| Contacts | Authorizing Official | Update | Change Request | Knepp, Keith E
President
Methodist Medical Center of Illinois
3096712528 | Hesch, Dennis P.
Executive VP and CFO
Carle Foundation Hospital
2173268231 | 1/30/2025 1:04 PM |
| Contacts | Primary Contact | Update | PC Change Request | Driscoll, Alician
Director, Pharmacy Services
Methodist Medical Center of Illinois
3092563683 | Koch, Katie
Director of 340B and Retail Pharmacy Operations
Carle Foundation Hospital
2179047016 | 1/15/2025 10:59 AM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2023 4:06:49 PM | 8/30/2024 2:45:15 PM | 8/30/2024 2:45 PM |
| Contacts | Primary Contact | Update | PC Change Request | Driscoll, Alician B.
Regional Director of Pharmacy
Methodist Medical Center of Illinois
3096725625 | Driscoll, Alician
Director, Pharmacy Services
Methodist Medical Center of Illinois
3092563683 | 8/26/2024 11:07 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Driscoll, Alician
Director, Pharmacy Services
Methodist Medical Center of Illinois
3092563683 | Knepp, Keith E
President
Methodist Medical Center of Illinois
3096712528 | 12/27/2023 6:55 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Knepp, Keith E.
CEO
Methodist Medical Center of Illinois
3096712528 | Driscoll, Alician
Director, Pharmacy Services
Methodist Medical Center of Illinois
3092563683 | 12/22/2023 8:22 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 3:44:15 PM | 9/11/2023 4:06:49 PM | 9/11/2023 4:06 PM |
| Details | Entity Subname | Update | Recertification | UnityPoint Health - Endocrinology, Diabetes, and Metabolism | Carle Health Methodist Atrium- Endocrinology and Diabetes | 9/11/2023 4:06 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2021 1:24:14 PM | 8/30/2022 3:44:15 PM | 8/30/2022 3:44 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2020 9:46:46 AM | 9/2/2021 1:24:14 PM | 9/2/2021 1:24 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1184670663 ( ) | | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1164474755 | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1184670663 | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1275583155 | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1982656575 | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 9/3/2020 9:46 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1164474755 ( ) | | 9/3/2020 9:46 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2019 4:50:04 PM | 9/3/2020 9:46:46 AM | 9/3/2020 9:46 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Quin, Robert A.
Chief Financial Officer
Methodist Medical Center of Illinois
3096724893 | Knepp, Keith E.
CEO
Methodist Medical Center of Illinois
3096712528 | 4/30/2020 2:14 PM |
| Contacts | Primary Contact | Update | Change Request | Hersemann, Joseph Michael
Regional Pharmacy IS Coordinator
Methodist Medical Center of Illinois
3096836257 | Driscoll, Alician B.
Regional Director of Pharmacy
Methodist Medical Center of Illinois
3096725625 | 12/18/2019 7:38 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2018 2:47:17 PM | 8/29/2019 4:50:04 PM | 8/29/2019 4:50 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Knepp, Keith E.
CEO
Methodist Medical Center of Illinois
3096712528 | Quin, Robert A.
Chief Financial Officer
Methodist Medical Center of Illinois
3096724893 | 8/7/2019 10:32 AM |
| Contacts | Primary Contact | Update | Change Request | Taylor, Ryan
Director of Pharmacy Services
Methodist Medical Center of Illinois
3096725635 | Hersemann, Joseph Michael
Regional Pharmacy IS Coordinator
Methodist Medical Center of Illinois
3096836257 | 8/5/2019 1:44 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Knepp, Keith E.
EVP & Chief Operating Officer
Methodist Medical Center of Illinois
3096712528 | Knepp, Keith E.
CEO
Methodist Medical Center of Illinois
3096712528 | 4/15/2019 2:50 PM |
| Contacts | Signed By | Update | Profile Change Request | Knepp, Keith E.
EVP & Chief Operating Officer
Methodist Medical Center of Illinois
3096712528 | Knepp, Keith E.
CEO
Methodist Medical Center of Illinois
3096712528 | 4/15/2019 2:50 PM |
| Addresses | Billing Address | Insert | Change Request | | METHODIST MEDICAL CENTER OF ILLINOIS
221 NE Glen Oak Ave.
Peoria, IL 61636 | 3/11/2019 2:39 PM |
| Addresses | Shipping Address | Insert | Change Request | | METHODIST MEDICAL CENTER OF ILLINOIS
