Covered Entity Details

DSH140012E OSF Saint Katharine Medical Center (Active) - information as of 5/20/2025 11:45:21 PM

Main Details

Name

OSF Saint Katharine Medical Center

Subdivision Name

Edwards Clinic / Pediatric

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140012E

Medicare Provider Number

140012

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/1/2024

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

OSF HealthCare
Sandra Salverson, SVP Pharmacy Services
(309) 624-8817

Primary Contact

OSF Healthcare
amy krantz, Manager Strategic Reimbursement
(309) 655-2865

Addresses

Street Address

144 N Court Street
Dixon, IL 61021

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Start Date 10/1/2017, Termination Date 7/1/2019, Reinstatement 7/1/2024	04/30/2024

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	363358384001,361000540001	1073592119,1427043546

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
DSH140012A	Child	DSH	KATHERINE SHAW BETHEA	KATHERINE SHAW BETHEA HOSPITAL / Edwards Clinic (Internal Medicine)	403 E FIRST ST	DIXON	IL	Terminated
DSH140012AA	Child	DSH	KATHERINE SHAW BETHEA	Mt Morris Clinic	405 Charles Street	Mt. Morris	IL	Terminated
DSH140012AB	Child	DSH	OSF Saint Katharine Medical Center	Polo Clinic	1107 S Division Ave.	Polo	IL	Active
DSH140012AC	Child	DSH	OSF Saint Katharine Medical Center	Town Square Centre/Internal Medicine	102 S. Hennepin Ave.	Dixon	IL	Active
DSH140012AD	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Endocrinology - Endocrinology	215 E First St.	Dixon	IL	Active
DSH140012AE	Child	DSH	OSF Saint Katharine Medical Center	Oregon Clinic Podiatry - Podiatry	1307 W. Washington	Oregon	IL	Active
DSH140012AF	Child	DSH	OSF Saint Katharine Medical Center	Amboy Clinic Podiatry - Podiatry	305 E Joe Dr.	Amboy	IL	Active
DSH140012AG	Child	DSH	OSF Saint Katharine Medical Center	Town Square Centre /Family Health Center - Family Practice	102 S. Hennepin Ave.	Dixon	IL	Active
DSH140012AH	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Cardio Pulmonary Rehab - Commerce Towers / Cardiac Pulmonary Rehab	215 E First St.	Dixon	IL	Active
DSH140012B	Child	DSH	KATHERINE SHAW BETHEA	Edwards Clinic / Primary Care	144 N Court Street	Dixon	IL	Terminated
DSH140012C	Child	DSH	KATHERINE SHAW BETHEA	Commerce Towers / Rheumatology	215 E. First St	Dixon	IL	Terminated
DSH140012D	Child	DSH	KATHERINE SHAW BETHEA	Town Square Centre / Opthamology	102 S. Hennepin Ave.	Dixon	IL	Terminated
DSH140012E	Child	DSH	OSF Saint Katharine Medical Center	Edwards Clinic / Pediatric	144 N Court Street	Dixon	IL	Active
DSH140012F	Child	DSH	OSF Saint Katharine Medical Center	Town Square Centre / Primary Care	102 S. Hennepin Ave.	Dixon	IL	Active
DSH140012G	Child	DSH	KATHERINE SHAW BETHEA	Town Square Centre / Surgery	102 S Hennepin Ave	Dixon	IL	Terminated
DSH140012H	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Cardiology	215 E First St.	Dixon	IL	Active
DSH140012J	Child	DSH	KATHERINE SHAW BETHEA	Commerce Towers / Diabetic Clinic	215 E First St.	Dixon	IL	Terminated
DSH140012K	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Gastroenterology	215 E First St.	Dixon	IL	Active
DSH140012L	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Infectious Disease	215 E First St.	Dixon	IL	Active
DSH140012M	Child	DSH	KATHERINE SHAW BETHEA	Commerce Towers / Internal Medicine	215 E First St.	Dixon	IL	Terminated
DSH140012N	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Neurology	215 E First St.	Dixon	IL	Active
DSH140012P	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Obstetrics	215 E First St.	Dixon	IL	Active
DSH140012Q	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Orthopedic	215 E First St.	Dixon	IL	Active
DSH140012R	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / ENT	215 E First St.	Dixon	IL	Active
