Covered Entity Details

DSH520177N FROEDTERT MEMORIAL LUTHERAN HOSPITAL (Active) - information as of 5/11/2025 11:42:36 PM

Main Details

Name

FROEDTERT MEMORIAL LUTHERAN HOSPITAL

Subdivision Name

FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Infectious Disease Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH520177N

Medicare Provider Number

520177

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/6/2016

Participating Start Date

1/1/2017

Participating Approval Date

10/18/2016

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Froedtert Memorial Lutheran Hospital
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925

Primary Contact

Froedtert Memorial Lutheran Hospital
Casey Drake Spitzer, 340B Manager
(920) 319-6030

Addresses

Street Address

840 N 87th St
Milwaukee, WI 53226-3522

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	11000400	1255334173
IA	939538	1255334173
IL	396105970001	1255334173
MI	40-4656061	1255334173
MN	923550700	1255334173

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
DSH520177D	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Tosa Health Center Radiology	1155 N. Mayfair Road	Wauwatosa	WI	Terminated
DSH520177E	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Sports Medicine Radiology	8700 Watertown Plank Road	Wauwatosa	WI	Terminated
DSH520177F	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Froedtert & Medical College of Wisconsin Reproductive Medicine Center	W129 N7055 Northfield Drive	Menomonee Falls	WI	Active
DSH520177G	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center - Infusion Clinic	4805 S. Moorland Road	New Berlin	WI	Active
DSH520177H	Child	DSH	FROEDTERT MEM. LUTHERAN HOSPT.	Plastic Surgery	8700 W. Watertown Plank Road	Milwaukee	WI	Terminated
DSH520177J	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center / Cancer Center Clinic	4805 South Moorland Road	New Berlin	WI	Active
DSH520177K	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Eye Institute	925 N. 87th Street	Milwaukee	WI	Active
DSH520177L	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Rheumatology Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177M	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Endocrine Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177N	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Infectious Disease Clinic	840 N 87th St	Milwaukee	WI	Active
DSH520177P	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Delivery Room & Labor Room	9000 West Wisconsin Avenue	Milwaukee	WI	Terminated
DSH520177Q	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER DREXEL TOWN SQUA - Drexel Cancer Center Clinic	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177R	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH INFUSION CLINIC DREXEL TOWN SQ - Drexel TSHC-General Infusion	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177S	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER MENOMONEE FALLS - Medical Oncology	W180N8085 TOWN HALL RD	MENOMONEE FALLS	WI	Active
DSH520177T	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER WEST BEND - Medical Oncology	3200 PLEASANT VALLEY RD	WEST BEND	WI	Active
DSH520177U	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH Clinic - Dermatology - Dermatology	601 N 99th Street	Milwaukee	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 7:36:20 PM	8/13/2024 10:57:11 AM	8/13/2024 10:57 AM
Contacts	Primary Contact	Update	Group Change Request	Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	Spitzer, Casey Drake 340B Manager Froedtert Memorial Lutheran Hospital 9203196030	5/7/2024 6:37 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 11:09:20 AM	8/29/2023 7:36:20 PM	8/29/2023 7:36 PM
Details	Last Recertification Date	Update	Recertification	8/20/2021 12:29:00 PM	8/24/2022 11:09:20 AM	8/24/2022 11:09 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 9:22:20 AM	8/20/2021 12:29:00 PM	8/20/2021 12:29 PM
Contacts	Primary Contact	Update	Profile Change Request	Olson, Jacob 340B Program Manager Froedtert and the Medical College of Wisconsin 2625325184	Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	5/17/2021 7:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:22 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/2/2020 9:22 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:22 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/2/2020 9:22 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:22 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/2/2020 9:22 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:22 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/2/2020 9:22 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:22 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/2/2020 9:22 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1255334173 ( )		9/2/2020 9:22 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 4:12:04 PM	9/2/2020 9:22:20 AM	9/2/2020 9:22 AM
