Covered Entity Details

DSH140182A ADVOCATE NORTH SIDE HEALTH NETWORK (Active) - information as of 4/29/2025 1:43:34 AM

Main Details

Name

ADVOCATE NORTH SIDE HEALTH NETWORK

Subdivision Name

ADVOCATE ILLINOIS MASONIC CRETICOS / Creticos Cancer Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140182A

Medicare Provider Number

140182

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/4/2015

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Advocate Aurora Health Care
Nan Nelson, SVP-Finance
(414) 378-4765

Primary Contact

Advocate Aurora Health
Jason G Nowak, Director, Pharmacy 340B Program
(414) 640-8457

Addresses

Street Address

900 W. NELSON AVE
CHICAGO, IL 60657-6708

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
IL	363196629020,363196629021,363196629406,363196629006	1912014564,1639657414,1134607005
WI	363196629006,363196629020,363196629021,363196629406	1134607005,1639657414,1912014564

Shipping Addresses

Shipping Address 1

ADVOCATE NORTHSIDE HEALTH SYSTEM
836 W. WELLINGTON AVE.
CHICAGO, IL 60657

Shipping Address 2

Advocate Integrated Service Center
15-17 W. College Dr
Arlington Heights, IL 60004

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
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15197	6121 N BROADWAY ST.	CHICAGO	IL	60660	01/11/2018	04/01/2018		01/11/2018	01/12/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140182A	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC CRETICOS / Creticos Cancer Center	900 W. NELSON AVE	CHICAGO	IL	Active
DSH140182B	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	Advocate North Side IMMC Infusion Center / IV Therapy - Infusion Center / IV Therapy	3000 N Halsted Street	Chicago	IL	Active
DSH140182C	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Pain Clinic	3000 N Halsted Street Suite 823	Chicago	IL	Active
DSH140182D	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Ultrasound	3000 N Halsted Street Suite 220	Chicago	IL	Terminated
DSH140182E	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Digestive Health Procedure Suite	900 W Nelson St	Chicago	IL	Active
DSH140182F	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Day Surgery	900 W Nelson St	Chicago	IL	Active
DSH140182G	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Mammography	3000 N Halsted Street Suite 220	Chicago	IL	Active
DSH140182H	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Radiation Oncology	900 W Nelson St	Chicago	IL	Active
DSH140182J	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC ANTENATAL - Antenatal Resource Center	3000 N HALSTED ST	CHICAGO	IL	Active
DSH140182K	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - MRI	3000 N Halsted Street Suite 100	Chicago	IL	Active
DSH140182L	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Radiology	3000 N Halsted Street Suite 100	Chicago	IL	Terminated
DSH140182M	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - CT Scan	3000 N Halsted Street Suite 100	Chicago	IL	Active
DSH140182N	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Park Ridge Clinic	1700 Luther Lane	Park Ridge	IL	Active
DSH140182P	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Darien Clinic	2622 W 83rd St	Darien	IL	Terminated
DSH140182Q	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Bhorade Clinic	3745 Highland Ave	Downers Grove	IL	Active
DSH140182R	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Good Shepard Infusion	450 W IL Route 22	Barrington	IL	Active
DSH140182S	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	ADVOCATE ILLINOIS MASONIC - Libertyville Clinic	1800 Hollister Dr.	Libertyville	IL	Active
DSH140182T	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	Pediatric Development Center - Rehab/Psych/Counseling	913 West Wellington Ave 3rd floor	Chicago	IL	Active
DSH140182U	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	Sleep Clinic - Sleep Clinic	3000 N. Halsted Street Suite 323	Chicago	IL	Active
DSH140182V	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	Electroencephalography - Neurology EEG	3000 N Halsted Street	Chicago	IL	Terminated
DSH140182W	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	Condell Infusion - Infusion	801 S MILWAUKEE AVE	Libertyville	IL	Active
DSH140182X	Child	DSH	ADVOCATE NORTH SIDE HEALTH NETWORK	IMC MOC PET - Nuclear Medicine	3000 N Halsted Street	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:59:49 PM	8/14/2024 8:44:29 PM	8/14/2024 8:44 PM
Contacts	Primary Contact	Update	Change Request	Nowak, Jason Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	Nowak, Jason G Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	7/22/2024 3:54 PM
Contacts	Authorizing Official	Update	Profile Change Request	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4142991610	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4143784765	2/7/2024 11:14 AM
Details	Last Recertification Date	Update	Recertification	9/2/2022 12:22:18 PM	8/23/2023 4:59:49 PM	8/23/2023 4:59 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 12:10:15 PM	9/2/2022 12:22:18 PM	9/2/2022 12:22 PM
Contacts	Primary Contact	Update	Group Change Request	De Ianni, Angela Vice President Pharmacy Supply Chain Advocate Aurora Health Care 4146301541	Nowak, Jason Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	5/6/2022 9:10 AM
Contacts	Primary Contact	Update	Profile Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4146301541	De Ianni, Angela Vice President Pharmacy Supply Chain Advocate Aurora Health Care 4146301541	10/7/2021 12:57 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 1:29:19 PM	9/10/2021 12:10:15 PM	9/10/2021 12:10 PM