DSH140012S	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Podiatry	215 E First St.	Dixon	IL	Active
DSH140012T	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Pulmonology	215 E First St.	Dixon	IL	Active
DSH140012U	Child	DSH	OSF Saint Katharine Medical Center	Commerce Towers / Surgery	215 E First St.	Dixon	IL	Active
DSH140012V	Child	DSH	KATHERINE SHAW BETHEA	Commerce Towers / Urology	215 E First St.	Dixon	IL	Terminated
DSH140012W	Child	DSH	OSF Saint Katharine Medical Center	Oregon Clinic	1307 W Washington St.	Oregon	IL	Active
DSH140012X	Child	DSH	OSF Saint Katharine Medical Center	KSB Eye and Vision	511 Palmyra	Dixon	IL	Active
DSH140012Y	Child	DSH	OSF Saint Katharine Medical Center	Amboy Clinic	305 E Joe Dr.	Amboy	IL	Active
DSH140012Z	Child	DSH	OSF Saint Katharine Medical Center	Ashton Clinic	320 N First St.	Ashton	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	KATHERINE SHAW BETHEA HOSPITAL	OSF Saint Katharine Medical Center	1/22/2025 12:23 PM
Contacts	Primary Contact	Update	Group Change Request	Herbert, Luke Director of Pharmacy Katherine Shaw Bethea Hospital 8152855587	krantz, amy Manager Strategic Reimbursement OSF Healthcare 3096552865	1/14/2025 7:54 AM
Contacts	Authorizing Official	Update	AO Change Request	Frazier Jr., Austin B CFO KSB Hospital 8152855513	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	1/6/2025 7:18 AM
Details	Last Recertification Date	Update	Recertification		8/29/2024 3:52:45 PM	8/29/2024 3:52 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1427043546 ( )		5/1/2024 8:40 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1073592119	5/1/2024 8:40 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		IL	5/1/2024 8:40 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1427043546	5/1/2024 8:40 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		IL	5/1/2024 8:40 AM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1073592119 ( )		5/1/2024 8:40 AM
Contacts	Authorizing Official	Update	Reinstatement	Mann, Julie D. VP/CAO Katherine Shaw Bethea Hospital 8152855538	Frazier Jr., Austin B CFO KSB Hospital 8152855513	5/1/2024 8:40 AM
Contacts	Signed By	Update	Reinstatement	Evers, Anthony CFO Katherine Shaw Bethea Hospital 8152855521	Frazier Jr., Austin B CFO KSB Hospital 8152855513	5/1/2024 8:40 AM
Contacts	Primary Contact	Update	Reinstatement	Mann, Julie D. VP/CAO Katherine Shaw Bethea Hospital 8152855538	Herbert, Luke Director of Pharmacy Katherine Shaw Bethea Hospital 8152855587	5/1/2024 8:40 AM
Details	Last Recertification Date	Update	Reinstatement	8/21/2018 4:18:38 PM		5/1/2024 8:40 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	5/31/2019 12:00:00 AM		5/1/2024 8:40 AM
Details	Entity Name	Update	Reinstatement	KATHERINE SHAW BETHEA	KATHERINE SHAW BETHEA HOSPITAL	5/1/2024 8:40 AM
Dates	Participating Approval Date	Update	Reinstatement	7/21/2017 12:00:00 AM	5/1/2024 8:40:47 AM	5/1/2024 8:40 AM
Details	State	Update	Reinstatement	Terminated	Approved	5/1/2024 8:40 AM
Dates	Registration Date	Update	Reinstatement	7/11/2017 12:00:00 AM	4/12/2024 2:50:27 PM	5/1/2024 8:40 AM
Dates	Signed By Date	Update	Reinstatement	7/11/2017 12:00:00 AM	4/15/2024 12:33:28 PM	5/1/2024 8:40 AM
Dates	Start Date	Update	Reinstatement	10/1/2017 12:00:00 AM	7/1/2024 12:00:00 AM	5/1/2024 8:40 AM
Terminations	Termination Date	Update	Reinstatement	7/1/2019 12:00:00 AM		5/1/2024 8:40 AM
Terminations	Termination Effective Date	Update	Reinstatement	5/31/2019 12:00:00 AM		5/1/2024 8:40 AM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		5/1/2024 8:40 AM
Details	Comments Public	Insert	Reinstatement		Participating Start Date 10/1/2017, Termination Date 7/1/2019, Reinstatement 7/1/2024	4/30/2024 2:14 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/31/2019 12:00:00 AM	5/31/2019 8:04 AM
