Covered Entity Details

DSH140304A UChicago Medicine AdventHealth Bolingbrook (Active) - information as of 4/25/2025 9:22:58 PM

Main Details

Name

UChicago Medicine AdventHealth Bolingbrook

Subdivision Name

UChicago Medicine AdventHealth Pain Management Bolingbrook

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140304A

Medicare Provider Number

140304

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/7/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/6/2013

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

UChicago Medicine AdventHealth Bolingbrook
Tristan R Shaw, CFO
(630) 312-6008

Primary Contact

UChicago Medicine AdventHealth Bolingbrook
DAVID TSANG, 340B PROGRAM DIRECTOR
(847) 372-8408

Addresses

Street Address

420 South Schmidt Road
Suite 135
Bolingbrook, IL 60440-1754

Billing Address

UChicago Medicine AdventHealth Bolingbrook
c/o AdventHealth
902 Inspiration Avenue
Suite 9100
Altamonte Springs, FL 32714

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	651219504001	1164530465,1184923260,1013372440,1205120706,1336925817

Shipping Addresses

Shipping Address 1

UChicago Medicine AdventHealth Bolingbrook
500 Remington Blvd.
Bolingbrook, IL 60440

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
DSH140304A	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Pain Management Bolingbrook	420 South Schmidt Road	Bolingbrook	IL	Active
DSH140304B	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Outpatient Women's Clinic	396 Remington Blvd	Bolingbrook	IL	Terminated
DSH140304C	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Plainfield Imaging and Outpatient Center	15720 S. Route 59	Plainfield	IL	Terminated
DSH140304D	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	PT Solutions at Adventist Bolingbrook Hospital	396 Remington Blvd	Bolingbrook	IL	Terminated
DSH140304E	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Wound Care Center	420 Schmidt Road	Bolingbrook	IL	Terminated
DSH140304F	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Infusion Center Bolingbrook	396 Remington Blvd	Bolingbrook	IL	Active
DSH140304G	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Infusion Center Hinsdale	1 Salt Creek Ln, STE 100	HINSDALE	IL	Active
DSH140304H	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Medication Therapy Management Clinic Bolingbrook	500 REMINGTON BLVD	BOLINGBROOK	IL	Active
DSH140304J	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Non-Chemo Infusion Hinsdale	1 SALT CREEK LN	HINSDALE	IL	Active
DSH140304K	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Ambulatory Clinic and Infusion Bolingbrook	420 South Schmidt Road	Bolingbrook	IL	Active
DSH140304L	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Bariatric Surgery Center Bolingbrook - Bariatric Surgery Center	420 S Schmidt Road	Bolingbrook	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	420 South Schmidt Road Suite 110/125/135 Bolingbrook, IL 60440-1754	420 South Schmidt Road Suite 135 Bolingbrook, IL 60440-1754	1/27/2025 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205120706	9/4/2024 2:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/4/2024 2:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336925817	9/4/2024 2:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/4/2024 2:08 PM
Details	Entity Subname	Update	Change Request	Pain Management Center	UChicago Medicine AdventHealth Pain Management Bolingbrook	9/4/2024 10:05 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 3:29:06 PM	8/12/2024 9:20:31 AM	8/12/2024 9:20 AM
Contacts	Primary Contact	Update	Change Request	TSANG, DAVID PHARMACY DIRECTOR ADVENT HEALTH 8473728408	TSANG, DAVID 340B PROGRAM DIRECTOR UChicago Medicine AdventHealth Bolingbrook 8473728408	4/29/2024 8:30 AM
Contacts	Authorizing Official	Update	Change Request	Lee, Sun C Regional VP Ancillary & Oncology UChicago Medicine AdventHealth Bolingbrook 6308566518	Shaw, Tristan R CFO UChicago Medicine AdventHealth Bolingbrook 6303126008	4/19/2024 7:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1013372440	4/11/2024 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/11/2024 2:50 PM
Details	Entity Name	Update	Recertification	ADVENTIST BOLINGBROOK HOSPITAL	UChicago Medicine AdventHealth Bolingbrook	9/5/2023 10:34 AM
