Covered Entity Details

DSH140150N UNIVERSITY OF ILLINOIS HOSPITAL (Active) - information as of 6/26/2025 3:12:59 AM

Main Details

Name

UNIVERSITY OF ILLINOIS HOSPITAL

Subdivision Name

Outpatient Care Center / Neurosciences Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140150N

Medicare Provider Number

140150

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/20/2015

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

University of Illinois Hospital
Laurence Appel, Chief Financial Officer
(312) 996-3620

Primary Contact

University of Illinois Hospital
Christina Maria Carrizales Cortez, Assistant Director, 340B Compliance
(312) 996-3692

Addresses

Street Address

1801 W. Taylor St., Suite 4-E
Chicago, IL 60612

Billing Address

University of Illinois
Invoice Processing Center
PO Box 820
Rantoul, IL 61866

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
IN	100035430A	1861431751
WI	80495000	1861431751
IL	376000511401,1861431751,1942244645,376000511011	1861431751,1942244645
CO	79820271	1861431751
IA	0590968	1861431751
KY	7100543520	1861431751
MI	1861431751	1861431751
MO	011768306	1861431751
MS	007120543	1861431751

Shipping Addresses

Shipping Address 1

University of Illinois SCB Pharmacy
1009 S. Wood Street, Suite 1025
Chicago, IL 60612

Shipping Address 2

University of Illinois Wood Street/PCC Pharmacy
840 S. Wood Street, Room 163 (M/C 884)
Chicago, IL 60612

Shipping Address 3

University of Illinois Outpatient Care Center Pharmacy
1801 W. Taylor, Street Suite 3B (M/C 884)
Chicago, IL 60612

Shipping Address 4

University of Illinois Oncology Pharmacy
1801 W. Taylor Street, Room 1411 (M/C 884)
Chicago, IL 60612

Shipping Address 5

University of Illinois Dermatology Pharmacy
1801 W. Taylor Street, Room 3402 (M/C 884)
Chicago, IL 60612

