Covered Entity Details

DSH140228AD SWEDISH AMERICAN HOSPITAL (Active) - information as of 6/8/2025 1:07:04 AM

Main Details

Name

SWEDISH AMERICAN HOSPITAL

Subdivision Name

1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST ORTHO

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140228AD

Medicare Provider Number

140228

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/16/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/24/2017

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

SwedishAmerican Hospital
Patricia Ann DeWane, Vice President, Finance and Treasurer
(779) 696-4009

Primary Contact

SwedishAmerican Hospital
Tom Carey, Director of Pharmacy Services
(779) 696-4580

Addresses

Street Address

1340 CHARLES ST
STE 100
ROCKFORD, IL 61104

Billing Address

SwedishAmerican Hospital
1401 E STATE STREET
ROCKFORD, IL 61104

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	362222696001,362222696401,362222696007	1760542732,1588093942

Shipping Addresses

Shipping Address 1

SWEDISH AMERICAN HOSPITAL
1401 E STATE ST
ROCKFORD, IL 61104

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
DSH140228AA	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST HEADACHE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AB	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH BREAST CENTER (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228AC	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN MEDICAL GROUP STATE-Stateline Clinic-Lab	4282 E ROCKTON RD STE 100	ROSCOE	IL	Terminated
DSH140228AD	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST ORTHO	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AE	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AF	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - SAH NEUROSURGERY	1340 CHARLES ST	ROCKFORD	IL	Terminated
DSH140228AG	Child	DSH	SWEDISH AMERICAN HOSPITAL	209 9TH ST CLINIC - UWNI SAH RKFRD VASC SURG AT SAHS	209 9TH ST	ROCKFORD	IL	Active
DSH140228AH	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST INFECTIOUS DISEASE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AJ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH DIABETES	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228AK	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH UW HEART FAILURE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AL	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN RENAISSANCE PAVILION - SAH UW HEALTH SURGERY AT SA FOURTH FL - SAH UW HEALTH SURGERY AT SA	1340 CHARLES ST	ROCKFORD	IL	Terminated
DSH140228AM	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR INFUSION (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228AN	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH NONINVASIVE CARDIOLOGY (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228AP	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR UW PROVIDERS (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228AQ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH CARDIOVASCULAR AND THORACIC SURGERY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AR	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH MFM	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AS	Child	DSH	SWEDISH AMERICAN HOSPITAL	NINTH STREET CLINIC CENTER - UWNI SAH CARD PULM REHAB	209 NINTH ST	ROCKFORD	IL	Active
DSH140228AT	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH UW PEDIATRIC CARDIOLOGY	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AU	Child	DSH	SWEDISH AMERICAN HOSPITAL	WOMEN AND CHILDREN'S HOSPITAL - UWNI SAH PEDIATRIC SPECIALITIES	1350 CHARLES ST	ROCKFORD	IL	Active
DSH140228AV	Child	DSH	SWEDISH AMERICAN HOSPITAL	209 9TH ST CLINIC - UWNI SAH UWH GEN SURG AT SAHS	209 9TH ST	ROCKFORD	IL	Active
DSH140228AW	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH CLINICAL NUTRITION	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228AX	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH BREAST CTR	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AY	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST PHYSICAL THERAPY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228AZ	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC LAB	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BA	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH HEART CLINIC RAD	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BB	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH PAIN CLINIC (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228BC	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH NHC CHARLES ST NEUROLOGY	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BD	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH PULMONARY MEDICINE	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BE	Child	DSH	SWEDISH AMERICAN HOSPITAL	1340 CHARLES ST CLINIC - UWNI SAH UWH GEN SURG AT SAHS	1340 CHARLES ST	ROCKFORD	IL	Active