Addresses	Shipping Address	Insert	Recertification		UChicago Medicine AdventHealth Bolingbrook 500 Remington Blvd. Bolingbrook, IL 60440	8/30/2023 3:29 PM
Addresses	Billing Address	Update	Recertification	Adventist Bolingbrook Hospital c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	UChicago Medicine AdventHealth Bolingbrook c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	8/30/2023 3:29 PM
Addresses	Shipping Address	Delete	Recertification	Adventist Bolingbook Hospital 500 Remington Blvd. Bolingbrook, IL 60440		8/30/2023 3:29 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 11:08:49 AM	8/30/2023 3:29:06 PM	8/30/2023 3:29 PM
Contacts	Authorizing Official	Update	Profile Change Request	Lee, Sun C Regional VP Ancillary & Oncology Adventist Bolingbrook Hospital 6308566518	Lee, Sun C Regional VP Ancillary & Oncology UChicago Medicine AdventHealth Bolingbrook 6308566518	8/17/2023 3:11 PM
Contacts	Authorizing Official	Update	AO Change Request	Brown, Jared Chief Financial Officer AdventHealth Bolingbrook 6303126003	Lee, Sun C Regional VP Ancillary & Oncology Adventist Bolingbrook Hospital 6308566518	7/26/2023 5:46 PM
Contacts	Authorizing Official	Update	Change Request	Radivojevic, Vladimir President & CEO AdventHealth GlenOaks 6305457258	Brown, Jared Chief Financial Officer AdventHealth Bolingbrook 6303126003	1/26/2023 12:21 PM
Contacts	Authorizing Official	Update	Profile Change Request	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	Radivojevic, Vladimir President & CEO AdventHealth GlenOaks 6305457258	10/19/2022 10:09 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1184923260	10/18/2022 8:28 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	10/18/2022 8:28 PM
Addresses	Main Address	Update	Change Request	420 Schmidt Road Suite 110/125/135 Bolingbrook, IL 60440	420 South Schmidt Road Suite 110/125/135 Bolingbrook, IL 60440-1754	9/19/2022 10:52 AM
Addresses	Billing Address	Update	Change Request	Adventist Bolingbrook Hospital Accounts Payable 902 Inspiration Ave, Ste 9100 Altamonte Springs, FL 32714	Adventist Bolingbrook Hospital c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	9/19/2022 10:52 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 2:43:00 PM	8/29/2022 11:08:49 AM	8/29/2022 11:08 AM
Addresses	Billing Address	Update	Change Request	Adventist Bolingbrook Hospital c/o Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	Adventist Bolingbrook Hospital Accounts Payable 902 Inspiration Ave, Ste 9100 Altamonte Springs, FL 32714	7/5/2022 2:22 PM
Contacts	Authorizing Official	Update	Profile Change Request	Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	4/14/2022 12:31 PM
Contacts	Primary Contact	Update	Change Request	Fischer, Rick System Director, 340B Amita Health 6303097828	TSANG, DAVID PHARMACY DIRECTOR ADVENT HEALTH 8473728408	2/24/2022 9:29 AM
Contacts	Primary Contact	Update	Profile Change Request	Fischer, Rick System Director, 340B Amita Health 6309147828	Fischer, Rick System Director, 340B Amita Health 6303097828	1/20/2022 2:41 PM
Details	Last Recertification Date	Update	Recertification	8/20/2020 4:14:55 PM	8/20/2021 2:43:00 PM	8/20/2021 2:43 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1184923260 (IL)		11/4/2020 9:14 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/20/2020 4:14 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/20/2020 4:14 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 9:30:33 AM	8/20/2020 4:14:55 PM	8/20/2020 4:14 PM
Contacts	Primary Contact	Update	Change Request	Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	Fischer, Rick System Director, 340B Amita Health 6309147828	8/7/2020 6:23 PM
Addresses	Main Address	Update	Change Request	420 Schmidt Road Suite 110/135 Bolingbrook, IL 60440	420 Schmidt Road Suite 110/125/135 Bolingbrook, IL 60440	10/21/2019 10:26 AM
Contacts	Primary Contact	Update	Profile Change Request	Whiteleather, Kim 340B Coordinator GlenOaks Hospital 6305457330	Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	9/3/2019 3:55 PM
Contacts	Primary Contact	Update	Recertification	Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	Whiteleather, Kim 340B Coordinator GlenOaks Hospital 6305457330	9/3/2019 2:54 PM
Contacts	Primary Contact	Update	Profile Change Request	Whiteleather, Kim 340B Coordinator GlenOaks Hospital 6305457330	Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	9/3/2019 2:26 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 12:11:02 PM	9/3/2019 9:30:33 AM	9/3/2019 9:30 AM
