Covered Entity Details

DSH520096AT WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS (Terminated) - information as of 6/23/2025 12:36:15 AM

Main Details

Name

WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS

Subdivision Name

WFMG -ONE MAIN CLINIC / CHIROPRACTIC SERVICES

Type

Disproportionate Share Hospital

Rural

340B ID

DSH520096AT

Medicare Provider Number

520096

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/22/2015

Last Recertification Date

11/28/2017

Termination Date
Termination Reason

4/1/2018
Site closure

Contacts

Authorizing Official

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

Primary Contact

Ascension WI
Cescilly Smith-Jenkins, 340B Program Director – Wisconsin
(414) 522-7533

Addresses

Street Address

1 MAIN ST
RACINE, WI 53403-1079

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	32833500
		1609881077

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
DSH520096A	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN MEDICAL GROUP	3807 SPRING STREET	RACINE	WI	Terminated
DSH520096AA	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mt Pleasant/WFMG NEUROLOGY	4328 Old Green Bay Road	Mount Pleasant	WI	Terminated
DSH520096AB	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mt Pleasant/WFMG ORTHOPEDICS	4328 OLD GREEN BAY RD	Mount Pleasant	WI	Active
DSH520096AC	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	Wheaton Francisca Medical Group- All Saints-Mt Pleasant/WFMG WOMEN'S HEALTH	3801 SPRING STREET	Racine	WI	Terminated
DSH520096AD	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan All Saints-Medical Group / WFMG PEDIATRICS	3807 Spring Street	Racine	WI	Active
DSH520096AE	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN HEALTHCARE-All Saints / WFMG STURTEVANT FAMILY MEDICINE	10340 WASHINGTON AVE	STURTEVANT	WI	Terminated
DSH520096AF	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN HEALTHCARE / WFH ALL SAINTS RADIOLOGY - STURTEVANT	10340 WASHINGTON AVE	STURTEVANT	WI	Terminated
DSH520096AG	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN HEALTHCARE / All Saints Washington Ave Clinics-STURTEVANT LAB	10340 WASHINGTON AVE	STURTEVANT	WI	Terminated
DSH520096AH	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	3805A Spring Street Clinics / WFMG ENDOCRINOLOGY	3805A Spring St	Racine	WI	Terminated
DSH520096AJ	Child	DSH	Ascension All Saints Hospital, Inc.	3805B Family and Child Therapy Center	3805B Spring Street	Racine	WI	Active
DSH520096AK	Child	DSH	Ascension All Saints Hospital, Inc.	3805 B Spring Street Clinics / WFH- NEUROSURGERY CLINIC	3805B Spring St	Racine	WI	Active
DSH520096AL	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFH UNION GROVE / MHS OUTPATIENT COUNSELING	1120 MAIN ST	UNION GROVE	WI	Terminated
DSH520096AM	Child	DSH	Ascension All Saints Hospital, Inc.	WFH UNION GROVE / WFMG WOMEN'S HEALTH CLINIC	1120 MAIN ST	UNION GROVE	WI	Terminated
DSH520096AN	Child	DSH	Ascension All Saints Hospital, Inc.	WFH UNION GROVE / FAMILY MEDICINE / PEDIATRICS CLINIC	1120 MAIN ST	UNION GROVE	WI	Active
DSH520096AP	Child	DSH	Ascension All Saints Hospital, Inc.	WFH UNION GROVE / ORTHOPEDIC CLINIC	1120 MAIN ST	UNION GROVE	WI	Active
DSH520096AQ	Child	DSH	Ascension All Saints Hospital, Inc.	All Saints Medical Center - WFMG / RHEUMATOLOGY	3811 Spring Street	RACINE	WI	Active
DSH520096AR	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFMG-ONE MAIN ST CLINIC / INTERNAL MEDICINE	1 MAIN ST	RACINE	WI	Terminated
DSH520096AS	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFMG-ONE MAIN ST. CLINIC / FAMILY MEDICINE	1 MAIN ST	RACINE	WI	Terminated
DSH520096AT	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFMG -ONE MAIN CLINIC / CHIROPRACTIC SERVICES	1 MAIN ST	RACINE	WI	Terminated