Contacts	Primary Contact	Update	Change Request	Olender, Brian Director, Center for Medication Use and Finance Froedtert and the Medical College of Wisconsin 2625325162	Olson, Jacob 340B Program Manager Froedtert and the Medical College of Wisconsin 2625325184	12/13/2019 3:53 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 9:39:58 AM	8/20/2019 4:12:04 PM	8/20/2019 4:12 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 12:27:50 PM	8/17/2018 9:39:58 AM	8/17/2018 9:39 AM
Contacts	Authorizing Official	Update	Profile Change Request	Klauck, James Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	12/8/2017 1:55 PM
Contacts	Signed By	Update	Profile Change Request	Klauck, James Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	12/8/2017 1:55 PM
Contacts	Primary Contact	Update	Change Request	Johnson, Chad 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325160	Olender, Brian Director, Center for Medication Use and Finance Froedtert and the Medical College of Wisconsin 2625325162	12/8/2017 12:45 PM
Details	Entity Name	Update	Recertification	FROEDTERT MEM. LUTHERAN HOSPT.	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	11/8/2017 2:14 PM
Details	Last Recertification Date	Update	Recertification		11/7/2017 12:27:50 PM	11/7/2017 12:27 PM
Contacts	Authorizing Official	Update	OPA Add Contract Pharmacy	Klauck, James Vice President, Ancillary Services 4147771925	Klauck, James Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	9/29/2017 12:08 PM
Contacts	Signed By	Update	OPA Add Contract Pharmacy	Klauck, James Vice President, Ancillary Services 4147771925	Klauck, James Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	9/29/2017 12:08 PM
Contacts	Primary Contact	Update		Johnson, Chad 340B Program Manager 2625325160	Johnson, Chad 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325160	9/19/2017 3:54 PM
Contacts	Authorizing Official	Insert			Klauck, James Vice President, Ancillary Services 4147771925	7/17/2017 5:27 PM
Contacts	Signed By	Insert			Klauck, James Vice President, Ancillary Services 4147771925	7/17/2017 5:27 PM
Contacts	Primary Contact	Insert			Johnson, Chad 340B Program Manager 2625325160	6/14/2017 12:07 PM
Addresses	Main Address	Insert			840 N 87th St Milwaukee, WI 53226-3522	4/25/2017 6:01 PM
Dates	Participating Approval Date	Update			10/18/2016 12:00:00 AM	10/18/2016 2:30 PM
Details	State	Update		Pending	Active	10/18/2016 2:30 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	10/18/2016 2:30 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_72591	DSH520177N	10/7/2016 8:32 AM
Details	Entity Subname	Update		FROEDTERT MEMORIAL LUTHERAN HOSPITA / Infectious Disease Clinic	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Infectious Disease Clinic	10/7/2016 8:32 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_72591	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Number	Insert			11000400	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: State	Insert			WI	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Number	Insert			939538	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: State	Insert			IA	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Number	Insert			396105970001	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: State	Insert			IL	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Number	Insert			40-4656061	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: State	Insert			MI	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: Number	Insert			923550700	10/6/2016 2:54 PM
Medicaid Billing	Medicaid: State	Insert			MN	10/6/2016 2:54 PM
Medicaid Billing	NPI: Number	Insert			1255334173	10/6/2016 2:54 PM
Details	Last Recertification Date	Insert				10/6/2016 2:54 PM
Details	Grant Number	Insert				10/6/2016 2:54 PM
Details	340B ID	Insert				10/6/2016 2:54 PM
Details	Is Authorizing Official EHB Data	Insert				10/6/2016 2:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/6/2016 2:54 PM
Details	Medicare Provider Number	Insert			520177	10/6/2016 2:54 PM
Details	Entity Name	Insert			FROEDTERT MEM. LUTHERAN HOSPT.	10/6/2016 2:54 PM
Details	Program Code	Insert			DSH	10/6/2016 2:54 PM
Details	Entity Subname	Insert			FROEDTERT MEMORIAL LUTHERAN HOSPITA / Infectious Disease Clinic	10/6/2016 2:54 PM
Dates	Participating Approval Date	Insert				10/6/2016 2:54 PM
Details	State	Insert			Pending	10/6/2016 2:54 PM
Dates	Registration Date	Insert			10/6/2016 12:00:00 AM	10/6/2016 2:54 PM
Dates	Signed By Date	Insert			10/6/2016 12:00:00 AM	10/6/2016 2:54 PM
Dates	Start Date	Insert				10/6/2016 2:54 PM
Terminations	Termination Comments	Insert				10/6/2016 2:54 PM
Terminations	Termination Date	Insert				10/6/2016 2:54 PM
Terminations	Termination Effective Date	Insert				10/6/2016 2:54 PM
Terminations	Termination Reason	Insert				10/6/2016 2:54 PM