Covered Entity Details

DSH140206L Humboldt Park Health (Active) - information as of 6/7/2025 6:08:57 AM

Main Details

Name

Humboldt Park Health

Subdivision Name

Corporate Health

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140206L

Medicare Provider Number

140206

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/19/2016

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Humboldt Park Health
Kenneth Coe, Chief Financial Officer
(773) 292-8200 Ext: 8208

Primary Contact

Humboldt Park Health
Ravina Gandhakwala, Director of Pharmacy
(773) 292-8200 Ext: 7380

Addresses

Street Address

1044N MOZART ST 100
CHICAGO, IL 60622-3644

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	361564290001	1972594877

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
DSH140206E	Child	DSH	Humboldt Park Health	OP Oncology/ Infusion Center	1044 N. Mozart Ave	Chicago	IL	Active
DSH140206F	Child	DSH	Humboldt Park Health	Women's Health Specialists	1044 N. Mozart Ave	Chicago	IL	Active
DSH140206G	Child	DSH	Humboldt Park Health	New Life Clinic	1666 N California Ave	Chicago	IL	Active
DSH140206H	Child	DSH	NORWEGIAN AMERICAN HOSPITAL	Norwegian American Hospital INC / Nurse Midwife Program	1044 N Mozart Ave	Chicago	IL	Terminated
DSH140206J	Child	DSH	Humboldt Park Health	Primary Care Practice	1044N MOZART ST 100	CHICAGO	IL	Active
DSH140206K	Child	DSH	Humboldt Park Health	Neurologist Professional Services	1044N MOZART ST 405	CHICAGO	IL	Active
DSH140206L	Child	DSH	Humboldt Park Health	Corporate Health	1044N MOZART ST 100	CHICAGO	IL	Active
DSH140206M	Child	DSH	Humboldt Park Health	Physician Specialty and Eye Center	1044N MOZART ST 500	CHICAGO	IL	Terminated
DSH140206N	Child	DSH	Humboldt Park Health	Intensive Outpatient Program	1044 N Mozart Ave	Chicago	IL	Active
DSH140206P	Child	DSH	Humboldt Park Health	NORWEGIAN AMERICAN HOSPITAL INC / Surgical Consultants	1044N MOZART ST 502	CHICAGO	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Garvey, Thomas Chief Financial Officer Humboldt Park Health 7732928200-8208	Coe, Kenneth Chief Financial Officer Humboldt Park Health 7732928200-8208	5/14/2025 1:03 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 4:21:13 PM	9/5/2024 3:11:57 PM	9/5/2024 3:11 PM
Details	Last Recertification Date	Update	Recertification	9/19/2022 8:23:00 AM	9/6/2023 4:21:13 PM	9/6/2023 4:21 PM
Contacts	Authorizing Official	Update	Change Request	Hendren, Kenneth Clifford CFO Humboldt Park Health 7732928208	Garvey, Thomas Chief Financial Officer Humboldt Park Health 7732928200-8208	4/12/2023 7:22 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 4:54:41 PM	9/19/2022 8:23:00 AM	9/19/2022 8:23 AM
Details	Entity Subname	Update	Recertification	NAH Corporate Health	Corporate Health	9/19/2022 8:23 AM
Contacts	Authorizing Official	Update	AO Change Request	Garvey, Thomas Interim Chief Financial Officer Humboldt Park Health 7732928200-8208	Hendren, Kenneth Clifford CFO Humboldt Park Health 7732928208	6/22/2022 4:44 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972594877	4/14/2022 2:57 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	4/14/2022 2:57 PM
Contacts	Authorizing Official	Update	Change Request	Porter, Jim Chief Financial Officer Humboldt Park Health 7732928200-8208	Garvey, Thomas Interim Chief Financial Officer Humboldt Park Health 7732928200-8208	3/22/2022 6:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Gandhakwala, Ravina Interim Pharmacy Director Humboldt Park Health 7732928200-7380	Gandhakwala, Ravina Director of Pharmacy Humboldt Park Health 7732928200-7380	3/18/2022 1:00 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 3:27:14 PM	8/16/2021 4:54:41 PM	8/16/2021 4:54 PM
Contacts	Primary Contact	Update	Group Change Request	Aziz, Aleem Director of Pharmacy Norwegian American Hospital 7732927380	Gandhakwala, Ravina Interim Pharmacy Director Humboldt Park Health 7732928200-7380	8/16/2021 9:52 AM
Details	Entity Name	Update	Change Request	NORWEGIAN AMERICAN HOSPITAL	Humboldt Park Health	8/10/2021 7:40 AM