Shipping Address 6

University of Illinois
Hospital Pharmacy
912 S. Paulina Street
Chicago, IL 60612

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
DSH140150A	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UI HEALTH Ambulatory Care Clinics	1801 W. TAYLOR STREET	CHICAGO	IL	Terminated
DSH140150AA	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Psychiatry Clinic	1747 W. Roosevelt Rd., 1st Fl. Suite 160A	Chicago	IL	Active
DSH140150AB	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Psychiatry Clinic - Adult	912 S. Wood Street	Chicago	IL	Active
DSH140150AC	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Renal Dialysis Center	1859 W. Taylor Street	Chicago	IL	Active
DSH140150AD	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Arthritis & Kidney Clinic	1801 W. Taylor St. Suite 3-D	Chicago	IL	Active
DSH140150AE	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - HEART CENTER AT ROOSEVELT	1640 W ROOSEVELT RD	CHICAGO	IL	Active
DSH140150AF	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center/Family Center for Infectious Disease	1801 W. Taylor St., Suite 3	Chicago	IL	Active
DSH140150AG	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Lions Eye Institute	1905 West Taylor Street, First Floor	Chicago	IL	Active
DSH140150AH	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Radiology	1009 S. Wood St.	Chicago	IL	Active
DSH140150AJ	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Pre-Post Op APEC Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AK	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Ophthalmology Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AL	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB GI Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150AM	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Anesthesia	1009 S. Wood St.	Chicago	IL	Active
DSH140150AN	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Perioperative Services	1009 S. Wood St.	Chicago	IL	Active
DSH140150AP	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB GI Diagnostic Svcs	1009 S. Wood St.	Chicago	IL	Active
DSH140150AQ	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building - SCB Urology Clinic	1009 S. Wood St.	Chicago	IL	Active
DSH140150B	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Liver Clinic	1801 W. Taylor St., Suite 1B	Chicago	IL	Active
DSH140150C	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Nutrition & Wellness Center	1801 W. Taylor St., Suite 1-C	Chicago	IL	Active
DSH140150D	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Therapeutic Infusion Services	1801 W. Taylor St., Suite 1-E	Chicago	IL	Active
DSH140150E	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Orthopedic Clinic	1801 W. Taylor St., Suite 2A	Chicago	IL	Active
DSH140150F	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Child & Youth Center	1801 W. Taylor St., Suite 2E	Chicago	IL	Active
DSH140150G	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Primary Care Plus Clinic	1801 W. Taylor St., Suite 3-AA	Chicago	IL	Active
DSH140150H	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Heart & Lung Center	1801 W. Taylor St., Suite 3-C	Chicago	IL	Active
DSH140150J	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Dermatology Clinic	1801 W. Taylor St., Suite 3-E	Chicago	IL	Active
DSH140150K	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Surgery Center	1801 W. Taylor St., Suite 3-F	Chicago	IL	Active
DSH140150L	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Center for Women's Health	1801 W. Taylor St., Suite 4-C	Chicago	IL	Active
DSH140150M	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Center for Women's Health	1801 W. Taylor Street, Suite 4-A	Chicago	IL	Active
DSH140150N	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Neurosciences Center	1801 W. Taylor St., Suite 4-E	Chicago	IL	Active
DSH140150P	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Internal Medicine Clinic	1801 W. Taylor St., Suite 3-A	Chicago	IL	Active
DSH140150Q	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Radiation Therapy	1801 W. Taylor St., Concourse	Chicago	IL	Active
DSH140150R	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Radiology MRI	1801 W. Taylor St. Suite 1-A	Chicago	IL	Active
DSH140150S	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - West Harrison Imaging Center	2242 W. Harrison St., Suite 103	Chicago	IL	Active
DSH140150T	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Mile Square Imaging Center	1220 S. Wood Street, Room 1047	Chicago	IL	Active
DSH140150U	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Telemedicine IDOC	1940 W. Taylor St., 3rd Floor	Chicago	IL	Active
DSH140150V	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Sleep Disorders Laboratory	2242 W. Harrison St., Suite 104	Chicago	IL	Active
DSH140150W	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Outpatient Care Center / Ophthalomology Center	1855 W. Taylor St.	Chicago	IL	Active
DSH140150X	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building / Transplant Center	1009 S. Wood Street, 2nd Floor SCB	Chicago	IL	Active
DSH140150Y	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	Specialty Care Building / Otolaryngology Clinic	1009 S. Wood Street, 6th Floor SCB	Chicago	IL	Active
