Covered Entity Details

DSH520066M MERCY HEALTH SYSTEM CORPORATION (Terminated) - information as of 4/28/2025 12:40:32 AM

Main Details

Name

MERCY HEALTH SYSTEM CORPORATION

Subdivision Name

MERCY HOSPITAL JANESVILLE-PHYSICAL - Sports Medicine Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH520066M

Medicare Provider Number

520066

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/10/2019

Participating Start Date

4/1/2019

Participating Approval Date

2/7/2019

Last Recertification Date

8/25/2023

Termination Date
Termination Reason

1/1/2024
Change of covered entity type

Contacts

Authorizing Official

Mercyhealth
Todd Anderson, Vice President Finance
(815) 971-6738

Primary Contact

Mercyhealth
Clark Montgomery, System Manager of Pharmacy Business and 340B Program
(406) 698-8719

Addresses

Street Address

557 NORTH WASHINGTON STREET
JANESVILLE, WI 53548-2907

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	11011400,32796500	1093768962,1598718603
IL	390816848001,390816848401	1093768962,1598718603

Shipping Addresses

Shipping Address 1

MERCY HEALTH SYSTEM CORPORATION
1000 MINERAL POINT AVENUE
JANESVILLE, WI 53548

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
DSH520066A	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - MHJ Cardiac Rehab	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066AA	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BRODHEAD MEDICAL CENTER - Brodhead Family Practice Clinic/Multispecialty	2310 1ST CENTER AVE	BRODHEAD	WI	Terminated
DSH520066AB	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY ELKHORN MEDICAL CENTER - Elkhorn Multispecialty Clinic	839N WISCONSIN ST	ELKHORN	WI	Terminated
DSH520066AC	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit XRay	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AD	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Phys Therapy	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AE	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Urgent Care	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AF	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Pediatrics Clinic	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AG	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit OB Gyn Clinic	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AH	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Family Practice Clinic/Multispecialty	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AJ	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Internal Med Clinic	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AK	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Podiatry Clinic	2825 PRAIRIE AVE	BELOIT	WI	Terminated
DSH520066AL	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East ENT Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AM	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East XRay	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AN	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Endocrinology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AP	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Pediatrics Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AQ	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Orthotics	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AR	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Orthopedics Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AS	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Family Practice Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AT	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Urgent Care Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AU	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Ophthalmology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AV	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Internal Medicine Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AW	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Rheumatology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AX	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Allergy Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AY	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Phys/Occ Therapy	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066AZ	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Dermatology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066B	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Hand Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066BA	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Optical Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066BB	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Podiatry Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066BC	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Audiology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066BD	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - MHJ Psych Day Trmnt	903 MINERAL POINT AVE	JANESVILLE	WI	Terminated
DSH520066BE	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - MHJ Child Day Trmnt	1000 MINERAL POINT AVE	JANESVILLE	WI	Terminated
DSH520066BF	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY SPORTS MEDICINE WHITEWATER - Whitewater Sports Medicine Clinic	519W MAIN ST	WHITEWATER	WI	Terminated
DSH520066BG	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Emergency/Urgent Care Dept	3400 DEERFIELD DR	JANESVILLE	WI	Terminated
DSH520066BH	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - MHJ Day Addictions	903 MINERAL POINT AVE	JANESVILLE	WI	Terminated
DSH520066BJ	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - OP Hemodialysis	903 MINERAL POINT AVE	JANESVILLE	WI	Terminated
DSH520066BK	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Pediatric Gastroenterology	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
DSH520066C	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Diabetic Center	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066D	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE - SLEEP C - MHJ Sleep Center	903 MINERAL POINT AVENUE	JANESVILLE	WI	Terminated
DSH520066E	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Multispecialty Clinic	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066F	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - MHJ Occ Conditioning	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066G	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY LAKE GENEVA MEDICAL CENTER - Lake Geneva Multispecialty Clinic	350 PELLER RD	LAKE GENEVA	WI	Terminated
DSH520066H	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY TERRACE - Terrace General Surgery Clinic	510N TERRACE ST	JANESVILLE	WI	Terminated
DSH520066J	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Multispecialty Clinic	3400 DEERFIELD DR	JANESVILLE	WI	Terminated
DSH520066K	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY WHITEWATER MEDICAL CENTER - Whitewater Family Practice Clinic	507W MAIN ST	WHITEWATER	WI	Terminated
DSH520066L	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Physiatry Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066M	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Sports Medicine Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066N	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Occ Therapy	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066P	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Rehab Psychologist	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066Q	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Phys Therapy	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Terminated
