Covered Entity Details

RRC140034-06 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS (Terminated) - information as of 4/27/2025 12:51:07 AM

Main Details

Name

ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Subdivision Name

SMGS Centralia ENT

Type

Rural Referral Center

Rural

Yes

340B ID

RRC140034-06

Medicare Provider Number

140034

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2017

Participating Start Date

7/1/2017

Participating Approval Date

5/1/2017

Last Recertification Date

9/11/2020

Termination Date
Termination Reason

7/1/2021
Site closure

Contacts

Authorizing Official

SSM Health - St. Mary's Hospital Centralia, IL
Damon Harbison, President
(618) 436-8000

Primary Contact

SSM Health
Jeffrey Peine, Finance Director
(314) 989-3532

Addresses

Street Address

1054 Martin Luther King Jr. Drive, Suite 105
Centralia, IL 62801

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	370662580001,370662580401	1083617245,1255391611,1629003074,1710105192,1770687196

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
RRC140034-01	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	Behavioral Health - Angela Center	444 N. Pleasant Avenue	Centralia	IL	Terminated
RRC140034-02	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	ST MARYS HOSPTIAL Work Safety Institute - Physical Therapy	1250 W WHITTAKER ST	SALEM	IL	Terminated
RRC140034-03	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	CENTRALIA WORK SAFETY INSTITUTE - Physical Therapy	1441 W BROADWAY	CENTRALIA	IL	Terminated
RRC140034-04	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	Weight Management Clinic	432 N Pleasant Avenue	Centralia	IL	Terminated
RRC140034-05	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Surgery	1054 Martin Luther King Jr. Drive, Suite 125	Centralia	IL	Terminated
RRC140034-06	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMGS Centralia ENT	1054 Martin Luther King Jr. Drive, Suite 105	Centralia	IL	Terminated
RRC140034-07	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Cardiology	1054 Martin Luther King Jr. Dr, Suite 222	Centralia	IL	Terminated
RRC140034-08	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMGS Centralia Pulmonology - Pulmonology	1054 Martin Luther King Drive Suite 222	Centralia	IL	Terminated
RRC140034-09	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Infusion Center	1052 Martin Luther King Jr Drive Suite 100	Centralia	IL	Terminated
RRC140034-10	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Podiatry General Surgery	402 N PLEASANT AVE	CENTRALIA	IL	Terminated
RRC140034-11	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Podiatry	402 N PLEASANT AVE	CENTRALIA	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/17/2021 12:00:00 AM	5/18/2021 2:51 PM
Details	State	Update	Termination Request	Active	To Be Terminated	5/18/2021 2:51 PM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/18/2021 2:51 PM
Terminations	Termination Effective Date	Update	Termination Request		5/17/2021 12:00:00 AM	5/18/2021 2:51 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	5/18/2021 2:51 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1083617245	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255391611	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1629003074	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1710105192	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1770687196	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1083617245 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1770687196 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1629003074 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1710105192 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1255391611 ( )		9/11/2020 10:40 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 1:55:17 PM	9/11/2020 10:40:35 AM	9/11/2020 10:40 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:58:30 PM	8/19/2019 1:55:17 PM	8/19/2019 1:55 PM
