Covered Entity Details

DSH140276AQ LOYOLA UNIVERSITY MEDICAL CENTER (Active) - information as of 4/25/2025 9:21:12 PM

Main Details

Name

LOYOLA UNIVERSITY MEDICAL CENTER

Subdivision Name

Burr Ridge - Radiology CT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140276AQ

Medicare Provider Number

140276

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/11/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/31/2019

Last Recertification Date

9/2/2024

Contacts

Authorizing Official

Loyola Medicine
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723

Primary Contact

Loyola Medicine
Zohra Saleem, Regional 340B Manager
(708) 216-3875

Addresses

Street Address

6800 N. Frontage Road
Burr Ridge, IL 60527

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	364015560018,364015560006,364015560001,364015560011,364015560017,364015560005	1104462126,1184789299,1376521575,1386785152,1063504165,1841361748

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
DSH140276A	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA UNIVERSITY MEDICAL CENTER - CARDINAL BERNARDIN CANCER CENTER	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Active
DSH140276AA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at Burr Ridge-Primary Care	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AB	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at River Forest	7617 W. North Ave	River Forest	IL	Terminated
DSH140276AC	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at Elmwood Park First Floor	7255 W. Grand Ave	Elmwood Park	IL	Active
DSH140276AD	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at Norridge	8307 W Lawrence Ave	Norridge	IL	Terminated
DSH140276AE	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Medicine at Palos Community Hospital	15300 West Ave	Orland Park	IL	Terminated
DSH140276AF	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Metabolic Surgery and Bariatric Care at Melrose Park	719 W. North Avenue	Melrose Park	IL	Active
DSH140276AG	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at Chicago	7634 W. Belmont Ave	Chicago	IL	Terminated
DSH140276AH	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - ENT	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AJ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Immediate Care	6800 N. Frontage Road, first floor	Burr Ridge	IL	Active
DSH140276AK	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LaGrange - Dermatology	321 North LaGrange Road	LaGrange Park	IL	Terminated
DSH140276AL	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Cardiac Rehab	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AM	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Audiology	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AN	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Ophthamology	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AP	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Rehab - Physical Therapy	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AQ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Radiology CT	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AR	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Allergy	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276AS	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Pain Clinic	2160 S. First Avenue	Maywood	IL	Active
DSH140276AT	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Immediate Care	15750 Marian Drive	Homer Glen	IL	Terminated
DSH140276AU	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Subspecialty	15750 Marian Drive	Homer Glen	IL	Terminated
DSH140276AV	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - Clinic Adult Hema Oncology	2160 S. First Avenue	Maywood	IL	Active
DSH140276AW	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrrace - Orthopedics	1S224 Summit Avenue & 1S260 Summit Avenue	Oak Brook Terrace	IL	Terminated
DSH140276AX	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - PCC	1S224 Summit Avenue	Oak Brook Terrace	IL	Active
DSH140276AY	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Travel Clinic	6800 N. Frontage Road	Burr Ridge	IL	Terminated
DSH140276AZ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Mammography	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276B	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA UNIVERSITY MEDICAL CENTER - LOYOLA OUTPATIENT CENTER	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Terminated
DSH140276BA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Subspecialities	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BB	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Radiology MRI	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BC	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - Day Hospital	2160 S. First Avenue	Maywood	IL	Active
DSH140276BD	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Rehab - Physical Medicine and Rehab	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BE	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Ophthalmology	2160 S. First Avenue	Maywood	IL	Active
