Covered Entity Details

DSH520051V COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC (Terminated) - information as of 6/27/2025 12:28:59 AM

Main Details

Name

COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC

Subdivision Name

CSM Cardiovascular Specialists - Milwaukee - Radiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH520051V

Medicare Provider Number

520051

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/15/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/12/2013

Last Recertification Date

9/8/2015

Termination Date
Termination Reason

4/1/2016
Site closure

Contacts

Authorizing Official

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

Primary Contact

Laura Alar, Director of Pharmacy and Retail Medicine
(414) 585-1071

Addresses

Street Address

2350 N. Lake Dr.
Suite 400
Milwaukee, WI 53211

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	32793800
		1023064482

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
DSH520051AA	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Green Bay Road - Radiology	9252 N. Green Bay Road	Brown Deer	WI	Terminated
DSH520051AB	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Bay View Family Health Center - Rehab	3056 S. Kinnickinnic Ave.	Bay View	WI	Terminated
DSH520051AC	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Green Bay Road - Rehab	9233 N. Green Bay Road	Brown Deer	WI	Terminated
DSH520051AD	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Green Bay Road - Surgery	9252 N. Green Bay Rd.	Brown Deer	WI	Terminated
DSH520051AE	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Mequon	13133 N. Port Washington Road	Mequon	WI	Active
DSH520051AF	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Bay View	3056 S. Kinnickinnic Ave.	Bay View	WI	Active
DSH520051AG	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Milwaukee	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051AH	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Westgate Medical Group	2727 N Mayfair Road	Wauwatosa	WI	Terminated
DSH520051AI	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Bay View Family Health Center	3056 S. Kinnickinnic Ave.	Bay View	WI	Active
DSH520051AJ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	West Allis Medical Clinic	2323 S. 102nd St.	West Allis	WI	Active
DSH520051AK	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Green Bay Road	9252 N. Green Bay Rd.	Brown Deer	WI	Active
DSH520051AL	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Port Washington Road	6900 N. Port Washington Rd.	Glendale	WI	Active
DSH520051AM	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Columbia West - Rehab	10950 W. Capitol Dr.	Wauwatosa	WI	Terminated
DSH520051AN	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Columbia West - Radiology	10950 W. Capitol Dr.	Wauwatosa	WI	Terminated
DSH520051AP	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Gateway Medical Clinic - Rehab	801 S. 70th St.	West Allis	WI	Terminated
DSH520051AQ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Gateway Medical Clinic - Radiology	801 S. 70th St.	West Allis	WI	Terminated
DSH520051AR	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Gateway Medical Clinic	801 S. 70th St.	West Allis	WI	Active
DSH520051AS	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - GI	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051AT	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Water Tower Medical Commons - GYN Oncology	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051AU	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Radiology	2311 N. Prospect Ave.	Milwaukee	WI	Terminated
DSH520051AV	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Surgery	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051AW	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons	2311 N. Prospect Ave.	Milwaukee	WI	Terminated
DSH520051AX	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Perioperative	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051AY	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Surgery Ambulatory	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051AZ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - GI Lab	375 W. River Woods Pkwy	Glendale	WI	Active
DSH520051B	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMCP OZAUKEE CANCER CLINIC	13111 NORTH PORT WASHINGTON ROAD	MEQUON	WI	Active
DSH520051BA	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Radiology Womens Imaging	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051BB	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Radiology MRI	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051BC	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Radiology Ultrasound	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051BD	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Radiology CT Scan	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051BE	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM River Woods - Radiology Diagnostic	375 W. River Woods Pkwy	Glendale	WI	Terminated