DSH520096AU	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / ENDOSCOPY	3811 SPRING STREET	RACINE	WI	Active
DSH520096AV	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL GROUP / WFH ATRIUM REHABILITATION OUTPATIENT	3811 SPRING STREET	RACINE	WI	Terminated
DSH520096AW	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ATRIUM RADIOLOGY- 3811 Spring St Clinics	3811 Spring St	Racine	WI	Active
DSH520096AX	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan-3805-A Clinics / WFMG DIABETES MANAGEMENT	3805A Spring St	Racine	WI	Active
DSH520096AY	Child	DSH	Ascension All Saints Hospital, Inc.	3805B Mental Health and Addiction Care	3805B SPRING STREET	Racine	WI	Active
DSH520096AZ	Child	DSH	Ascension All Saints Hospital, Inc.	CANCER CENTER / WFMG-ONCOLOGY INFUSION	3809 SPRING STREET	RACINE	WI	Active
DSH520096B	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN MEDICAL GROUP	2408 FOUR MILE ROAD	RACINE	WI	Terminated
DSH520096BA	Child	DSH	Ascension All Saints Hospital, Inc.	CANCER CENTER / WFH RADIATION ONCOLOGY	3809 SPRING STREET	RACINE	WI	Active
DSH520096BB	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ANTI-COAGULANT CLINIC	3807 SPRING STREET	RACINE	WI	Active
DSH520096BC	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	ALL SAINTS MEDICAL CENTER / WFMG HOPE CLINIC	3807 SPRING STREET	RACINE	WI	Terminated
DSH520096BD	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH S3807 CARDIAC DIAGNOSTICS	3807 SPRING STREET	RACINE	WI	Active
DSH520096BE	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH RADIOLOGY	3807 SPRING STREET	RACINE	WI	Active
DSH520096BF	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN HEALTHCARE- ALL / WFMG CARDIOLOGY-ONE MAIN	1 MAIN ST	RACINE	WI	Terminated
DSH520096BG	Child	DSH	Ascension All Saints Hospital, Inc.	WFMG / WFMG WOMEN'S HEALTH - MT PLEASANT	4328 OLD GREEN BAY RD	MOUNT PLEASANT	WI	Active
DSH520096BH	Child	DSH	Ascension All Saints Hospital, Inc.	WFMG / WFMG PEDIATRICS - MT PLEASANT	4328 OLD GREEN BAY RD	MOUNT PLEASANT	WI	Active
DSH520096BJ	Child	DSH	Ascension All Saints Hospital, Inc.	WFH-ALL SAINTS-NORTHSIDE / WFMG ORTHOPEDICS - FOUR MILE-All Saints	2408 4 Mile Rd	Racine	WI	Terminated
DSH520096BK	Child	DSH	Ascension All Saints Hospital, Inc.	WFH-ALL SAINTS-NORTHSIDE / WFMG INTERNAL MEDICINE - FOUR MILE-All Saints	2408 4 Mile Rd	Racine	WI	Active
DSH520096BL	Child	DSH	Ascension All Saints Hospital, Inc.	WFH-ALL SAINTS-NORTHSIDE / WFMG FAMILY MEDICINE - FOUR MILE	2408 4 Mile Rd	Racine	WI	Active
DSH520096BM	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFHC ALL SAINTS PULMONARY FUCNTION LAB	3807 SPRING STREET	RACINE	WI	Terminated
DSH520096BP	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFMG INTERNAL MEDICINE - ALL SAINTS	3807 SPRING STREET	RACINE	WI	Active
DSH520096BQ	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFMG ALLERGY & IMMUNOLOGY	3803 SPRING STREET	RACINE	WI	Active
DSH520096BR	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFMG FAMILY MEDICINE / COMPREHENSIVE CARE	3807 SPRING STREET	RACINE	WI	Active
DSH520096BS	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER URGENT CARE / RESPIRATORY	3807 SPRING STREET	RACINE	WI	Active
DSH520096BT	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS CARDIAC DIAGNOSTICS	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096BU	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH All Saints CVI RADIOLOGY	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096BV	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS CHRONIC DISEASE CENTER	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096BW	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS OBSERVATION UNIT	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096BX	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS CARDIAC CATH LAB	3803 SPRING STREET	RACINE	WI	Active