Contacts	Authorizing Official	Update	Change Request	Gallagher, Sean B Chief Finanical Officer Norwegian American Hospital 7732928208	Porter, Jim Chief Financial Officer Humboldt Park Health 7732928200-8208	5/28/2021 10:57 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1972594877 ( )		8/25/2020 3:27 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 10:32:54 AM	8/25/2020 3:27:14 PM	8/25/2020 3:27 PM
Contacts	Authorizing Official	Update	Change Request	Pagliuzza, Greg Chief Financial Officer Norwegian American Hospital 3123583046	Gallagher, Sean B Chief Finanical Officer Norwegian American Hospital 7732928208	6/3/2020 3:23 PM
Contacts	Authorizing Official	Update	Change Request	Krugel, Gary CFO Norwegian American Hospital 7732928208	Pagliuzza, Greg Chief Financial Officer Norwegian American Hospital 3123583046	1/29/2020 2:50 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 9:27:36 AM	8/27/2019 10:32:54 AM	8/27/2019 10:32 AM
Details	Last Recertification Date	Update	Recertification	11/30/2017 3:56:46 PM	8/23/2018 9:27:36 AM	8/23/2018 9:27 AM
Details	Entity Subname	Update	Change Request	Occupational/Employee Health	NAH Corporate Health	2/7/2018 8:48 AM
Contacts	Primary Contact	Insert	Recertification		Aziz, Aleem Director of Pharmacy Norwegian American Hospital 7732927380	11/30/2017 3:56 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/30/2017 3:56:46 PM	11/30/2017 3:56 PM
Contacts	Authorizing Official	Update		Krugel, Gary CFO 7732928208	Krugel, Gary CFO Norwegian American Hospital 7732928208	10/2/2017 4:05 PM
Contacts	Signed By	Update		Krugel, Gary CFO 7732928208	Krugel, Gary CFO Norwegian American Hospital 7732928208	10/2/2017 4:05 PM
Contacts	Authorizing Official	Insert			Krugel, Gary CFO 7732928208	7/20/2017 2:28 PM
Contacts	Signed By	Insert			Krugel, Gary CFO 7732928208	7/20/2017 2:28 PM
Addresses	Main Address	Insert			1044N MOZART ST 100 CHICAGO, IL 60622-3644	9/1/2016 2:53 PM
Details	Last Recertification Date	Update			9/1/2016 12:00:00 AM	9/1/2016 2:53 PM
Dates	Participating Approval Date	Update			2/19/2016 12:00:00 AM	2/19/2016 1:13 PM
Details	State	Update		Pending	Active	2/19/2016 1:13 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/19/2016 1:13 PM
Details	Entity Subname	Update		Occupation Employee Health	Occupational/Employee Health	2/9/2016 5:16 PM
Details	Entity Subname	Update		Healthworks	Occupation Employee Health	2/5/2016 11:29 AM
Details	Entity Subname	Update		Healthworks / Healthworks	Healthworks	2/5/2016 8:38 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57547	DSH140206L	2/1/2016 12:06 PM
Details	Entity Subname	Update		NORWEGIAN AMERICAN HOSPITAL INC / Healthworks	Healthworks / Healthworks	2/1/2016 12:06 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57547	1/13/2016 2:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/13/2016 2:14 PM
Medicaid Billing	Medicaid: Number	Insert			361564290001	1/13/2016 2:14 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/13/2016 2:14 PM
Medicaid Billing	NPI: Number	Insert			1972594877	1/13/2016 2:14 PM
Details	Last Recertification Date	Insert				1/13/2016 2:14 PM
Details	Grant Number	Insert				1/13/2016 2:14 PM
Details	340B ID	Insert				1/13/2016 2:14 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 2:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 2:14 PM
Details	Medicare Provider Number	Insert			140206	1/13/2016 2:14 PM
Details	Entity Name	Insert			NORWEGIAN AMERICAN HOSPITAL	1/13/2016 2:14 PM
Details	Program Code	Insert			DSH	1/13/2016 2:14 PM
Details	Entity Subname	Insert			NORWEGIAN AMERICAN HOSPITAL INC / Healthworks	1/13/2016 2:14 PM
Dates	Participating Approval Date	Insert				1/13/2016 2:14 PM
Details	State	Insert			Pending	1/13/2016 2:14 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 2:14 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 2:14 PM
Dates	Start Date	Insert				1/13/2016 2:14 PM
Terminations	Termination Comments	Insert				1/13/2016 2:14 PM
Terminations	Termination Date	Insert				1/13/2016 2:14 PM
Terminations	Termination Effective Date	Insert				1/13/2016 2:14 PM
Terminations	Termination Reason	Insert				1/13/2016 2:14 PM