DSH140228BF	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI SAH HEART CLINIC	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228BG	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC ENT	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BH	Child	DSH	SWEDISH AMERICAN HOSPITAL	VILLAGREEN CLINIC - UWNI VILLAGREEN VIEW	6861 VILLAGREEN VIEW	ROCKFORD	IL	Active
DSH140228BJ	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC PODIATRY	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BK	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI NAC ALLERGY	1253 N ALPINE RD	ROCKFORD	IL	Active
DSH140228BL	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH PALLIATIVE CARE	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228BM	Child	DSH	SWEDISH AMERICAN HOSPITAL	IMMEDIATE CARE CLINIC - UWNI N MULFORD RD IMMEDIATE CARE	3775 N MULFORD RD	ROCKFORD	IL	Active
DSH140228BN	Child	DSH	SWEDISH AMERICAN HOSPITAL	NORTH ALPINE CLINIC - UWNI UROGYNECOLOGY	1253 N ALPINE RD	ROCKFORD	IL	Approved
DSH140228C	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR HEM ONC (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228D	Child	DSH	SWEDISH AMERICAN HOSPITAL	HOME HEALTH AGENCY - UWNI SAH HOME HEALTH INTERMITTENT SERVICES	2550 CHARLES ST	ROCKFORD	IL	Active
DSH140228E	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISHAMERICAN HOME HEALTH CARE	2550 CHARLES STREET	ROCKFORD	IL	Terminated
DSH140228G	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Operating Room	1625 South State Street	Belvidere	IL	Terminated
DSH140228H	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Recovery Room	1625 South State Street	Belvidere	IL	Terminated
DSH140228J	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Surgicare	1625 South State Street	Belvidere	IL	Terminated
DSH140228K	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Outpatient Health SVC	1625 South State Street	Belvidere	IL	Terminated
DSH140228L	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Medical Center Belvidere - Anesthesia	1625 South State Street	Belvidere	IL	Terminated
DSH140228M	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD DR (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228N	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH INFUSION ROOM (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228P	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH ED (SAB)	1625 South State Street	Belvidere	IL	Active
DSH140228Q	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH HYPERBARIC	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228R	Child	DSH	SWEDISH AMERICAN HOSPITAL	1415 E STATE ST CLINIC - UWNI SAH WOUND CARE	1415 E STATE ST	ROCKFORD	IL	Active
DSH140228S	Child	DSH	SWEDISH AMERICAN HOSPITAL	SwedishAmerican Regional Cancer Center / CT	3535 N BELL SCHOOL RD	ROCKFORD	IL	Terminated
DSH140228T	Child	DSH	SWEDISH AMERICAN HOSPITAL	CARBONE CANCER CENTER ROCKFORD - UWNI SAH CCR RAD ONC (RCC)	3535 N BELL SCHOOL RD	ROCKFORD	IL	Active
DSH140228U	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH SLEEP CLINIC (SAB)	1625 S STATE ST	BELVIDERE	IL	Active
DSH140228V	Child	DSH	SWEDISH AMERICAN HOSPITAL	SWEDISH AMERICAN MEDICAL CENTER BELVIDERE / Pulmonary Function	1625 S STATE ST	BELVIDERE	IL	Terminated
DSH140228W	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RESPIRATORY THERAPY (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228X	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH ANTICOAGULATION CLINIC (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228Y	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD MRI (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active
DSH140228Z	Child	DSH	SWEDISH AMERICAN HOSPITAL	BELVIDERE HOSPITAL - UWNI BEH RAD CT (SAB)	1625 SOUTH STATE ST	BELVIDERE	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Change Request		SWEDISH AMERICAN HOSPITAL 1401 E STATE ST ROCKFORD, IL 61104	2/11/2025 12:55 PM
Details	Entity Subname	Update	Change Request	1340 CHARLES ST CLINIC - SAH ORTHOPEDICS	1340 CHARLES ST CLINIC - UWNI SAH CHARLES ST ORTHO	2/11/2025 12:55 PM
Addresses	Billing Address	Insert	Recertification		SwedishAmerican Hospital 1401 E STATE STREET ROCKFORD, IL 61104	8/28/2024 10:14 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 5:38:32 PM	8/28/2024 10:14:43 AM	8/28/2024 10:14 AM
Contacts	Primary Contact	Update	Group Change Request	Carey, Tom Director of Pharmacy Services SwedishAmerican Hospital 8154894580	Carey, Tom Director of Pharmacy Services SwedishAmerican Hospital 7796964580	3/12/2024 1:07 PM
Details	Entity Subname	Update	Change Request	Lundholm Orthopedics	1340 CHARLES ST CLINIC - SAH ORTHOPEDICS	1/25/2024 1:07 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1760542732 (WI)		9/6/2023 5:38 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 4:13:20 PM	9/6/2023 5:38:32 PM	9/6/2023 5:38 PM
Addresses	Main Address	Update	Change Request	1340 CHARLES ST STE 100 ROCKFORD, IL 61104-2200	1340 CHARLES ST STE 100 ROCKFORD, IL 61104	1/19/2023 1:27 PM