Contacts	Authorizing Official	Update	Change Request	AALBORG, CHASE CFO AMITA Health Adventist Medical Center Bolingbrook & GlenOaks 6303126001	Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	10/4/2018 10:23 AM
Addresses	Billing Address	Update	Recertification	Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	Adventist Bolingbrook Hospital c/o Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	8/24/2018 12:11 PM
Details	Last Recertification Date	Update	Recertification	11/9/2017 7:40:59 AM	8/24/2018 12:11:02 PM	8/24/2018 12:11 PM
Addresses	Billing Address	Update	Change Request	Adventist Bolingbrook Hospital P.O. Box 9245 Oak Brook, IL 60522	Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	8/13/2018 6:00 AM
Addresses	Main Address	Update	Recertification	420 Schmidt Road Suite 125 Bolingbrook, IL 60440	420 Schmidt Road Suite 110/135 Bolingbrook, IL 60440	11/9/2017 7:40 AM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/9/2017 7:40:59 AM	11/9/2017 7:40 AM
Contacts	Primary Contact	Update	Change Request	PONTERIO, JODI MANAGER OF PHARMACY 6303123965	Whiteleather, Kim 340B Coordinator GlenOaks Hospital 6305457330	10/13/2017 6:29 PM
Details	Entity Name	Update	Change Request	Adventist Bolingbrook Hospital	ADVENTIST BOLINGBROOK HOSPITAL	10/13/2017 6:20 PM
Contacts	Authorizing Official	Update		AALBORG, CHASE CFO 6303126001	AALBORG, CHASE CFO AMITA Health Adventist Medical Center Bolingbrook & GlenOaks 6303126001	10/6/2017 3:53 PM
Contacts	Authorizing Official	Update		MURRILL, MICHAEL COO 6303126001	AALBORG, CHASE CFO 6303126001	9/11/2017 3:29 PM
Contacts	Signed By	Insert			MURRILL, MICHAEL CFO 6303126001	8/23/2016 2:10 PM
Contacts	Authorizing Official	Insert			MURRILL, MICHAEL COO 6303126001	8/23/2016 2:10 PM
Addresses	Main Address	Insert			420 Schmidt Road Suite 125 Bolingbrook, IL 60440	8/23/2016 2:09 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 2:09 PM
Contacts	Primary Contact	Update		AZIZ, ALEEM DIRECTOR OF PHARMACY 6303123979	PONTERIO, JODI MANAGER OF PHARMACY 6303123965	12/21/2015 1:27 PM
Addresses	Billing Address	Insert			Adventist Bolingbrook Hospital P.O. Box 9245 Oak Brook, IL 60522	12/21/2015 1:27 PM
Addresses	Shipping Address	Insert			Adventist Bolingbook Hospital 500 Remington Blvd. Bolingbrook, IL 60440	12/21/2015 1:27 PM
Medicaid Billing	NPI: Number	Insert			1184923260	9/1/2015 12:40 PM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 12:40 PM
Contacts	Primary Contact	Insert			AZIZ, ALEEM DIRECTOR OF PHARMACY 6303123979	6/5/2015 2:40 PM
Details	Last Recertification Date	Update			8/22/2014 12:00:00 AM	8/22/2014 8:10 AM
Dates	Participating Approval Date	Update			12/6/2013 12:00:00 AM	12/6/2013 4:29 PM
Details	State	Update		Pending	Active	12/6/2013 4:29 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	12/6/2013 4:29 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH140304A	12/6/2013 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/7/2013 2:32 PM
Medicaid Billing	Medicaid: Number	Insert			651219504001	10/7/2013 2:32 PM
Medicaid Billing	Medicaid: State	Insert			IL	10/7/2013 2:32 PM
Medicaid Billing	NPI: Number	Insert			1164530465	10/7/2013 2:32 PM
Details	Last Recertification Date	Insert				10/7/2013 2:32 PM
Details	Grant Number	Insert				10/7/2013 2:32 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/7/2013 2:32 PM
Details	Is Authorizing Official EHB Data	Insert				10/7/2013 2:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/7/2013 2:32 PM
Details	Medicare Provider Number	Insert			140304	10/7/2013 2:32 PM
Details	Entity Name	Insert			Adventist Bolingbrook Hospital	10/7/2013 2:32 PM
Details	Program Code	Insert			DSH	10/7/2013 2:32 PM
Details	Entity Subname	Insert			Pain Management Center	10/7/2013 2:32 PM
Dates	Participating Approval Date	Insert				10/7/2013 2:32 PM
Details	State	Insert			Pending	10/7/2013 2:32 PM
Dates	Registration Date	Insert			10/7/2013 12:00:00 AM	10/7/2013 2:32 PM
Dates	Signed By Date	Insert			10/7/2013 12:00:00 AM	10/7/2013 2:32 PM
Dates	Start Date	Insert				10/7/2013 2:32 PM
Terminations	Termination Comments	Insert				10/7/2013 2:32 PM
Terminations	Termination Date	Insert				10/7/2013 2:32 PM
Terminations	Termination Effective Date	Insert				10/7/2013 2:32 PM
Terminations	Termination Reason	Insert				10/7/2013 2:32 PM