DSH520066R	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY MILTON MEDICAL CENTER - Milton Family Practice Clinic/Multispecialty	725S JANESVILLE ST	MILTON	WI	Terminated
DSH520066S	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY MILTON MEDICAL CENTER - Milton Phys Therapy	725S JANESVILLE ST	MILTON	WI	Terminated
DSH520066T	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY EDGERTON MEDICAL CENTER - Edgerton Family Practice Clinic/Multispecialty	217N MAIN ST	EDGERTON	WI	Terminated
DSH520066U	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY EVANSVILLE MEDICAL CENTER - Evansville Family Practice Clinic/Multispecialty	300 UNION ST	EVANSVILLE	WI	Terminated
DSH520066V	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Optical Clinic	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066W	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Urgent Care Clinic	1010N WASHINGTON ST 109	JANESVILLE	WI	Terminated
DSH520066X	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Radiology	3400 DEERFIELD DR	JANESVILLE	WI	Terminated
DSH520066Y	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY DELAVAN MEDICAL CENTER - Delavan Family Practice Clinic/Multispecialty	1038E GENEVA ST	DELAVAN	WI	Terminated
DSH520066Z	Child	DSH	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC SOUTH - South Family Practice Clinic/Multispecialty	849 KELLOGG AVE	JANESVILLE	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	Montgomery, Clark System Manager of Pharmacy Business and 340B Program Mercyhealth 4066988719	2/27/2025 12:55 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	12/1/2023 6:34 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	12/1/2023 6:34 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	12/1/2023 6:34 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	12/1/2023 6:34 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	12/1/2023 6:34 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 5:20:44 PM	8/25/2023 10:22:49 AM	8/25/2023 10:22 AM
Contacts	Primary Contact	Update	Group Change Request	Carlson, Kyle Manager of Pharmacy 340B Program Mercyhealth 8159716216	Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	4/10/2023 12:18 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 8:50:40 AM	9/6/2022 5:20:44 PM	9/6/2022 5:20 PM
Contacts	Primary Contact	Update	Profile Change Request	Carlson, Kyle 340B Program Coordinator MercyHealth 8159716216	Carlson, Kyle Manager of Pharmacy 340B Program Mercyhealth 8159716216	9/1/2022 12:43 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 11:15:34 AM	8/16/2021 8:50:40 AM	8/16/2021 8:50 AM
Contacts	Authorizing Official	Update	Change Request	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	Anderson, Todd Vice President Finance Mercyhealth 8159716738	3/10/2021 2:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1598718603 ( )		9/8/2020 11:15 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1093768962	9/8/2020 11:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 11:15 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598718603	9/8/2020 11:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 11:15 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1093768962	9/8/2020 11:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/8/2020 11:15 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598718603	9/8/2020 11:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/8/2020 11:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1093768962 ( )		9/8/2020 11:15 AM
Details	Last Recertification Date	Update	Recertification	8/22/2019 5:57:23 PM	9/8/2020 11:15:34 AM	9/8/2020 11:15 AM
Contacts	Primary Contact	Update	Change Request	Gee, Katie Business Coordinator Mercyhealth 8159712394	Carlson, Kyle 340B Program Coordinator MercyHealth 8159716216	8/7/2020 5:36 PM
Details	Last Recertification Date	Update	Recertification		8/22/2019 5:57:23 PM	8/22/2019 5:57 PM
Contacts	Authorizing Official	Update	Change Request	Cook, John Senior VP / CFO Mercyhealth 6087566642	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	7/1/2019 9:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/21/2019 4:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		32796500	5/21/2019 4:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	5/21/2019 4:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598718603	5/21/2019 4:45 PM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Cook, John Senior VP / CFO Mercyhealth 6087566642	2/7/2019 5:08 PM
Details	340B ID	Update	New Registration		DSH520066M	2/7/2019 5:08 PM
Details	Entity Subname	Update	New Registration	MERCY HOSPITAL JANESVILLE-PHYSICAL	MERCY HOSPITAL JANESVILLE-PHYSICAL - Sports Medicine Clinic	2/7/2019 5:08 PM
Dates	Participating Approval Date	Update	New Registration		2/7/2019 5:08:11 PM	2/7/2019 5:08 PM
Details	State	Update	New Registration	Pending	Approved	2/7/2019 5:08 PM
Dates	Signed By Date	Update	New Registration		1/11/2019 9:47:47 AM	2/7/2019 5:08 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	2/7/2019 5:08 PM
Addresses	Main Address	Insert	New Registration		557 NORTH WASHINGTON STREET JANESVILLE, WI 53548-2907	1/10/2019 4:24 PM
Addresses	Shipping Address	Insert	New Registration		MERCY HEALTH SYSTEM CORPORATION 1000 MINERAL POINT AVENUE JANESVILLE, WI 53548	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11011400	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		390816848001	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		390816848401	1/10/2019 4:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/10/2019 4:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093768962	1/10/2019 4:24 PM
Contacts	Authorizing Official	Insert	New Registration		Cook, John Senior VP / CFO Mercyhealth 6087566642	1/10/2019 4:24 PM
Contacts	Primary Contact	Insert	New Registration		Gee, Katie Business Coordinator Mercyhealth 8159712394	1/10/2019 4:24 PM
Details	Last Recertification Date	Insert	New Registration			1/10/2019 4:24 PM
Details	Grant Number	Insert	New Registration			1/10/2019 4:24 PM
Details	340B ID	Insert	New Registration			1/10/2019 4:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2019 4:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2019 4:24 PM
Details	Medicare Provider Number	Insert	New Registration		520066	1/10/2019 4:24 PM
Details	Entity Name	Insert	New Registration		MERCY HEALTH SYSTEM CORPORATION	1/10/2019 4:24 PM
Details	Program Code	Insert	New Registration		DSH	1/10/2019 4:24 PM
Details	Entity Subname	Insert	New Registration		MERCY HOSPITAL JANESVILLE-PHYSICAL	1/10/2019 4:24 PM
Dates	Participating Approval Date	Insert	New Registration			1/10/2019 4:24 PM
Details	State	Insert	New Registration		Pending	1/10/2019 4:24 PM
Dates	Registration Date	Insert	New Registration		1/10/2019 4:24:42 PM	1/10/2019 4:24 PM
Dates	Signed By Date	Insert	New Registration			1/10/2019 4:24 PM
Dates	Start Date	Insert	New Registration			1/10/2019 4:24 PM
Terminations	Termination Comments	Insert	New Registration			1/10/2019 4:24 PM
Terminations	Termination Date	Insert	New Registration			1/10/2019 4:24 PM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2019 4:24 PM
Terminations	Termination Reason	Insert	New Registration			1/10/2019 4:24 PM