DSH520051BF	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Columbia West	10950 W. Capitol Dr.	Wauwatosa	WI	Active
DSH520051BG	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMM Gateway Clinic / GI, Urology, Pain	801 S. 70th St.	West Allis	WI	Active
DSH520051BH	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Riverwoods Urgent Care	375 W. River Woods Pkwy	Glendale	WI	Active
DSH520051BJ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons / Urology	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051BK	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Columbia West / Integrative Medicine	10950 W. Capitol Dr.	Wauwatosa	WI	Terminated
DSH520051BL	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Gateway Medical Clinic / Integrative Medicine	801 S. 70th St.	West Allis	WI	Terminated
DSH520051BM	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Neurology Milwaukee	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051BN	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM PMC Neurology/SMO	13133 N. Port Washington Rd	Mequon	WI	Active
DSH520051BP	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Podiatry	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051BQ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Allergy / Allergy	2311 N. Prospect Ave.	Milwaukee	WI	Terminated
DSH520051BR	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE	Prospect Medical Commons / Cadiology	2311 N. Prospect Ave.	Milwaukee	WI	Terminated
DSH520051BS	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons / Pulmonary	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051BT	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons / Internal Medicine	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051BU	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Family Practice	2311 N PROSPECT AVE	MILWAUKEE	WI	Active
DSH520051BV	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	COLUMBIA ST MARYS HOSPITAL MILWAUKE / Prospect Medical Commons - Express Care	2311 N PROSPECT AVE	MILWAUKEE	WI	Terminated
DSH520051BW	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - OB/GYN	2311 N PROSPECT AVE	MILWAUKEE	WI	Active
DSH520051BX	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Prospect Medical Commons - Pediatrics	2311 N PROSPECT AVE	MILWAUKEE	WI	Active
DSH520051BY	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	COLUMBIA ST MARYS HOSPITAL MILWAUKE / Prospect Medical Commons - Pain Management	2311 N PROSPECT AVE	MILWAUKEE	WI	Active
DSH520051BZ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Radiation Oncology	2350 N LAKE DR	MILWAUKEE	WI	Active
DSH520051C	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Airport Medical Clinic	4848 S. 6th Street	Milwaukee	WI	Terminated
DSH520051CA	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardio Vasc Interventional Specialties	13133 N PORT WASHINGTON RD	MEQUON	WI	Active
DSH520051CB	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	90.02/Water Tower Medical Commons/6000642650/WTMC Urology Clinic	2350 N LAKE DR	MILWAUKEE	WI	Terminated
DSH520051CC	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	6000554904/Cancer Center MDC SMO	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051CD	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	6000554903/Cancer Center MDC SMM	2350 N LAKE DR	MILWAUKEE	WI	Active
DSH520051CE	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	90.26 CATHEDRAL SQUARE CLINIC / 6000632401 URGENT CARE	734 North Jackson St.	Milwaukee	WI	Terminated
DSH520051CF	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	55/Radiology - Therapeutic/6000516290/Radiation Oncology Anc 001	2350 N LAKE DR	MILWAUKEE	WI	Active
DSH520051CG	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiothoracic Surgery WTMC/ 6000648007 - Cardiothoracic Surgery	2350 N LAKE DR	Milwaukee	WI	Terminated
DSH520051CH	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiothoracic Surgery SMO/ 6000648007 - Cardiothoracic Surgery	13133 N. Port Washington Road	Mequon	WI	Terminated
DSH520051CJ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Heart Failure Clinic/SMO	13133 N. Port Washington Road	Mequon	WI	Active
DSH520051CK	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	PMC Neurosurgery Clinic	2311 N. Prospect Ave	Milwaukee	WI	Approved
DSH520051CL	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	PMC - Podiatry (Gateway) 6000647702 - Podiatry	801 S. 70th St.	West Allis	WI	Terminated
DSH520051CM	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Shorewood Clinic/OB	4027 North Oakland Ave	Shorewood	WI	Terminated