DSH520096BY	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS SEXUAL ASSAULT TREATMENT CENTER	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096BZ	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE VEIN AND VASCULAR	3803 SPRING STREET	RACINE	WI	Active
DSH520096C	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN MEDICAL GROUP	4328 OLD GREEN BAY ROAD	MOUNT PLESANT	WI	Terminated
DSH520096CA	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFMG PULMONARY MEDICINE	3803 SPRING STREET	RACINE	WI	Active
DSH520096CB	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFMG NEPHROLOGY - ALL SAINTS	3805B SPRING STREET	RACINE	WI	Active
DSH520096CC	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFMG LIPIDOLOGY	3803 SPRING STREET	RACINE	WI	Active
DSH520096CD	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFMG CARDIOLOGY	3803 SPRING STREET	RACINE	WI	Active
DSH520096CE	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFMG CARDIAC ELECTROPHYSIOLOGY	3803 SPRING STREET	RACINE	WI	Active
DSH520096CF	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS ULTRASOUND	3821 SPRING STREET	RACINE	WI	Active
DSH520096CG	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS MAMMOGRAPHY	3821 SPRING STREET	RACINE	WI	Active
DSH520096CH	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS REHABILITATION SERVICES OUTPATIENT	3821 SPRING STREET	RACINE	WI	Terminated
DSH520096CJ	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS PERINATAL ASSESSMENT CENTER	3821 SPRING STREET	RACINE	WI	Active
DSH520096CK	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS LABOR AND DELIVERY	3821 SPRING STREET	RACINE	WI	Active
DSH520096CL	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS SLEEP CENTER-3821 Spring St Clinic	3821 SPRING STREET	RACINE	WI	Terminated
DSH520096CM	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS WOMEN'S HEALTH	3821 SPRING STREET	RACINE	WI	Active
DSH520096CN	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS INTENSIVE CARE UNIT	3803 SPRING STREET	RACINE	WI	Active
DSH520096CP	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	ATRIUM MEDICAL OFFICES / WFH ALL SAINTS ATRIUM LAB	3811 SPRING STREET	RACINE	WI	Terminated
DSH520096CR	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / GASTROENTEROLOGY	3811 SPRING STREET	RACINE	WI	Active
DSH520096CS	Child	DSH	Ascension All Saints Hospital, Inc.	ATRIUM MEDICAL OFFICES / UROLOGY	3811 SPRING STREET	RACINE	WI	Active
DSH520096CT	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group - INFECTIOUS DISEASE	3811 SPRING STREET	RACINE	WI	Active
DSH520096CU	Child	DSH	Ascension All Saints Hospital, Inc.	ATRIUM MEDICAL OFFICES / PLASTIC SURGERY	3811 SPRING STREET	RACINE	WI	Active
DSH520096CV	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / GENERAL SURGERY	3811 SPRING STREET	RACINE	WI	Active
DSH520096CW	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / ORTHOPEDICS	3811 SPRING STREET	RACINE	WI	Active
DSH520096CX	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS ASTHMA MANAGEMENT CLINIC -Wisconsin Ave Clinic	1320 WISCONSIN AVENUE	RACINE	WI	Active
DSH520096CY	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS HOSPITAL MENTAL HEALTH SERVICE PARTIAL HOSPITAL PR-Wiscosnin Ave Clinics	1320 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096CZ	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFMG FAMILY MEDICINE - WISCONSIN AVE Clinic	1320 WISCONSIN AVENUE	RACINE	WI	Active