DSH140150Z	Child	DSH	UNIVERSITY OF ILLINOIS HOSPITAL	UIH - Craniofacial Center	811 S. Paulina St., Suite 161	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Update	Change Request	University of Illinois Outpatient Care Center Pharmacy 1801 W. Taylor, Street Room Suite 3B (M/C 884) Chicago, IL 60612	University of Illinois Outpatient Care Center Pharmacy 1801 W. Taylor, Street Suite 3B (M/C 884) Chicago, IL 60612	6/2/2025 7:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/30/2024 6:43 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		007120543	8/30/2024 6:43 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	8/30/2024 6:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861431751	8/30/2024 6:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/30/2024 6:43 PM
Details	Last Recertification Date	Update	Recertification	9/5/2023 4:37:19 PM	8/30/2024 6:43:03 PM	8/30/2024 6:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/5/2023 4:37 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1861431751	9/5/2023 4:37 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/5/2023 4:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/5/2023 4:37 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1942244645	9/5/2023 4:37 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/5/2023 4:37 PM
Details	Last Recertification Date	Update	Recertification	9/13/2022 4:46:17 PM	9/5/2023 4:37:19 PM	9/5/2023 4:37 PM
Contacts	Authorizing Official	Update	AO Change Request	Zenn, Michael B. Chief Executive Officer University of Illinois Hospital 3123555706	Appel, Laurence Chief Financial Officer University of Illinois Hospital 3129963620	8/10/2023 6:24 AM
Contacts	Primary Contact	Update	Profile Change Request	Cortez, Christina Maria Carrizales 340B Compliance Coordinator University of Illinois Hospital 3129963692	Cortez, Christina Maria Carrizales Assistant Director, 340B Compliance University of Illinois Hospital 3129963692	5/10/2023 4:44 PM
Addresses	Shipping Address	Update	Change Request	University of Illinois Hospital Pharmacy 912 S. Paulina Street #C300 Chicago, IL 60612	University of Illinois Hospital Pharmacy 912 S. Paulina Street Chicago, IL 60612	1/17/2023 3:15 PM
Addresses	Shipping Address	Update	Change Request	University of Illinois Outpatient Care Center Pharmacy 1801 W. Taylor, Street Room 3003, Suite 3B (M/C 884) Chicago, IL 60612	University of Illinois Outpatient Care Center Pharmacy 1801 W. Taylor, Street Room Suite 3B (M/C 884) Chicago, IL 60612	1/17/2023 3:15 PM
Contacts	Primary Contact	Update	Group Change Request	Durley, Sandra F Senior Associate Director Ambulatory Pharmacy University of Illinois Hospital 3129964940	Cortez, Christina Maria Carrizales 340B Compliance Coordinator University of Illinois Hospital 3129963692	1/11/2023 10:34 AM
Addresses	Shipping Address	Update	Change Request	University of Illinois Taylor Street/EEI Pharmacy 1855 W. Taylor Street, Room 1071 (M/C 884) Chicago, IL 60612	University of Illinois SCB Pharmacy 1009 S. Wood Street, Suite 1025 Chicago, IL 60612	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		79820271	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0590968	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100543520	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		011768306	12/14/2022 9:25 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	12/14/2022 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/14/2022 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	12/14/2022 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	12/14/2022 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	12/14/2022 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861431751	12/14/2022 9:25 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	12/14/2022 9:25 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 4:42:52 PM	9/13/2022 4:46:17 PM	9/13/2022 4:46 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 9:58:03 AM	9/9/2021 4:42:52 PM	9/9/2021 4:42 PM
Addresses	Shipping Address	Insert	Group Change Request		University of Illinois Hospital Pharmacy 912 S. Paulina Street #C300 Chicago, IL 60612	8/6/2021 8:01 AM
Contacts	Authorizing Official	Update	Profile Change Request	Zenn, Michael B. CFO University of Illinois Hospital 3129963620	Zenn, Michael B. Chief Executive Officer University of Illinois Hospital 3123555706	8/6/2021 6:29 AM
Contacts	Primary Contact	Update	Profile Change Request	Durley, Sandra F Associate Director Ambulatory Pharmacy University of Illinois Hospital 3129964940	Durley, Sandra F Senior Associate Director Ambulatory Pharmacy University of Illinois Hospital 3129964940	8/4/2021 5:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861431751	9/10/2020 9:58 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/10/2020 9:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1942244645	9/10/2020 9:58 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/10/2020 9:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1861431751	9/10/2020 9:58 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/10/2020 9:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1861431751	9/10/2020 9:58 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/10/2020 9:58 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1942244645 ( )		9/10/2020 9:58 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1861431751 ( )		9/10/2020 9:58 AM