DSH520051CN	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Chemotherapy (SMO) 6000516401 - Chemotherapy	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051CP	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Thoracic Surgery	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051CQ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM PMC Specialty Services/Nephrology	2311 N Prospect Ave	Milwaukee	WI	Terminated
DSH520051CR	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Chemotherapy (Water Tower Medical Commons) 6000516400 - Chemotherapy	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051CS	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Stroke Clinic 6000653704 - Stroke	2350 N. Lake Dr.	Milwaukee	WI	Terminated
DSH520051CT	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac & Vascular Interventional Specialties - Cardiac & Vascular Interventional	2350 N. Lake Drive	Milwaukee	WI	Active
DSH520051CU	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	PMC Behavioral Health - Behavioral Health	2311 N. Prospect Ave.	Milwaukee	WI	Active
DSH520051CV	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Behavioral Health - Behavioral Medicine	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051CW	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Grafton - CLINIC	2061 Cheyenne Ct.	Grafton	WI	Terminated
DSH520051CX	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Mammography - Radiology-Diagnostic	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051CY	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Diagnostic Cardiology - Electrocardiology	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051CZ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Testing and Treatment - Testing & Treatment	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DA	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Surgery - Operating Room	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DB	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Cardiac Rehabilitation - Cardiac Rehabilitation	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DC	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Hyperbaric Oxygen - Hyperbaric Oxygen Therapy	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DD	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Cardiac Cath Labs - Cardiac Catheterization	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DE	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Nuclear Medicine - Radioisotope	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DF	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital MRI - MRI	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DG	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Respiratory Therapy - Respiratory Therapy	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DH	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Emergency Department - Emergency	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DJ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Interventional Radiology - Radiology-Diagnostic	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DK	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	PMC Epilepsy Clinic	2311 N. Prospect Ave	Milwaukee	WI	Active
DSH520051DL	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Grafton Medical Clinic - CLINIC	2061 Cheyenne Ct.	Grafton	WI	Active
DSH520051DM	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Radiation Oncology - Radiology-Therapeutic	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DN	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Anesthesiology - Anesthesiology	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DP	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Ultrasound - Radiology-Diagnostic	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DQ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cedar Mills Clinic - CLINIC	N143W6515 Pioneer Rd.	Cedarburg	WI	Active
DSH520051DR	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Grafton Urgent Care - CLINIC	2061 Cheyenne Ct.	Grafton	WI	Active
DSH520051DS	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Meadowview OBGYN Clinic - CLINIC	13133 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DT	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Bariatric Services - Bariatric Center	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DU	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Perioperative Care - Operating Room	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DV	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital GI Lab - GI Lab	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DW	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Surgery Recovery Room - Recovery Room	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DX	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital LDRPN Unit - Labor & Delivery	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051DY	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Greenlane Clinic - CLINIC	830 E. Green Bay Ave.	Saukville	WI	Active
