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/12/2013 10:02 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISJMDSH140053E	8/4/2013 9:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/12/2013 8:59 AM
Medicaid Billing	Medicaid: Number	Insert			370661238001	7/12/2013 8:59 AM
Medicaid Billing	Medicaid: State	Insert			IL	7/12/2013 8:59 AM
Details	Last Recertification Date	Insert				7/12/2013 8:59 AM
Details	Grant Number	Insert				7/12/2013 8:59 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/12/2013 8:59 AM
Details	Is Authorizing Official EHB Data	Insert				7/12/2013 8:59 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/12/2013 8:59 AM
Details	Medicare Provider Number	Insert			140053	7/12/2013 8:59 AM
Details	Entity Name	Insert			ST. JOHNS HOSPITAL	7/12/2013 8:59 AM
Details	Program Code	Insert			DSH	7/12/2013 8:59 AM
Details	Entity Subname	Insert			Prairie Diagnostic Center	7/12/2013 8:59 AM
Dates	Participating Approval Date	Insert				7/12/2013 8:59 AM
Details	State	Insert			Pending	7/12/2013 8:59 AM
Dates	Registration Date	Insert			7/12/2013 12:00:00 AM	7/12/2013 8:59 AM
Dates	Signed By Date	Insert			7/12/2013 12:00:00 AM	7/12/2013 8:59 AM
Dates	Start Date	Insert				7/12/2013 8:59 AM
Terminations	Termination Comments	Insert				7/12/2013 8:59 AM
Terminations	Termination Date	Insert				7/12/2013 8:59 AM
Terminations	Termination Effective Date	Insert				7/12/2013 8:59 AM
Terminations	Termination Reason	Insert				7/12/2013 8:59 AM