Details	Entity Subname	Update	Change Request	Lundholm Orthopedics, UW Health General Surgery	Lundholm Orthopedics	1/19/2023 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 10:15:31 AM	9/6/2022 4:13:20 PM	9/6/2022 4:13 PM
Contacts	Authorizing Official	Update	AO Change Request	DeWane, Patricia A. Vice President, Finance and Treasurer Swedish American Hospital 7796964727	DeWane, Patricia Ann Vice President, Finance and Treasurer SwedishAmerican Hospital 7796964009	8/26/2022 9:03 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 12:20:06 PM	8/17/2021 10:15:31 AM	8/17/2021 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 12:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1760542732	8/26/2020 12:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/26/2020 12:20 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 12:20 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 12:20 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:30:27 PM	8/26/2020 12:20:06 PM	8/26/2020 12:20 PM
Details	Last Recertification Date	Update	Recertification	8/31/2018 1:10:38 PM	8/26/2019 6:30:27 PM	8/26/2019 6:30 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 8:53:04 PM	8/31/2018 1:10:38 PM	8/31/2018 1:10 PM
Addresses	Main Address	Update	Change Request	1340 CHARLES ST STE 200 ROCKFORD, IL 61104-2200	1340 CHARLES ST STE 100 ROCKFORD, IL 61104-2200	1/10/2018 2:58 PM
Details	Entity Subname	Update	Change Request	Lundholm Orthopedics, UW Health General Surgery, Rockford Vascular Surgery	Lundholm Orthopedics, UW Health General Surgery	1/10/2018 2:58 PM
Addresses	Main Address	Update	Recertification	1340 CHARLES ST STE 100 ROCKFORD, IL 61104-2200	1340 CHARLES ST STE 200 ROCKFORD, IL 61104-2200	11/15/2017 8:53 PM
Details	Last Recertification Date	Update	Recertification		11/15/2017 8:53:04 PM	11/15/2017 8:53 PM
Details	Entity Subname	Update	Recertification	LUNDHOLM ORTHOPEDICS, UW HEALTH, RO	Lundholm Orthopedics, UW Health General Surgery, Rockford Vascular Surgery	11/15/2017 8:53 PM
Details	Entity Name	Update	Recertification	SWEDISHAMERICAN HOSPITAL	SWEDISH AMERICAN HOSPITAL	11/15/2017 8:50 PM
Contacts	Primary Contact	Update	Recertification	Carey, Tom Director of Pharmacy Services 8154894580	Carey, Tom Director of Pharmacy Services SwedishAmerican Hospital 8154894580	11/10/2017 11:45 AM
Contacts	Authorizing Official	Update		DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	DeWane, Patricia A. Vice President, Finance and Treasurer Swedish American Hospital 7796964727	11/6/2017 3:00 PM
Contacts	Signed By	Update		DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	DeWane, Patricia A. Vice President, Finance and Treasurer Swedish American Hospital 7796964727	11/6/2017 3:00 PM
Contacts	Authorizing Official	Insert			DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	3/20/2017 3:30 PM
Contacts	Signed By	Insert			DeWane, Patricia A. Vice President, Finance and Treasurer 7796964727	3/20/2017 3:30 PM
Contacts	Primary Contact	Insert			Carey, Tom Director of Pharmacy Services 8154894580	2/24/2017 2:17 PM
Addresses	Main Address	Insert			1340 CHARLES ST STE 100 ROCKFORD, IL 61104-2200	2/24/2017 2:17 PM
Dates	Participating Approval Date	Update			2/24/2017 12:00:00 AM	2/24/2017 2:17 PM
Details	State	Update		Pending	Active	2/24/2017 2:17 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/24/2017 2:17 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75053	DSH140228AD	2/1/2017 8:54 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75053	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Number	Insert			362222696001	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Number	Insert			362222696401	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: Number	Insert			362222696007	1/16/2017 1:43 PM
Medicaid Billing	Medicaid: State	Insert			IL	1/16/2017 1:43 PM
Medicaid Billing	NPI: Number	Insert			1760542732	1/16/2017 1:43 PM
Medicaid Billing	NPI: Number	Insert			1588093942	1/16/2017 1:43 PM
Details	Last Recertification Date	Insert				1/16/2017 1:43 PM
Details	Grant Number	Insert				1/16/2017 1:43 PM
Details	340B ID	Insert				1/16/2017 1:43 PM
Details	Is Authorizing Official EHB Data	Insert				1/16/2017 1:43 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/16/2017 1:43 PM
Details	Medicare Provider Number	Insert			140228	1/16/2017 1:43 PM
Details	Entity Name	Insert			SWEDISHAMERICAN HOSPITAL	1/16/2017 1:43 PM
Details	Program Code	Insert			DSH	1/16/2017 1:43 PM
Details	Entity Subname	Insert			LUNDHOLM ORTHOPEDICS, UW HEALTH, RO	1/16/2017 1:43 PM
Dates	Participating Approval Date	Insert				1/16/2017 1:43 PM
Details	State	Insert			Pending	1/16/2017 1:43 PM
Dates	Registration Date	Insert			1/16/2017 12:00:00 AM	1/16/2017 1:43 PM
Dates	Signed By Date	Insert			1/16/2017 12:00:00 AM	1/16/2017 1:43 PM
Dates	Start Date	Insert				1/16/2017 1:43 PM
Terminations	Termination Comments	Insert				1/16/2017 1:43 PM
Terminations	Termination Date	Insert				1/16/2017 1:43 PM
Terminations	Termination Effective Date	Insert				1/16/2017 1:43 PM
Terminations	Termination Reason	Insert				1/16/2017 1:43 PM