DSH520051DZ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Germantown Clinic - CLINIC	N112W15415 Mequon Rd.	Germantown	WI	Active
DSH520051E	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	ENT Associates - Milwaukee	2311 N PROSPECT AVE	Milwaukee	WI	Active
DSH520051EA	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Diagnostic Radiology - Radiology-Diagnostic	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051EB	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cedarburg Clinic - CLINIC	W62N179 Washington Ave.	Cedarburg	WI	Active
DSH520051EC	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital CT - CT Scan	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051ED	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Gateway / OBGYN - Clinic	801 S. 70th St.	West Allis	WI	Terminated
DSH520051EE	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSMO Hospital Wound Care - Wound Care	13111 N. Port Washington Rd.	Mequon	WI	Active
DSH520051EF	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cedar Mills / Radiology - Clinic	N143W6515 Pioneer Rd.	Cedarburg	WI	Terminated
DSH520051EG	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Airport / Urology - Clinic	4848 S. 6th St.	Milwaukee	WI	Terminated
DSH520051EH	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Grafton / Behavioral Medicine - Behavioral Medicine	2061 Cheyenne Ct.	Grafton	WI	Active
DSH520051EJ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Bay View / Pain Management - Clinic	3056 S. Kinnickinnic Ave.	Bay View	WI	Active
DSH520051EK	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Airport / Podiatry - Clinic	4848 S. 6th St.	Milwaukee	WI	Terminated
DSH520051EL	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM West Allis / Pain Management - Clinic	2323 S. 102nd St.	West Allis	WI	Active
DSH520051EM	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM WTMC Heart Failure Clinic - Clinic	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051EN	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Shorewood / Radiology - Clinic	4027 N. Oakland Ave.	Shorewood	WI	Terminated
DSH520051EP	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Germantown / Pain Management - Clinic	N112 W15415 Mequon Rd.	Germantown	WI	Active
DSH520051EQ	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Gateway / Neurology - Clinic	801 S. 70th St.	West Allis	WI	Active
DSH520051ER	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Gateway / Pain Management - Clinic	801 S. 70th St.	West Allis	WI	Active
DSH520051ES	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Glendale GB / Behavioral Medicine - Behavioral Medicine	9252 N. Green Bay Rd.	Brown Deer	WI	Active
DSH520051ET	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Germantown / Radiology - Clinic	N112 W15415 Mequon Rd.	Germantown	WI	Terminated
DSH520051EU	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Greenlane / Radiology - Clinic	830 E. Green Bay Ave.	Saukville	WI	Terminated
DSH520051EV	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Grafton / Radiology - Clinic	2061 Cheyenne Ct.	Grafton	WI	Terminated
DSH520051EW	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Gateway / Behavioral Medicine - Behavioral Medicine	801 S. 70th St.	West Allis	WI	Active
DSH520051EX	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM WTMC Surgical Oncology - Surgical Oncology	2350 N. Lake Dr.	Milwaukee	WI	Active
DSH520051EY	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardio Vasc Intervent - Bay View - Cardiovascular	3056 S. Kinnickinnic Ave.	Bay View	WI	Active
DSH520051F	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	ENT Associates - Ozaukee	13133 N. Port Washington Rd	Mequon	WI	Active
DSH520051G	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cancer Center - Milwaukee	2350 N. Lake Drive	Milwaukee	WI	Active
DSH520051H	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Family Health Center	1121 E. North Ave.	Milwaukee	WI	Active
DSH520051J	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac & Vascular Interventional Specialties	2301 N. Lake Drive	Milwaukee	WI	Terminated
DSH520051K	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac Rhythm Specialists - Milwaukee	2350 N. Lake Drive	Milwaukee	WI	Active
DSH520051L	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac Rhythm Specialists - Bay View	3056 S. Kinnickinnic Avenue	Bay View	WI	Active
DSH520051M	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac Rhythm Specialists - Gateway	801 S. 70th St.	West Allis	WI	Active
DSH520051N	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cardiac Rhythm Specialists - Mequon	13133 N. Port Washington Road	Mequon	WI	Active