DSH520096DA	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS HOSPITAL MENTAL HEALTH AND ADDICTION-Wisconsin Ave Clinic	1320 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096DB	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH All Saints Fresh Start-Wisconsin Ave Clinics	1320 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096DC	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFMG / WFMG ORTHOPEDICS - MT PLEASANT	4328 OLD GREEN BAY RD	MOUNT PLEASANT	WI	Terminated
DSH520096DD	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WFMG / WFMG NEUROLOGY - MT PLEASANT	4328 OLD GREEN BAY RD	MOUNT PLEASANT	WI	Terminated
DSH520096DE	Child	DSH	Ascension All Saints Hospital, Inc.	ATRIUM MEDICAL OFFICES / WFH ALL SAINTS ATRIUM RADIOLOGY-3811 Spring St Clinic	3811 SPRING STREET	RACINE	WI	Terminated
DSH520096DF	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS HOSPITAL PSYCH CHILD/ADOLESCENT-Wisconsin Ave Clinic	1320 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096DG	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS WOMEN & INFANTS	3821 SPRING STREET	RACINE	WI	Active
DSH520096DH	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS PEDIATRICS	3821 SPRING STREET	RACINE	WI	Terminated
DSH520096DK	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS CARDIAC GENERAL MEDICAL	3803 SPRING STREET	RACINE	WI	Active
DSH520096DL	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / WFH ALL SAINTS CVI CV2	3803 SPRING STREET	RACINE	WI	Active
DSH520096DM	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / ST LUKE'S HOSPITAL PSYCH ADULT	1320 WISCONSIN AVENUE	RACINE	WI	Active
DSH520096DN	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFMG WISCONSIN AVENUE MEDICAL HOME	1320 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096DP	Child	DSH	Ascension All Saints Hospital, Inc.	ATRIUM MEDICAL OFFICES / WFMG PHYSICAL MEDICINE & REHABILITATION - ALL SAINTS	3811 SPRING STREET	RACINE	WI	Active
DSH520096DQ	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	CARDIOVASCULAR INSTITUTE / WFMG ANTICOAGULATION CLINIC - ALL SAINTS	3803 SPRING STREET	RACINE	WI	Terminated
DSH520096DR	Child	DSH	Ascension All Saints Hospital, Inc.	CARDIOVASCULAR INSTITUTE / CVI EMERGENCY DEPARTMENT	3803 SPRING STREET	RACINE	WI	Active
DSH520096DS	Child	DSH	Ascension All Saints Hospital, Inc.	ATRIUM MEDICAL OFFICES / Otolaryngology	3811 SPRING STREET	RACINE	WI	ToBeTerminated
DSH520096DT	Child	DSH	Ascension All Saints Hospital, Inc.	Wisconsin Avenue AMG Psychiatry	1244 WISCONSIN AVE	RACINE	WI	Active
DSH520096DU	Child	DSH	Ascension All Saints Hospital, Inc.	ALL SAINTS MEDICAL CENTER / WFH ALL SAINTS MEDICATION CLINIC	1320 WISCONSIN AVENUE	RACINE	WI	Active
DSH520096DV	Child	DSH	Ascension All Saints Hospital, Inc.	WHEATON FRANCISCAN HEALTHCARE - Family Care Center	2400W VILLARD AVE	MILWAUKEE	WI	Approved
DSH520096DW	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group - All Saints Orthopedics - Sturtevant - Orthopedics	10340 Washington Ave.	Sturtevant	WI	Terminated
DSH520096DX	Child	DSH	Ascension All Saints Hospital, Inc.	Wisconsin Avenue Adolescent Day Treatment - Behavioral Health	1320 Wisconsin Avenue	Racine	WI	Active
DSH520096DY	Child	DSH	Ascension All Saints Hospital, Inc.	Four Mile Women's Health - OB/GYN	2408 4 Mile Rd	Racine	WI	Active
DSH520096DZ	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Rheumatology - Rheumatology	4328 Old Green Bay Road	Mount Pleasant	WI	Active
DSH520096E	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN MEDICAL GROUP	1120 MAIN STREET	UNION GROVE	WI	Terminated
DSH520096EA	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Psychiatry - Psychiatry	4328 Old Green Bay Road	Mount Pleasant	WI	Active
DSH520096EB	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant PACU - Surgery	10180 Washington Ave	Mount Pleasant	WI	Approved
