Covered Entity Details

DSH140304E ADVENTIST BOLINGBROOK HOSPITAL (Terminated) - information as of 5/19/2025 12:53:40 AM

Main Details

Name

ADVENTIST BOLINGBROOK HOSPITAL

Subdivision Name

Wound Care Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140304E

Medicare Provider Number

140304

Outpatient Facility Provider Number

140304

Additional Details

Current Program Status

Terminated

Registration Date

7/8/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/4/2014

Last Recertification Date

8/23/2016

Termination Date
Termination Reason

1/1/2018
Site closure

Contacts

Authorizing Official

AdventHealth GlenOaks
Vladimir Radivojevic, President & CEO
(630) 545-7258

Primary Contact

Adventist Bolingbrook Hospital
JODI PONTERIO, MANAGER OF PHARMACY
(630) 312-3965

Addresses

Street Address

420 Schmidt Road
Suite 110
Bolingbrook, IL 60440

Billing Address

Adventist Bolingbrook Hospital
P.O. Box 9245
Oak Brook, IL 60522

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

Shipping Addresses

Shipping Address 1

Adventist Bolingbrook Hospital
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
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
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	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
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/30/2016 12:00:00 AM	10/18/2017 2:19 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/18/2017 2:19 PM
Terminations	Termination Comments	Update	Termination Request		Wound Care department closed due to change in service line structure in healthcare system.	10/18/2017 2:19 PM
Terminations	Termination Date	Update	Termination Request		1/1/2018 12:00:00 AM	10/18/2017 2:19 PM
Terminations	Termination Effective Date	Update	Termination Request		1/2/2017 12:00:00 AM	10/18/2017 2:19 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/18/2017 2:19 PM
Contacts	Primary Contact	Update		PONTERIO, JODI MANAGER OF PHARMACY 6303123965	PONTERIO, JODI MANAGER OF PHARMACY Adventist Bolingbrook Hospital 6303123965	10/10/2017 10:22 AM
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	Primary Contact	Update		PONTERIO, JODI MANAGER OF PHARMACY 6303123965	PONTERIO, JODI MANAGER OF PHARMACY 6303123965	11/23/2016 11:48 AM
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 110 Bolingbrook, IL 60440	8/23/2016 2:10 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 2:10 PM
Contacts	Primary Contact	Insert			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	9/1/2015 12:40 PM
Addresses	Shipping Address	Insert			Adventist Bolingbrook Hospital 500 Remington Blvd Bolingbrook, IL 60440	9/1/2015 12:40 PM
Medicaid Billing	NPI: Number	Insert			1164530465	9/1/2015 12:40 PM
Medicaid Billing	NPI: Number	Insert			1184923260	9/1/2015 12:40 PM
Details	Last Recertification Date	Update			9/1/2015 12:00:00 AM	9/1/2015 12:40 PM
Dates	Participating Approval Date	Update			9/4/2014 12:00:00 AM	9/4/2014 5:45 PM
Details	State	Update		Pending	Active	9/4/2014 5:45 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/4/2014 5:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_44649	DSH140304E	9/3/2014 11:20 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_44649	7/8/2014 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/8/2014 10:39 AM
Medicaid Billing	Medicaid: Number	Insert			651219504001	7/8/2014 10:39 AM
Medicaid Billing	Medicaid: State	Insert			IL	7/8/2014 10:39 AM
Details	Last Recertification Date	Insert				7/8/2014 10:39 AM
Details	Grant Number	Insert				7/8/2014 10:39 AM
Details	340B ID	Insert				7/8/2014 10:39 AM
Details	Is Authorizing Official EHB Data	Insert				7/8/2014 10:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/8/2014 10:39 AM
Details	Medicare Provider Number	Insert			140304	7/8/2014 10:39 AM
Details	Entity Name	Insert			ADVENTIST BOLINGBROOK HOSPITAL	7/8/2014 10:39 AM
Details	Program Code	Insert			DSH	7/8/2014 10:39 AM
Details	Entity Subname	Insert			Wound Care Center	7/8/2014 10:39 AM
Dates	Participating Approval Date	Insert				7/8/2014 10:39 AM
Details	State	Insert			Pending	7/8/2014 10:39 AM
Dates	Registration Date	Insert			7/8/2014 12:00:00 AM	7/8/2014 10:39 AM
Dates	Signed By Date	Insert			7/8/2014 12:00:00 AM	7/8/2014 10:39 AM
Dates	Start Date	Insert				7/8/2014 10:39 AM
Terminations	Termination Comments	Insert				7/8/2014 10:39 AM
Terminations	Termination Date	Insert				7/8/2014 10:39 AM
Terminations	Termination Effective Date	Insert				7/8/2014 10:39 AM
Terminations	Termination Reason	Insert				7/8/2014 10:39 AM