DSH520051P	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Shorewood Family Physicians	4027 N. Oakland Ave.	Shorewood	WI	Active
DSH520051Q	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Columbia St. Mary's Hospital Ozaukee - Suite 206	13133 N. Port Washington Rd.	Mequon	WI	Active
DSH520051S	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Cathedral Square Rehab	734 N. Jackson St.	Milwaukee	WI	Terminated
DSH520051T	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Mequon - Radiology	13133 N. Port Washington Rd.	Mequon	WI	Terminated
DSH520051U	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Bay View - Radiology	3056 S. Kinnickinnic Ave.	Bay View	WI	Terminated
DSH520051V	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	CSM Cardiovascular Specialists - Milwaukee - Radiology	2350 N. Lake Dr.	Milwaukee	WI	Terminated
DSH520051W	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Westgate Medical Group - Radiology	2727 N Mayfair Rd	Wauwatosa	WI	Terminated
DSH520051X	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	West Allis Medical Clinic - Radiology	2323 S. 102nd St.	West Allis	WI	Terminated
DSH520051Y	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Airport Medical Clinic - Radiology	4848 S. 6th St.	Milwaukee	WI	Terminated
DSH520051Z	Child	DSH	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	Glendale Clinic - Port Washington Road - Radiology	6900 N. Port Washington Road	Glendale	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		Andersen, Travis D. President/CEO 4145854870	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Andersen, Travis D. President/CEO 4145854870	8/13/2017 7:38 PM
Contacts	Signed By	Insert			Anderson, Rhonda PRESIDENT & CFO 4142704850	8/13/2017 7:37 PM
Contacts	Primary Contact	Update		Hsu, Philip Director of Pharmacy 4142911069	Alar, Laura Director of Pharmacy and Retail Medicine 4145851071	6/29/2017 9:09 AM
Addresses	Main Address	Insert			2350 N. Lake Dr. Suite 400 Milwaukee, WI 53211	3/15/2016 8:00 AM
Dates	Last Date That 340B Drugs Purchased	Update			11/30/2015 12:00:00 AM	3/15/2016 8:00 AM
Details	State	Update		Active	Terminated	3/15/2016 8:00 AM
Terminations	Termination Comments	Update			This 340B ID was a department of the parent, which was closed and merged into an existing 340B ID/Department - DSH520051AG.	3/15/2016 8:00 AM
Terminations	Termination Date	Update			4/1/2016 12:00:00 AM	3/15/2016 8:00 AM
Terminations	Termination Effective Date	Update			11/30/2015 12:00:00 AM	3/15/2016 8:00 AM
Terminations	Termination Reason	Update			Site closure	3/15/2016 8:00 AM
Details	Last Recertification Date	Update		9/10/2014 12:00:00 AM	9/8/2015 12:00:00 AM	9/8/2015 3:53 PM
Details	Entity Name	Update		ST MARYS HOSPITAL OF MILWAUKEE	COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC	12/10/2014 9:32 AM
Details	Entity Subname	Update		Wisconsin Cardiovascular Group - Milwaukee - Radiology	CSM Cardiovascular Specialists - Milwaukee - Radiology	11/14/2014 10:02 AM
Details	Last Recertification Date	Update			9/10/2014 12:00:00 AM	9/10/2014 4:07 PM
Contacts	Primary Contact	Insert			Hsu, Philip Director of Pharmacy 4142911069	7/3/2014 4:20 PM
Dates	Participating Approval Date	Update			12/12/2013 12:00:00 AM	12/12/2013 6:43 AM
Details	State	Update		Pending	Active	12/12/2013 6:43 AM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	12/12/2013 6:43 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH520051V	12/10/2013 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2013 6:06 PM
Medicaid Billing	Medicaid: Number	Insert			32793800	10/15/2013 6:06 PM
Medicaid Billing	Medicaid: State	Insert			WI	10/15/2013 6:06 PM
Medicaid Billing	NPI: Number	Insert			1023064482	10/15/2013 6:06 PM
Details	Last Recertification Date	Insert				10/15/2013 6:06 PM
Details	Grant Number	Insert				10/15/2013 6:06 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/15/2013 6:06 PM
Details	Is Authorizing Official EHB Data	Insert				10/15/2013 6:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/15/2013 6:06 PM
Details	Medicare Provider Number	Insert			520051	10/15/2013 6:06 PM
Details	Entity Name	Insert			ST MARYS HOSPITAL OF MILWAUKEE	10/15/2013 6:06 PM
Details	Program Code	Insert			DSH	10/15/2013 6:06 PM
Details	Entity Subname	Insert			Wisconsin Cardiovascular Group - Milwaukee - Radiology	10/15/2013 6:06 PM
Dates	Participating Approval Date	Insert				10/15/2013 6:06 PM
Details	State	Insert			Pending	10/15/2013 6:06 PM
Dates	Registration Date	Insert			10/15/2013 12:00:00 AM	10/15/2013 6:06 PM
Dates	Signed By Date	Insert			10/15/2013 12:00:00 AM	10/15/2013 6:06 PM
Dates	Start Date	Insert				10/15/2013 6:06 PM
Terminations	Termination Comments	Insert				10/15/2013 6:06 PM
Terminations	Termination Date	Insert				10/15/2013 6:06 PM
Terminations	Termination Effective Date	Insert				10/15/2013 6:06 PM
Terminations	Termination Reason	Insert				10/15/2013 6:06 PM