221 NE Glen Oak Ave.
Peoria, IL 61636 | 3/11/2019 2:39 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1184670663 | 3/11/2019 2:39 PM |
| Details | Last Recertification Date | Update | Recertification | 11/20/2017 11:17:13 AM | 8/27/2018 2:47:17 PM | 8/27/2018 2:47 PM |
| Addresses | Main Address | Update | Change Request |
900 Main St. STE 100
Peoria, IL 61602 |
900 Main St. STE 470
Peoria, IL 61602 | 7/3/2018 2:09 PM |
| Details | Entity Subname | Update | Change Request | UnityPoint Health Endocrinology Clinic | UnityPoint Health - Endocrinology, Diabetes, and Metabolism | 1/5/2018 10:50 AM |
| Details | Entity Name | Update | Recertification | METHODIST MEDICAL CTR OF ILLINOIS | METHODIST MEDICAL CENTER OF ILLINOIS | 11/20/2017 11:31 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2016 12:00:00 AM | 11/20/2017 11:17:13 AM | 11/20/2017 11:17 AM |
| Details | Entity Subname | Update | Change Request | Diabetes Care Center / Diabetes Care | UnityPoint Health Endocrinology Clinic | 10/19/2017 4:17 PM |
| Addresses | Main Address | Update | OPA Edit |
900 Main St. STE 210
Peoria, IL 61602 |
900 Main St. STE 100
Peoria, IL 61602 | 10/18/2017 12:22 PM |
| Contacts | Authorizing Official | Update | | Knepp, Keith E.
EVP & Chief Operating Officer
3096712528 | Knepp, Keith E.
EVP & Chief Operating Officer
Methodist Medical Center of Illinois
3096712528 | 9/29/2017 9:51 AM |
| Contacts | Signed By | Update | | Knepp, Keith E.
EVP & Chief Operating Officer
3096712528 | Knepp, Keith E.
EVP & Chief Operating Officer
Methodist Medical Center of Illinois
3096712528 | 9/29/2017 9:51 AM |
| Contacts | Primary Contact | Update | | Taylor, Ryan
Director of Pharmacy Services
3096725635 | Taylor, Ryan
Director of Pharmacy Services
Methodist Medical Center of Illinois
3096725635 | 9/29/2017 9:44 AM |
| Addresses | Main Address | Insert | | |
900 Main St. STE 210
Peoria, IL 61602 | 8/30/2016 11:17 AM |
| Contacts | Authorizing Official | Insert | | | Knepp, Keith E.
EVP & Chief Operating Officer
3096712528 | 8/30/2016 11:17 AM |
| Contacts | Signed By | Insert | | | Knepp, Keith E.
EVP & Chief Operating Officer
3096712528 | 8/30/2016 11:17 AM |
| Contacts | Primary Contact | Insert | | | Taylor, Ryan
Director of Pharmacy Services
3096725635 | 8/30/2016 11:17 AM |
| Details | Last Recertification Date | Update | | | 8/30/2016 12:00:00 AM | 8/30/2016 11:17 AM |
| Dates | Participating Approval Date | Update | | | 5/20/2016 12:00:00 AM | 5/20/2016 4:47 PM |
| Details | State | Update | | Pending | Active | 5/20/2016 4:47 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 5/20/2016 4:47 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_60124 | DSH140209D | 4/28/2016 7:09 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_60124 | 4/13/2016 4:16 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/13/2016 4:16 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 37-0661223 | 4/13/2016 4:16 PM |
| Medicaid Billing | Medicaid: State | Insert | | | IL | 4/13/2016 4:16 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1164474755 | 4/13/2016 4:16 PM |
| Details | Last Recertification Date | Insert | | | | 4/13/2016 4:16 PM |
| Details | Grant Number | Insert | | | | 4/13/2016 4:16 PM |
| Details | 340B ID | Insert | | | | 4/13/2016 4:16 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/13/2016 4:16 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/13/2016 4:16 PM |
| Details | Medicare Provider Number | Insert | | | 140209 | 4/13/2016 4:16 PM |
| Details | Entity Name | Insert | | | METHODIST MEDICAL CTR OF ILLINOIS | 4/13/2016 4:16 PM |
| Details | Program Code | Insert | | | DSH | 4/13/2016 4:16 PM |
| Details | Entity Subname | Insert | | | Diabetes Care Center / Diabetes Care | 4/13/2016 4:16 PM |
| Dates | Participating Approval Date | Insert | | | | 4/13/2016 4:16 PM |
| Details | State | Insert | | | Pending | 4/13/2016 4:16 PM |
| Dates | Registration Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 4:16 PM |
| Dates | Signed By Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 4:16 PM |
| Dates | Start Date | Insert | | | | 4/13/2016 4:16 PM |
| Terminations | Termination Comments | Insert | | | | 4/13/2016 4:16 PM |
| Terminations | Termination Date | Insert | | | | 4/13/2016 4:16 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/13/2016 4:16 PM |
| Terminations | Termination Reason | Insert | | | | 4/13/2016 4:16 PM |