DSH140276BF	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Psychiatry	2160 S. First Avenue	Maywood	IL	Active
DSH140276BG	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Travel Clinic	2160 S. First Avenue	Maywood	IL	Terminated
DSH140276BH	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Rad Diagnostic	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BJ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Orthopediics	2160 S. First Avenue	Maywood	IL	Active
DSH140276BK	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Pain	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BL	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Urology	2160 S. First Avenue	Maywood	IL	Active
DSH140276BM	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - General Medicine/ Primary Care	2160 S. First Avenue	Maywood	IL	Active
DSH140276BN	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Elmwood Park - Family Medicine 2nd Floor	7255 W. Grand Ave	Elmwood Park	IL	Active
DSH140276BP	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Other Specialities - Stress Test / Cardiographics	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BQ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Park Ridge - Specialty	1030 W. Higgins Road	Park Ridge	IL	Active
DSH140276BR	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Orland Park - Pediatrics	16621 South 107th Court	Orland Park	IL	Terminated
DSH140276BS	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Hickory Hills - Specialty - Ophthalmology	9608 Roberts Road	Hickory Hills	IL	Active
DSH140276BT	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Pulmonary Diagnostic Lab	2160 S. First Avenue	Maywood	IL	Active
DSH140276BU	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Palos - Lab	15300 West Avenue	Orland Park	IL	Terminated
DSH140276BV	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Orthopedics	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276BW	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Sub-specialty Med - Allergy	2160 S. First Avenue	Maywood	IL	Terminated
DSH140276BX	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Neurology	2160 S. First Avenue	Maywood	IL	Active
DSH140276BY	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - Pediatrics	1S224 Summit Avenue & 1S260 Summit Avenue	Oak Brook Terrace	IL	Terminated
DSH140276BZ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Pediatrics	2160 S. First Avenue	Maywood	IL	Active
DSH140276CA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Hickory Hills - G.I.	9608 Roberts Road	Hickory Hills	IL	Terminated
DSH140276CB	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Urogynecology	2160 S. First Avenue	Maywood	IL	Active
DSH140276CC	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - High Dose	2160 S. First Avenue	Maywood	IL	Active
DSH140276CD	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace Outpatient Center - Dermatology	1S260 Summit Avenue	Oak Brook Terrace	IL	Active
DSH140276CE	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - CT	2160 S. First Avenue	Maywood	IL	Active
DSH140276CF	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - MRI	2160 S. First Avenue	Maywood	IL	Active
DSH140276CG	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Womens Health Imaging	2160 S. First Avenue	Maywood	IL	Active
DSH140276CH	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Surgery	2160 S. First Avenue	Maywood	IL	Active
DSH140276CJ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Obstetrics / Gyne Practice	2160 S. First Avenue	Maywood	IL	Active
DSH140276CK	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health on Roosevelt Road - Rehab	1219 W Roosevelt Road	Maywood	IL	Active
DSH140276CL	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Hickory Hills - Medical Specialty	9608 Roberts Road	Hickory Hills	IL	Active
DSH140276CM	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - Clinical Surg Oncology	2160 S. First Avenue	Maywood	IL	Active
DSH140276CN	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - Opthamology	1S260 Summit Avenue	Oak Brook Terrace	IL	Terminated
DSH140276CP	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - Plastic Surgery	1S260 Summit Avenue	Oak Brook Terrace	IL	Active
DSH140276CQ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Orthopedics	15750 Marian Drive	Homer Glen	IL	Terminated
DSH140276CR	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Rad Oncology	2160 S. First Avenue	Maywood	IL	Active
DSH140276CS	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - ENT	2160 S. First Avenue	Maywood	IL	Active
DSH140276CT	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Hickory Hills - Rehab	9608 Roberts Road	Hickory Hills	IL	Active
DSH140276CU	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - Mammography	1S224 Summit Avenue & 1S260 Summit Avenue	Oak Brook Terrace	IL	Active
DSH140276CV	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Palos - Orthopedics	15300 West Avenue	Orland Park	IL	Terminated