Details	State	Update	Termination Request	Active	To Be Terminated	5/31/2019 8:04 AM
Terminations	Termination Date	Update	Termination Request		7/1/2019 12:00:00 AM	5/31/2019 8:04 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2019 12:00:00 AM	5/31/2019 8:04 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	5/31/2019 8:04 AM
Contacts	Authorizing Official	Update	Change Request	Evers, Anthony CFO Katherine Shaw Bethea Hospital 8152855521	Mann, Julie D. VP/CAO Katherine Shaw Bethea Hospital 8152855538	4/10/2019 1:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/7/2018 11:46 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363358384001	12/7/2018 11:46 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/7/2018 11:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073592119	12/7/2018 11:46 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 10:16:14 AM	8/21/2018 4:18:38 PM	8/21/2018 4:18 PM
Addresses	Main Address	Update	Change Request	102 S Hennepin Ave. Dixon, IL 61021	144 N Court Street Dixon, IL 61021	6/14/2018 1:29 PM
Details	Entity Subname	Update	Change Request	Town Square Centre / Pediatric	Edwards Clinic / Pediatric	6/14/2018 1:29 PM
Contacts	Primary Contact	Insert	Recertification		Mann, Julie D. VP/CAO Katherine Shaw Bethea Hospital 8152855538	11/15/2017 10:16 AM
Details	Last Recertification Date	Update	Recertification		11/15/2017 10:16:14 AM	11/15/2017 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/29/2017 3:27 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		361000540001	9/29/2017 3:27 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	9/29/2017 3:27 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427043546	9/29/2017 3:27 PM
Details	State	Update	Change Request	Approved	Active	9/29/2017 3:27 PM
Contacts	Authorizing Official	Update		Evers, Anthony CFO 8152855521	Evers, Anthony CFO Katherine Shaw Bethea Hospital 8152855521	9/29/2017 2:21 PM
Contacts	Signed By	Update		Evers, Anthony CFO 8152855521	Evers, Anthony CFO Katherine Shaw Bethea Hospital 8152855521	9/29/2017 2:21 PM
Contacts	Authorizing Official	Insert			Evers, Anthony CFO 8152855521	8/4/2017 4:38 PM
Contacts	Signed By	Insert			Evers, Anthony CFO 8152855521	8/4/2017 4:38 PM
Addresses	Main Address	Insert			102 S Hennepin Ave. Dixon, IL 61021	8/4/2017 4:38 PM
Dates	Participating Approval Date	Update			7/21/2017 12:00:00 AM	7/21/2017 6:47 PM
Details	State	Update		Pending	Approved	7/21/2017 6:47 PM
Dates	Start Date	Update			10/1/2017 12:00:00 AM	7/21/2017 6:47 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_78190	DSH140012E	7/12/2017 2:24 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_78190	7/11/2017 11:28 AM
Details	Last Recertification Date	Insert				7/11/2017 11:28 AM
Details	Grant Number	Insert				7/11/2017 11:28 AM
Details	340B ID	Insert				7/11/2017 11:28 AM
Details	Is Authorizing Official EHB Data	Insert				7/11/2017 11:28 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2017 11:28 AM
Details	Medicare Provider Number	Insert			140012	7/11/2017 11:28 AM
Details	Entity Name	Insert			KATHERINE SHAW BETHEA	7/11/2017 11:28 AM
Details	Program Code	Insert			DSH	7/11/2017 11:28 AM
Details	Entity Subname	Insert			Town Square Centre / Pediatric	7/11/2017 11:28 AM
Dates	Participating Approval Date	Insert				7/11/2017 11:28 AM
Details	State	Insert			Pending	7/11/2017 11:28 AM
Dates	Registration Date	Insert			7/11/2017 12:00:00 AM	7/11/2017 11:28 AM
Dates	Signed By Date	Insert			7/11/2017 12:00:00 AM	7/11/2017 11:28 AM
Dates	Start Date	Insert				7/11/2017 11:28 AM
Terminations	Termination Comments	Insert				7/11/2017 11:28 AM
Terminations	Termination Date	Insert				7/11/2017 11:28 AM
Terminations	Termination Effective Date	Insert				7/11/2017 11:28 AM
Terminations	Termination Reason	Insert				7/11/2017 11:28 AM