Details	Last Recertification Date	Update	Recertification	9/13/2019 1:17:25 PM	9/10/2020 9:58:03 AM	9/10/2020 9:58 AM
Details	Last Recertification Date	Update	Recertification	9/11/2018 8:04:53 AM	9/13/2019 1:17:25 PM	9/13/2019 1:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2018 8:04 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100035430A	9/11/2018 8:04 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/11/2018 8:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2018 8:04 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		80495000	9/11/2018 8:04 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2018 8:04 AM
Details	Last Recertification Date	Update	Recertification	11/30/2017 6:12:29 PM	9/11/2018 8:04:53 AM	9/11/2018 8:04 AM
Contacts	Signed By	Update	Recertification	Ghosh, Avijit CEO 3123555706	Ghosh, Avijit Interim Vice President and CFO Un iversity of Illinois System 2172650263	12/4/2017 1:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/30/2017 6:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		376000511011	11/30/2017 6:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	11/30/2017 6:12 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1861431751 ( )		11/30/2017 6:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942244645	11/30/2017 6:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861431751	11/30/2017 6:12 PM
Details	Last Recertification Date	Update	Recertification	9/7/2016 12:00:00 AM	11/30/2017 6:12:29 PM	11/30/2017 6:12 PM
Contacts	Primary Contact	Insert	Change Request		Durley, Sandra F Associate Director Ambulatory Pharmacy University of Illinois Hospital 3129964940	10/11/2017 2:01 PM
Contacts	Authorizing Official	Update		Zenn, Michael B. CFO 3129963620	Zenn, Michael B. CFO University of Illinois Hospital 3129963620	9/27/2017 11:35 AM
Contacts	Signed By	Insert			Ghosh, Avijit CEO 3123555706	2/22/2017 9:59 AM
Contacts	Authorizing Official	Insert			Zenn, Michael B. CFO 3129963620	2/22/2017 9:59 AM
Addresses	Main Address	Insert			1801 W. Taylor St., Suite 4-E Chicago, IL 60612	2/22/2017 9:59 AM
Addresses	Billing Address	Insert			University of Illinois Invoice Processing Center PO Box 820 Rantoul, IL 61866	2/22/2017 9:59 AM
Addresses	Shipping Address	Insert			University of Illinois Oncology Pharmacy 1801 W. Taylor Street, Room 1411 (M/C 884) Chicago, IL 60612	2/22/2017 9:59 AM
Addresses	Shipping Address	Insert			University of Illinois Wood Street/PCC Pharmacy 840 S. Wood Street, Room 163 (M/C 884) Chicago, IL 60612	2/22/2017 9:59 AM
Addresses	Shipping Address	Insert			University of Illinois Taylor Street/EEI Pharmacy 1855 W. Taylor Street, Room 1071 (M/C 884) Chicago, IL 60612	2/22/2017 9:59 AM
Addresses	Shipping Address	Insert			University of Illinois Dermatology Pharmacy 1801 W. Taylor Street, Room 3402 (M/C 884) Chicago, IL 60612	2/22/2017 9:59 AM
Addresses	Shipping Address	Insert			University of Illinois Outpatient Care Center Pharmacy 1801 W. Taylor, Street Room 3003, Suite 3B (M/C 884) Chicago, IL 60612	2/22/2017 9:59 AM
Details	Last Recertification Date	Update		9/8/2015 12:00:00 AM	9/7/2016 12:00:00 AM	9/7/2016 11:16 AM
Medicaid Billing	Medicaid: Number	Update		37-600511-041	376000511401	9/8/2015 2:29 PM
Details	Last Recertification Date	Update			9/8/2015 12:00:00 AM	9/8/2015 2:29 PM
Dates	Participating Approval Date	Update			5/20/2015 12:00:00 AM	5/20/2015 2:36 PM
Details	State	Update		Pending	Active	5/20/2015 2:36 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/20/2015 2:36 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51697	DSH140150N	4/20/2015 8:46 AM
Details	Entity Name	Update		BOARD OF TRUSTEES OF THE UNIVERSITY	UNIVERSITY OF ILLINOIS HOSPITAL	4/20/2015 8:46 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51697	4/15/2015 4:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/15/2015 4:30 PM
Medicaid Billing	Medicaid: Number	Insert			37-600511-041	4/15/2015 4:30 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/15/2015 4:30 PM
Medicaid Billing	NPI: Number	Insert			1861431751	4/15/2015 4:30 PM
Details	Last Recertification Date	Insert				4/15/2015 4:30 PM
Details	Grant Number	Insert				4/15/2015 4:30 PM
Details	340B ID	Insert				4/15/2015 4:30 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2015 4:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2015 4:30 PM
Details	Medicare Provider Number	Insert			140150	4/15/2015 4:30 PM
Details	Entity Name	Insert			BOARD OF TRUSTEES OF THE UNIVERSITY	4/15/2015 4:30 PM
Details	Program Code	Insert			DSH	4/15/2015 4:30 PM
Details	Entity Subname	Insert			Outpatient Care Center / Neurosciences Center	4/15/2015 4:30 PM
Dates	Participating Approval Date	Insert				4/15/2015 4:30 PM
Details	State	Insert			Pending	4/15/2015 4:30 PM
Dates	Registration Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 4:30 PM
Dates	Signed By Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 4:30 PM
Dates	Start Date	Insert				4/15/2015 4:30 PM
Terminations	Termination Comments	Insert				4/15/2015 4:30 PM
Terminations	Termination Date	Insert				4/15/2015 4:30 PM
Terminations	Termination Effective Date	Insert				4/15/2015 4:30 PM
Terminations	Termination Reason	Insert				4/15/2015 4:30 PM