DSH140276CW	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Palos - Neurosciences	15300 West Avenue	Orland Park	IL	Terminated
DSH140276CX	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen - Palos - Primary Care	15300 West Avenue	Orland Park	IL	Terminated
DSH140276CY	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 260 Summit- Orthopedics - Oak Brook Terrace at 1 S 260 Summit- Orthopedics	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276CZ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Infusion - Burr Ridge - Infusion	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276D	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT ELMHURST - Med Peds-Elmhurst	300 NORTH YORK STREET	ELMHURST	IL	Terminated
DSH140276DA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Oncology Infusion - Burr Ridge - Oncology Infusion	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276DB	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Elmhurst Women's Health - Elmhurst Women's Health	300 N. York Street	Elmhurst	IL	Terminated
DSH140276DD	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Subspecialty Med - Loyola Outpatient Center - Subspecialty Med	2160 S. First Avenue	Maywood	IL	Active
DSH140276DE	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 260 Summit- MRI - Oak Brook Terrace at 1 S 260 Summit- MRI	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276DF	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LaGrange FC - Medical - LaGrange FC - Medical	321 N. LaGrange Road	LaGrange Park	IL	Terminated
DSH140276DG	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola at Gottlieb Suite 414 - Loyola at Gottlieb Suite 414	675 W. North Avenue	Melrose Park	IL	Terminated
DSH140276DH	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Lab Oncology - Burr Ridge - Lab Oncology	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276DJ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	River Forest - Specialty - River Forest - Specialty	7617 W. North Avenue	River Forest	IL	Active
DSH140276DK	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Dialysis-Maywood	1201 W. Roosevelt Road	Maywood	IL	Active
DSH140276DQ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 260 Summit- MC Specialty - Oak Brook Terrace at 1 S 260 Summit- MC Specialty	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276DS	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 224 Summit- Specialty - Oak Brook Terrace at 1 S 224 Summit- Specialty	1 S 224 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276DU	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Homer Glen Primary Care - Homer Glen Primary Care	15750 Marian Drive	Homer Glen	IL	Active
DSH140276DV	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Outpatient Center - Lab Phlebotomy - Loyola Outpatient Center - Lab Phlebotomy	2160 S. First Avenue	Maywood	IL	Active
DSH140276DY	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 224 Summit - Women's Health - Oak Brook Terrace at 1 S 224 Summit - Women's Health	1 S 224 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276DZ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Park Ridge - Nuclear Medicine - Park Ridge - Nuclear Medicine	1030 W. Higgins Road	Park Ridge	IL	Active
DSH140276EA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Hematology / Oncology - Burr Ridge - Hematology / Oncology	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276EB	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Womens Health-Burr Ridge - Womens Health-Burr Ridge	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276ED	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	River Forest - Orthopaedics - River Forest - Orthopaedics	7617 W. North Avenue	River Forest	IL	Active
DSH140276EE	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 260 Summit- Pediatrics - Oak Brook Terrace at 1 S 260 Summit- Pediatrics	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Terminated
DSH140276EF	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 224 Summit- MC Specialty - Oak Brook Terrace at 1 S 224 Summit- MC Specialty	1 S 224 Summit Avenue	Oakbrook Terrace	IL	Terminated
DSH140276EG	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 224 Summit- Pediatrics - Oak Brook Terrace at 1 S 224 Summit- Pediatrics	1 S 224 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276EH	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Neurology & Neurosurgery - Burr Ridge - Neurology & Neurosurgery	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276EJ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Burr Ridge - Cardiology - Burr Ridge - Cardiology	6800 N. Frontage Road	Burr Ridge	IL	Active
DSH140276EL	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - Coleman Center - Cancer Center - Coleman Center	2160 S. First Avenue	Maywood	IL	Active
DSH140276EM	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loyola Center for Health at Elmwood Park - Got Ctr For Health - Loyola Center for Health at Elmwood Park - Got Ctr For Health	7255 W. Grand Avenue	Elmwood Park	IL	Terminated