DSH520096EC	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Procedure Center - Surgery	10180 Washington Ave	Mount Pleasant	WI	Approved
DSH520096ED	Child	DSH	Ascension All Saints Hospital, Inc.	3805B TMS Therapy - Behavioral Health	3805B Spring Street	Racine	WI	Approved
DSH520096EE	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Anesthesia - Surgery	10180 Washington Ave	Mount Pleasant	WI	Approved
DSH520096EF	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Surgery - Surgery	10180 Washington Ave	Mount Pleasant	WI	Approved
DSH520096EG	Child	DSH	Ascension All Saints Hospital, Inc.	Mount Pleasant Urgent Care - Urgent Care	10180 Washington Ave	Mount Pleasant	WI	Approved
DSH520096EH	Child	DSH	Ascension All Saints Hospital, Inc.	Union Grove Pain Management - Pain Management	1120 Main St	Union Grove	WI	Approved
DSH520096F	Child	DSH	Ascension All Saints Hospital, Inc.	COUNSELING CENTER - RACINE	1333 College Avenue	RACINE	WI	Active
DSH520096G	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	COUNSELING CENTER - BURLINGTON	152 EAST STATE STREET	BURLINGTON	WI	Terminated
DSH520096H	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	COUNSELING CENTER - KENOSHA	10117 74TH STREET	KENOSHA	WI	Terminated
DSH520096J	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	WHEATON FRANCISCAN MEDICAL GROUP	ONE MAIN STREET	RACINE	WI	Terminated
DSH520096M	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS		1244 WISCONSIN AVENUE	RACINE	WI	Terminated
DSH520096N	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS		3811 SPRING STREET - ATRIUM	RACINE	WI	Terminated
DSH520096O	Child	DSH	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS		3807 SPRING STREET	RACINE	WI	Terminated
DSH520096P	Child	DSH	Ascension All Saints Hospital, Inc.	WHEATON FRANCISCAN HEALTHCARE-All Saints / WFMG STURTEVANT FAMILY MEDICINE	10340 Washington Ave	Sturtevant	WI	Terminated
DSH520096Q	Child	DSH	Ascension All Saints Hospital, Inc.	Medical Oncology	3809 SPRING STREET	RACINE	WI	Active
DSH520096R	Child	DSH	Ascension All Saints Hospital, Inc.	WFH All Saints – WFMG – Sturtevant Occupational Health	10340 Washington Avenue	Sturtevant	WI	Terminated
DSH520096S	Child	DSH	Ascension All Saints Hospital, Inc.	3805B Neurology	3805B Spring Street	Racine	WI	Active
DSH520096T	Child	DSH	Ascension All Saints Hospital, Inc.	3805A ENDOCRINOLOGY	3805A SPRING STREET	RACINE	WI	Active
DSH520096U	Child	DSH	Ascension All Saints Hospital, Inc.	All Saints Medical Center / WFH All Saints PAIN MANAGEMENT	3805B Spring St	Racine	WI	Active
DSH520096V	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mount Pleasant / WFMG CARDIOLOGY	4328 Old Green Bay Road	Mount Pleasant	WI	Active
DSH520096W	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mount Pleasant / WFMG GASTROENTEROLOGY	4328 Old Green Bay Road	Mount Pleasant	WI	Terminated
DSH520096X	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mount Pleasant / WFMG PEDIATRICS	4328 Old Green Bay Road	Mount Pleasant	WI	Terminated
DSH520096Y	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saint-Mount Pleasant / WFMG ADULT MEDICINE	4328 Old Green Bay Road	Mount Pleasant	WI	Active
DSH520096Z	Child	DSH	Ascension All Saints Hospital, Inc.	Wheaton Franciscan Medical Group-All Saints-Mount Pleasant / WFMG FAMILY MEDICINE	4328 Old Green Bay Road	Mount Pleasant	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4144996174	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4145227533	11/28/2023 2:37 PM
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	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascension WI 4148746268	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4144996174	10/15/2020 7:25 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/19/2018 12:00:00 AM	1/16/2018 11:06 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/16/2018 11:06 AM