Contacts	Primary Contact	Update	Profile Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4146301541	9/1/2021 1:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		363196629006	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		363196629020	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		363196629021	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		363196629406	9/8/2020 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1134607005	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1639657414	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912014564	9/8/2020 1:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:29 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 6:43:38 AM	9/8/2020 1:29:19 PM	9/8/2020 1:29 PM
Contacts	Authorizing Official	Update	Change Request	Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4142991610	6/17/2020 10:19 AM
Contacts	Primary Contact	Update	Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	6/3/2020 8:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363196629020	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363196629021	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363196629406	3/2/2020 11:49 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:49 AM
Addresses	Shipping Address	Delete	Change Request	Advocate Integrated Service Center 15 W. College Dr Arlington Heights, IL 60004		10/10/2019 7:46 AM
Addresses	Shipping Address	Insert	Change Request		Advocate Integrated Service Center 15-17 W. College Dr Arlington Heights, IL 60004	10/10/2019 7:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1639657414	10/10/2019 7:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1134607005	10/10/2019 7:46 AM
Addresses	Shipping Address	Insert	Recertification		Advocate Integrated Service Center 15 W. College Dr Arlington Heights, IL 60004	9/13/2019 6:43 AM
Addresses	Shipping Address	Delete	Recertification	Advocate Consolidated Service Center 515 Towns CAROL STREAM, IL 60188		9/13/2019 6:43 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912014564	9/13/2019 6:43 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 9:06:22 AM	9/13/2019 6:43:38 AM	9/13/2019 6:43 AM
Contacts	Primary Contact	Update	Change Request	Saleem, Zohra 340B Manager Advocate Healthcare 6309295626	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	7/3/2019 11:27 AM
Contacts	Authorizing Official	Update	AO Change Request	Bury, Peter VP Finance Advocate Health Care 7732967809	Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	6/25/2019 7:09 AM
Details	Last Recertification Date	Update	Recertification	11/10/2017 10:25:13 AM	9/10/2018 9:06:22 AM	9/10/2018 9:06 AM
Contacts	Authorizing Official	Update	Change Request	Forslev, William Chief Pharmacy Officer Advocate Healthcare 6309295934	Bury, Peter VP Finance Advocate Health Care 7732967809	6/28/2018 2:48 PM
Contacts	Authorizing Official	Update	Change Request	GILBERT, JACK VP FINANCE Advocate North Side Health Network 7732967809	Forslev, William Chief Pharmacy Officer Advocate Healthcare 6309295934	12/20/2017 2:26 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/10/2017 10:25:13 AM	11/10/2017 10:25 AM
Contacts	Primary Contact	Insert	Change Request		Saleem, Zohra 340B Manager Advocate Healthcare 6309295626	10/4/2017 12:36 PM
Details	Entity Name	Update	Change Request	ADVOCATE NORTHSIDE HEALTH SYSTEM	ADVOCATE NORTH SIDE HEALTH NETWORK	10/4/2017 12:21 PM
Contacts	Authorizing Official	Update		GILBERT, JACK VP FINANCE 7732967809	GILBERT, JACK VP FINANCE Advocate North Side Health Network 7732967809	10/4/2017 12:13 PM
Contacts	Signed By	Update		GILBERT, JACK VP FINANCE 7732967809	GILBERT, JACK VP FINANCE Advocate North Side Health Network 7732967809	10/4/2017 12:13 PM
Contacts	Authorizing Official	Insert			GILBERT, JACK VP FINANCE 7732967809	8/9/2017 2:54 PM
Contacts	Signed By	Insert			GILBERT, JACK VP FINANCE 7732967809	8/9/2017 2:54 PM
Addresses	Main Address	Insert			900 W. NELSON AVE CHICAGO, IL 60657-6708	9/6/2016 1:21 PM
Addresses	Shipping Address	Insert			Advocate Health Care CSC 515 Tower Blvd CAROL STREAM, IL 60188	9/6/2016 1:21 PM
Addresses	Shipping Address	Update		Advocate Health Care CSC 515 Tower Blvd CAROL STREAM, IL 60188	Advocate Consolidated Service Center 515 Towns CAROL STREAM, IL 60188	9/6/2016 1:21 PM
Addresses	Shipping Address	Insert			ADVOCATE NORTHSIDE HEALTH SYSTEM 836 W. WELLINGTON AVE. CHICAGO, IL 60657	9/6/2016 1:21 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 1:20 PM
Details	Last Recertification Date	Update			9/2/2015 12:00:00 AM	9/2/2015 1:26 PM
Dates	Participating Approval Date	Update			3/4/2015 12:00:00 AM	3/4/2015 2:51 PM
Details	State	Update		Pending	Active	3/4/2015 2:51 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/4/2015 2:51 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49907	DSH140182A	2/4/2015 1:48 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49907	1/15/2015 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 4:20 PM
Medicaid Billing	Medicaid: Number	Insert			363196629006	1/15/2015 4:20 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/15/2015 4:20 PM
Details	Last Recertification Date	Insert				1/15/2015 4:20 PM
Details	Grant Number	Insert				1/15/2015 4:20 PM
Details	340B ID	Insert				1/15/2015 4:20 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 4:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 4:20 PM
Details	Medicare Provider Number	Insert			140182	1/15/2015 4:20 PM
Details	Entity Name	Insert			ADVOCATE NORTHSIDE HEALTH SYSTEM	1/15/2015 4:20 PM
Details	Program Code	Insert			DSH	1/15/2015 4:20 PM
Details	Entity Subname	Insert			ADVOCATE ILLINOIS MASONIC CRETICOS / Creticos Cancer Center	1/15/2015 4:20 PM
Dates	Participating Approval Date	Insert				1/15/2015 4:20 PM
Details	State	Insert			Pending	1/15/2015 4:20 PM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 4:20 PM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 4:20 PM
Dates	Start Date	Insert				1/15/2015 4:20 PM
Terminations	Termination Comments	Insert				1/15/2015 4:20 PM
Terminations	Termination Date	Insert				1/15/2015 4:20 PM
Terminations	Termination Effective Date	Insert				1/15/2015 4:20 PM
Terminations	Termination Reason	Insert				1/15/2015 4:20 PM