DSH140276EN	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace at 1 S 260 Summit- Primary Care - Oak Brook Terrace at 1 S 260 Summit- Primary Care	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Terminated
DSH140276EP	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Oak Brook Terrace - CAT Scan Imaging Services - Oak Brook Terrace - CAT Scan Imaging Services	1 S 260 Summit Avenue	Oakbrook Terrace	IL	Active
DSH140276EQ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	River Forest - Immediate Care - River Forest - Immediate Care	7617 W. North Avenue	River Forest	IL	Active
DSH140276ER	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Orland Park at Homer Glen - Medical - Orland Park - Medical	15750 Marian Drive	Homer Glen	IL	Terminated
DSH140276ES	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Park Ridge - Primary Care - Park Ridge - Primary Care	1030 W. Higgins Road	Park Ridge	IL	Active
DSH140276ET	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Cancer Center - Chemo - Chemo	2160 S. First Avenue	Maywood	IL	Active
DSH140276EU	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Ambulatory Surgery Center - Amb Surgery Center	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Active
DSH140276EV	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loc Outpatient Center - Anticoagulation-LOC	2160 SOUTH FIRST AVENUE	Maywood	IL	Active
DSH140276EW	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Loc Outpatient Center - Oncology-Peds LOC	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Active
DSH140276EX	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Tinley Cancer Center - Tinley Cancer Center	17901 S LA GRANGE ROAD	TINLEY PARK	IL	Approved
DSH140276EY	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Tinley Infusion Center - Tinley Infusion Center	17901 S LA GRANGE ROAD	TINLEY PARK	IL	Approved
DSH140276EZ	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Tinley Radiation Oncology - Tinley Radiation Oncology	17901 S LA GRANGE ROAD	TINLEY PARK	IL	Approved
DSH140276F	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	HICKORY HILLS - Primary Care	9608 ROBERTS ROAD	HICKORY HILLS	IL	Active
DSH140276FA	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	Tinley Urgent Care Center - Tinley Urgent Care Center	17901 S LA GRANGE ROAD	Tinley Park	IL	Approved
DSH140276G	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT HOMER GLEN- Specialty	15750 MARIAN DRIVE	HOMER GLEN	IL	Active
DSH140276H	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEARING AT WOODRIDGE	6440 MAIN STREET	WOODRIDGE	IL	Terminated
DSH140276J	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	OAK BROOK TERRACE OUTPATIENT CENTER- Rehab	1S224 SUMMIT AVENUE	OAKBROOK TERRACE	IL	Active
DSH140276K	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	PSYCHIATRY SERVICE	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Active
DSH140276N	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA FAMILY PRACTICE AT THE LOYOLA CENTER FOR HEALTH ON ROOSEVELT ROAD	1211 WEST ROOSEVELT ROAD	MAYWOOD	IL	Active
DSH140276P	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT NORTH RIVERSIDE	1950 SOUTH HARLEM AVENUE	NORTH RIVERSIDE	IL	Active
DSH140276Q	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT OAK PARK	7005 WEST NORTH AVENUE	OAK PARK	IL	Active
DSH140276R	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT ORLAND PARK	16621 SOUTH 107TH COURT	ORLAND PARK	IL	Terminated
DSH140276S	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA PRIMARY CARE CENTER AT WHEATON	Loyola University Wheaton Pharmacy	WHEATON	IL	Terminated
DSH140276T	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEART & VASCULAR MEDICINE AT PARK RIDGE	1030 W. HIGGINS ROAD	PARK RIDGE	IL	Terminated
DSH140276V	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA UNIVERSITY MEDICAL CENTER, RENAL DIALYSIS	OUTPATIENT/MAIN HOSPITAL NEPHROLOGY; LUH - 3306	MAYWOOD	IL	Active
DSH140276W	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CLINIC AT GOTTLIEB	675 W. NORTH AVENUE	MELROSE PARK	IL	Terminated
DSH140276X	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA OUTPATIENT BURN CENTER	2160 SOUTH FIRST AVENUE	MAYWOOD	IL	Active
DSH140276Y	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CENTER FOR HEALTH AT LAGRANGE PARK	321 NORTH LAGRANGE ROAD	LAGRANGE PARK	IL	Terminated
DSH140276Z	Child	DSH	LOYOLA UNIVERSITY MEDICAL CENTER	LOYOLA CANCER CARE & RESEARCH AT THE MARJORIE G. WEINBERG CANCER CENTER AT MELROSE PARK	715 WEST NORTH AVENUE	MELROSE PARK	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/7/2023 11:05:41 PM	9/2/2024 8:14:22 PM	9/2/2024 8:14 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 11:41:04 AM	9/7/2023 11:05:41 PM	9/7/2023 11:05 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 7:28:13 AM	9/8/2022 11:41:04 AM	9/8/2022 11:41 AM