Terminations	Termination Date	Update	Termination Request		4/1/2018 12:00:00 AM	1/16/2018 11:06 AM
Terminations	Termination Effective Date	Update	Termination Request		1/19/2018 12:00:00 AM	1/16/2018 11:06 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	1/16/2018 11:06 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/28/2017 4:56:58 PM	11/28/2017 4:56 PM
Contacts	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascesnion WI 4148746268	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascension WI 4148746268	10/10/2017 2:09 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	Primary Contact	Update		Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy 4148746268	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascesnion WI 4148746268	9/18/2017 5:55 PM
Contacts	Authorizing Official	Insert			Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	8/13/2017 7:38 PM
Contacts	Primary Contact	Update		Boman, David Director of Pharmacy 2626874145	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy 4148746268	8/13/2017 7:38 PM
Contacts	Signed By	Insert			Gresham, James Senior Vice President 4148746277	7/6/2017 1:16 PM
Addresses	Main Address	Insert			1 MAIN ST RACINE, WI 53403-1079	5/18/2017 11:48 AM
Contacts	Primary Contact	Insert			Boman, David Director of Pharmacy 2626874145	10/3/2016 9:59 PM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 12:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/4/2015 8:14 AM
Medicaid Billing	Medicaid: Number	Insert			32833500	9/4/2015 8:14 AM
Medicaid Billing	Medicaid: State	Insert			WI	9/4/2015 8:14 AM
Medicaid Billing	NPI: Number	Insert			1609881077	9/4/2015 8:14 AM
Details	Last Recertification Date	Update			9/4/2015 12:00:00 AM	9/4/2015 8:14 AM
Dates	Participating Approval Date	Update			5/22/2015 12:00:00 AM	5/22/2015 3:09 PM
Details	State	Update		Pending	Active	5/22/2015 3:09 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/22/2015 3:09 PM
Details	340B ID	Update		DSH520096AU	DSH520096AT	5/13/2015 2:53 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51631	DSH520096AU	4/22/2015 2:42 PM
Details	Entity Name	Update		WHEATON FRANCISCAN HEALTHCARE - ALL	WHEATON FRANCISCAN HEALTHCARE - ALL SAINTS	4/22/2015 2:42 PM
Details	Entity Subname	Update		ONE MAIN CLINIC / WFMG CHIROPRACTIC SERVICES-ONE MAIN ST Clinic	WFMG -ONE MAIN CLINIC / CHIROPRACTIC SERVICES	4/22/2015 2:42 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51631	4/15/2015 2:23 PM
Details	Last Recertification Date	Insert				4/15/2015 2:23 PM
Details	Grant Number	Insert				4/15/2015 2:23 PM
Details	340B ID	Insert				4/15/2015 2:23 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2015 2:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2015 2:23 PM
Details	Medicare Provider Number	Insert			520096	4/15/2015 2:23 PM
Details	Entity Name	Insert			WHEATON FRANCISCAN HEALTHCARE - ALL	4/15/2015 2:23 PM
Details	Program Code	Insert			DSH	4/15/2015 2:23 PM
Details	Entity Subname	Insert			ONE MAIN CLINIC / WFMG CHIROPRACTIC SERVICES-ONE MAIN ST Clinic	4/15/2015 2:23 PM
Dates	Participating Approval Date	Insert				4/15/2015 2:23 PM
Details	State	Insert			Pending	4/15/2015 2:23 PM
Dates	Registration Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 2:23 PM
Dates	Signed By Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 2:23 PM
Dates	Start Date	Insert				4/15/2015 2:23 PM
Terminations	Termination Comments	Insert				4/15/2015 2:23 PM
Terminations	Termination Date	Insert				4/15/2015 2:23 PM
Terminations	Termination Effective Date	Insert				4/15/2015 2:23 PM
Terminations	Termination Reason	Insert				4/15/2015 2:23 PM