Covered Entity Details

CAH141333-03 Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital (Active) - information as of 5/6/2025 12:03:48 AM

Main Details

Name

Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital

Subdivision Name

RUSHVILLE FAMILY PRACTICE - Rural Health Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141333-03

Medicare Provider Number

141333

Outpatient Facility Provider Number

148578

Additional Details

Current Program Status

Active

Registration Date

10/8/2018

Participating Start Date

1/1/2019

Participating Approval Date

10/10/2018

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Schuyler County Hospital District
Tamra S Gadberry, Chief Financial Officer
(217) 322-5296

Primary Contact

Schuyler County Hospital District
Sarah Brockhouse, Pharmacist
(217) 322-4321 Ext: 5294

Addresses

Street Address

233 S CONGRESS ST
RUSHVILLE, IL 62681-1409

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	376006672003	1073979308

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
CAH141333-01	Child	CAH	Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital	SCHUYLER COUNTY HOSPITAL DISTRICT - Elmer Hugh Taylor Clinic	100W 15TH ST	BEARDSTOWN	IL	Active
CAH141333-02	Child	CAH	Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital	Schuyler County Hospital District Community Medical Clinic Astoria - Rural Health Clinic	135 W Broadway	Astoria	IL	Active
CAH141333-03	Child	CAH	Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital	RUSHVILLE FAMILY PRACTICE - Rural Health Clinic	233 S CONGRESS ST	RUSHVILLE	IL	Active
CAH141333-04	Child	CAH	Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital	Community Medical Clinic of Table Grove - Rural Health Clinic	130 N Broadway Street	Table Grove	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 10:44:26 AM	8/26/2024 11:25:31 AM	8/26/2024 11:25 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 3:17:06 PM	9/6/2023 10:44:26 AM	9/6/2023 10:44 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 3:45:24 PM	8/29/2022 3:17:06 PM	8/29/2022 3:17 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 12:03:11 PM	8/31/2021 3:45:24 PM	8/31/2021 3:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 12:03 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		376006672003	9/2/2020 12:03 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/2/2020 12:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073979308	9/2/2020 12:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/2/2020 12:03 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 1:07:51 PM	9/2/2020 12:03:11 PM	9/2/2020 12:03 PM
Details	Last Recertification Date	Update	Recertification		8/26/2019 1:07:51 PM	8/26/2019 1:07 PM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Gadberry, Tamra S Chief Financial Officer Schuyler County Hospital District 2173225296	10/10/2018 7:53 AM
Details	340B ID	Update	New Registration		CAH141333-03	10/10/2018 7:53 AM
Details	Entity Name	Update	New Registration	SARAH D CULBERTSON	Schuyler County Hospital District dba Sarah D. Culbertson Memorial Hospital	10/10/2018 7:53 AM
Details	Entity Subname	Update	New Registration	RUSHVILLE FAMILY PRACTICE	RUSHVILLE FAMILY PRACTICE - Rural Health Clinic	10/10/2018 7:53 AM
Dates	Participating Approval Date	Update	New Registration		10/10/2018 7:53:04 AM	10/10/2018 7:53 AM
Details	State	Update	New Registration	Pending	Approved	10/10/2018 7:53 AM
Dates	Signed By Date	Update	New Registration		10/9/2018 10:17:27 AM	10/10/2018 7:53 AM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	10/10/2018 7:53 AM
Addresses	Main Address	Insert	New Registration		233 S CONGRESS ST RUSHVILLE, IL 62681-1409	10/8/2018 1:51 PM
Contacts	Authorizing Official	Insert	New Registration		Gadberry, Tamra S Chief Financial Officer Schuyler County Hospital District 2173225296	10/8/2018 1:51 PM
Contacts	Primary Contact	Insert	New Registration		Brockhouse, Sarah Pharmacist Schuyler County Hospital District 2173224321-5294	10/8/2018 1:51 PM
Details	Last Recertification Date	Insert	New Registration			10/8/2018 1:51 PM
Details	Grant Number	Insert	New Registration			10/8/2018 1:51 PM
Details	340B ID	Insert	New Registration			10/8/2018 1:51 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2018 1:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2018 1:51 PM
Details	Medicare Provider Number	Insert	New Registration		141333	10/8/2018 1:51 PM
Details	Entity Name	Insert	New Registration		SARAH D CULBERTSON	10/8/2018 1:51 PM
Details	Program Code	Insert	New Registration		CAH	10/8/2018 1:51 PM
Details	Entity Subname	Insert	New Registration		RUSHVILLE FAMILY PRACTICE	10/8/2018 1:51 PM
Dates	Participating Approval Date	Insert	New Registration			10/8/2018 1:51 PM
Details	State	Insert	New Registration		Pending	10/8/2018 1:51 PM
Dates	Registration Date	Insert	New Registration		10/8/2018 1:51:52 PM	10/8/2018 1:51 PM
Dates	Signed By Date	Insert	New Registration			10/8/2018 1:51 PM
Dates	Start Date	Insert	New Registration			10/8/2018 1:51 PM
Terminations	Termination Comments	Insert	New Registration			10/8/2018 1:51 PM
Terminations	Termination Date	Insert	New Registration			10/8/2018 1:51 PM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2018 1:51 PM
Terminations	Termination Reason	Insert	New Registration			10/8/2018 1:51 PM