Contacts	Primary Contact	Update	Group Change Request	Vadakara, Joe Regional Pharmacy Director Loyola Medicine 7082160399	Saleem, Zohra Regional 340B Manager Loyola Medicine 7082163875	7/14/2022 10:12 AM
Contacts	Authorizing Official	Update	Change Request	Isacksen, Daniel Paul EVP and Regional CFO Loyola University Medical Center 7082164252	Lukasick, Melissa M. CFO Illinois Region Loyola Medicine 7082165723	2/4/2022 10:16 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 2:30:08 PM	9/9/2021 7:28:13 AM	9/9/2021 7:28 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	364015560001 (IL)		9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560018	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560006	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560001	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560011	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560017	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		364015560005	9/11/2020 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104462126	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184789299	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1376521575	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1386785152	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1063504165	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1841361748	9/11/2020 2:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1376521575 ( )		9/11/2020 2:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1184789299 ( )		9/11/2020 2:30 PM
Details	Last Recertification Date	Update	Recertification	9/6/2019 1:17:01 PM	9/11/2020 2:30:08 PM	9/11/2020 2:30 PM
Contacts	Primary Contact	Update	Change Request	McMullen, Mollie Ann 340B Program Assistant Loyola University Medical Center 7082166487	Vadakara, Joe Regional Pharmacy Director Loyola Medicine 7082160399	4/21/2020 4:45 PM
Contacts	Authorizing Official	Update	Change Request	Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	Isacksen, Daniel Paul EVP and Regional CFO Loyola University Medical Center 7082164252	1/7/2020 2:23 PM
Details	Last Recertification Date	Update	Recertification		9/6/2019 1:17:01 PM	9/6/2019 1:17 PM
Contacts	Primary Contact	Update	Change Request	Pong, William Administrative Director, Pharmacy Services Loyola University Medical Center 7082160399	McMullen, Mollie Ann 340B Program Assistant Loyola University Medical Center 7082166487	6/12/2019 7:07 AM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	1/31/2019 8:16 AM
Details	340B ID	Update	New Registration		DSH140276AQ	1/31/2019 8:16 AM
Details	Entity Subname	Update	New Registration	Burr Ridge	Burr Ridge - Radiology CT	1/31/2019 8:16 AM
Dates	Participating Approval Date	Update	New Registration		1/31/2019 8:16:48 AM	1/31/2019 8:16 AM
Details	State	Update	New Registration	Pending	Approved	1/31/2019 8:16 AM
Dates	Signed By Date	Update	New Registration		1/13/2019 10:18:15 PM	1/31/2019 8:16 AM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/31/2019 8:16 AM
Addresses	Main Address	Insert	New Registration		6800 N. Frontage Road Burr Ridge, IL 60527	1/11/2019 4:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/11/2019 4:24 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		364015560001	1/11/2019 4:24 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/11/2019 4:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376521575	1/11/2019 4:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1184789299	1/11/2019 4:24 PM
Contacts	Primary Contact	Insert	New Registration		Pong, William Administrative Director, Pharmacy Services Loyola University Medical Center 7082160399	1/11/2019 4:24 PM
Contacts	Authorizing Official	Insert	New Registration		Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	1/11/2019 4:24 PM
Details	Last Recertification Date	Insert	New Registration			1/11/2019 4:24 PM
Details	Grant Number	Insert	New Registration			1/11/2019 4:24 PM
Details	340B ID	Insert	New Registration			1/11/2019 4:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/11/2019 4:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/11/2019 4:24 PM
Details	Medicare Provider Number	Insert	New Registration		140276	1/11/2019 4:24 PM
Details	Entity Name	Insert	New Registration		LOYOLA UNIVERSITY MEDICAL CENTER	1/11/2019 4:24 PM
Details	Program Code	Insert	New Registration		DSH	1/11/2019 4:24 PM
Details	Entity Subname	Insert	New Registration		Burr Ridge	1/11/2019 4:24 PM
Dates	Participating Approval Date	Insert	New Registration			1/11/2019 4:24 PM
Details	State	Insert	New Registration		Pending	1/11/2019 4:24 PM
Dates	Registration Date	Insert	New Registration		1/11/2019 4:24:22 PM	1/11/2019 4:24 PM
Dates	Signed By Date	Insert	New Registration			1/11/2019 4:24 PM
Dates	Start Date	Insert	New Registration			1/11/2019 4:24 PM
Terminations	Termination Comments	Insert	New Registration			1/11/2019 4:24 PM
Terminations	Termination Date	Insert	New Registration			1/11/2019 4:24 PM
Terminations	Termination Effective Date	Insert	New Registration			1/11/2019 4:24 PM
Terminations	Termination Reason	Insert	New Registration			1/11/2019 4:24 PM