Contacts	Authorizing Official	Update	Change Request	Swanson, Kerry Regional President SSM Health 6184366500	Harbison, Damon President SSM Health - St. Mary's Hospital Centralia, IL 6184368000	7/1/2019 6:48 AM
Details	Last Recertification Date	Update	Recertification	11/14/2017 11:27:28 AM	8/21/2018 4:58:30 PM	8/21/2018 4:58 PM
Contacts	Primary Contact	Update	Profile Change Request	Peine, Jeffrey Sr. Financial Analyst 340B SSM Health 3149893532	Peine, Jeffrey Finance Director SSM Health 3149893532	4/12/2018 5:13 PM
Contacts	Authorizing Official	Update	Change Request	Sigsbury, John PRESIDENT SSM St. Mary's Hospital - Centralia 6184366525	Swanson, Kerry Regional President SSM Health 6184366500	1/23/2018 7:42 AM
Contacts	Primary Contact	Update	Change Request	Geringer, Greta Finance Director SSM Health 3149893518	Peine, Jeffrey Sr. Financial Analyst 340B SSM Health 3149893532	1/19/2018 2:15 PM
Details	Entity Name	Update	Recertification	SSM HEALTH ST. MARYS HOSPITAL	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	11/16/2017 12:30 PM
Details	Last Recertification Date	Update	Recertification		11/14/2017 11:27:28 AM	11/14/2017 11:27 AM
Contacts	Authorizing Official	Update		Sigsbury, John PRESIDENT 6184366525	Sigsbury, John PRESIDENT SSM St. Mary's Hospital - Centralia 6184366525	10/17/2017 3:01 PM
Contacts	Primary Contact	Update		Geringer, Greta Finance Director 3149893518	Geringer, Greta Finance Director SSM Health 3149893518	9/19/2017 11:20 AM
Contacts	Authorizing Official	Update		Sigsbury, John PRESIDENT 6184366525	Sigsbury, John PRESIDENT 6184366525	9/11/2017 3:29 PM
Contacts	Primary Contact	Insert			Geringer, Greta Finance Director 3149893518	7/27/2017 3:23 PM
Contacts	Authorizing Official	Insert			Sigsbury, John PRESIDENT 6184366525	5/23/2017 11:51 AM
Contacts	Signed By	Insert			Sigsbury, John PRESIDENT 6184366525	5/23/2017 11:51 AM
Addresses	Main Address	Insert			1054 Martin Luther King Jr. Drive, Suite 105 Centralia, IL 62801	5/1/2017 1:34 PM
Details	340B ID	Update		RRC140034-14	RRC140034-06	5/1/2017 1:33 PM
Dates	Participating Approval Date	Update			5/1/2017 12:00:00 AM	5/1/2017 1:33 PM
Details	State	Update		Pending	Active	5/1/2017 1:33 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	5/1/2017 1:33 PM
Details	340B ID	Update		RRC140046-14	RRC140034-14	4/25/2017 8:13 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_76769	RRC140046-14	4/19/2017 11:18 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_76769	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: Number	Insert			370662580001	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: Number	Insert			370662580401	4/12/2017 5:07 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/12/2017 5:07 PM
Medicaid Billing	NPI: Number	Insert			1083617245	4/12/2017 5:07 PM
Medicaid Billing	NPI: Number	Insert			1770687196	4/12/2017 5:07 PM
Medicaid Billing	NPI: Number	Insert			1629003074	4/12/2017 5:07 PM
Medicaid Billing	NPI: Number	Insert			1710105192	4/12/2017 5:07 PM
Medicaid Billing	NPI: Number	Insert			1255391611	4/12/2017 5:07 PM
Details	Last Recertification Date	Insert				4/12/2017 5:07 PM
Details	Grant Number	Insert				4/12/2017 5:07 PM
Details	340B ID	Insert				4/12/2017 5:07 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2017 5:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2017 5:07 PM
Details	Medicare Provider Number	Insert			140034	4/12/2017 5:07 PM
Details	Entity Name	Insert			SSM HEALTH ST. MARYS HOSPITAL	4/12/2017 5:07 PM
Details	Program Code	Insert			RRC	4/12/2017 5:07 PM
Details	Entity Subname	Insert			SMGS Centralia ENT	4/12/2017 5:07 PM
Dates	Participating Approval Date	Insert				4/12/2017 5:07 PM
Details	State	Insert			Pending	4/12/2017 5:07 PM
Dates	Registration Date	Insert			4/12/2017 12:00:00 AM	4/12/2017 5:07 PM
Dates	Signed By Date	Insert			4/12/2017 12:00:00 AM	4/12/2017 5:07 PM
Dates	Start Date	Insert				4/12/2017 5:07 PM
Terminations	Termination Comments	Insert				4/12/2017 5:07 PM
Terminations	Termination Date	Insert				4/12/2017 5:07 PM
Terminations	Termination Effective Date	Insert				4/12/2017 5:07 PM
Terminations	Termination Reason	Insert				4/12/2017 5:07 PM