Covered Entity Details

CAH141310-01 Mendota Community Hospital d/b/a OSF Saint Paul Medical Center (Terminated) - information as of 4/25/2025 6:34:23 PM

Main Details

Name

Mendota Community Hospital d/b/a OSF Saint Paul Medical Center

Subdivision Name

OSF Medical Group- Washington Street

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141310-01

Medicare Provider Number

141310

Outpatient Facility Provider Number

148567

Additional Details

Current Program Status

Terminated

Registration Date

4/5/2019

Participating Start Date

7/1/2019

Participating Approval Date

4/9/2019

Last Recertification Date

9/3/2024

Termination Date
Termination Reason

1/1/2025
Site closure

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

1404 WASHINGTON STREET
MENDOTA, IL 61342-1471

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		1205383197

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
CAH141310-01	Child	CAH	Mendota Community Hospital d/b/a OSF Saint Paul Medical Center	OSF Medical Group- Washington Street	1404 WASHINGTON STREET	MENDOTA	IL	Terminated
CAH141310-02	Child	CAH	Mendota Community Hospital d/b/a OSF Saint Paul Medical Center	OSF Medical Group-Mendota	1405 E. 12th ST	Mendota	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/11/2024 12:00:00 AM	10/10/2024 7:24 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/10/2024 7:24 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	10/10/2024 7:24 AM
Terminations	Termination Effective Date	Update	Termination Request		3/11/2024 12:00:00 AM	10/10/2024 7:24 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/10/2024 7:24 AM
Details	Last Recertification Date	Update	Recertification	8/23/2023 10:13:39 AM	9/3/2024 8:57:36 AM	9/3/2024 8:57 AM
Contacts	Primary Contact	Update	Change Request	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	krantz, amy Manager Strategic Reimbursement OSF Healthcare 3096552865	6/28/2024 2:08 PM
Contacts	Authorizing Official	Update	Change Request	McGrew, Diane L. President OSF Healthcare 3096552850	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	6/27/2024 7:57 AM
Details	Last Recertification Date	Update	Recertification	9/20/2022 9:28:23 AM	8/23/2023 10:13:39 AM	8/23/2023 10:13 AM
Contacts	Primary Contact	Update	Group Change Request	Storm, Jerry Senior Vice President of Pharmacy Services OSF Healthcare 3096553489	Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	4/25/2023 4:13 PM
Details	Last Recertification Date	Update	Recertification	8/26/2021 11:30:23 AM	9/20/2022 9:28:23 AM	9/20/2022 9:28 AM
Details	Entity Subname	Update	Recertification	MENDOTA COMMUNITY HOSPITAL - rural health clinic	OSF Medical Group- Washington Street	9/20/2022 9:28 AM
Contacts	Authorizing Official	Update	Profile Change Request	McGrew, Diane Marie President OSF Healthcare 3096552850	McGrew, Diane L. President OSF Healthcare 3096552850	4/11/2022 5:02 PM
Contacts	Signed By	Update	Profile Change Request	McGrew, Diane Marie President OSF Healthcare 3096552850	McGrew, Diane L. President OSF Healthcare 3096552850	4/11/2022 5:02 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 12:34:48 PM	8/26/2021 11:30:23 AM	8/26/2021 11:30 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/10/2020 12:34 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 9:19:27 AM	9/10/2020 12:34:48 PM	9/10/2020 12:34 PM
Details	Last Recertification Date	Update	Recertification		9/5/2019 9:19:27 AM	9/5/2019 9:19 AM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		McGrew, Diane Marie President OSF Healthcare 3096552850	4/9/2019 10:05 AM
Details	340B ID	Update	New Registration		CAH141310-01	4/9/2019 10:05 AM
Details	Entity Name	Update	New Registration	MENDOTA COMMUNITY HOSPITAL	Mendota Community Hospital d/b/a OSF Saint Paul Medical Center	4/9/2019 10:05 AM
Details	Entity Subname	Update	New Registration	MENDOTA COMMUNITY HOSPITAL	MENDOTA COMMUNITY HOSPITAL - rural health clinic	4/9/2019 10:05 AM
Dates	Participating Approval Date	Update	New Registration		4/9/2019 10:05:05 AM	4/9/2019 10:05 AM
Details	State	Update	New Registration	Pending	Approved	4/9/2019 10:05 AM
Dates	Signed By Date	Update	New Registration		4/5/2019 3:54:01 PM	4/9/2019 10:05 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	4/9/2019 10:05 AM
Addresses	Main Address	Insert	New Registration		1404 WASHINGTON STREET MENDOTA, IL 61342-1471	4/5/2019 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205383197	4/5/2019 3:53 PM
Contacts	Primary Contact	Insert	New Registration		Storm, Jerry Senior Vice President of Pharmacy Services OSF Healthcare 3096553489	4/5/2019 3:53 PM
Contacts	Authorizing Official	Insert	New Registration		McGrew, Diane Marie President OSF Healthcare 3096552850	4/5/2019 3:53 PM
Details	Last Recertification Date	Insert	New Registration			4/5/2019 3:53 PM
Details	Grant Number	Insert	New Registration			4/5/2019 3:53 PM
Details	340B ID	Insert	New Registration			4/5/2019 3:53 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2019 3:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2019 3:53 PM
Details	Medicare Provider Number	Insert	New Registration		141310	4/5/2019 3:53 PM
Details	Entity Name	Insert	New Registration		MENDOTA COMMUNITY HOSPITAL	4/5/2019 3:53 PM
Details	Program Code	Insert	New Registration		CAH	4/5/2019 3:53 PM
Details	Entity Subname	Insert	New Registration		MENDOTA COMMUNITY HOSPITAL	4/5/2019 3:53 PM
Dates	Participating Approval Date	Insert	New Registration			4/5/2019 3:53 PM
Details	State	Insert	New Registration		Pending	4/5/2019 3:53 PM
Dates	Registration Date	Insert	New Registration		4/5/2019 3:53:57 PM	4/5/2019 3:53 PM
Dates	Signed By Date	Insert	New Registration			4/5/2019 3:53 PM
Dates	Start Date	Insert	New Registration			4/5/2019 3:53 PM
Terminations	Termination Comments	Insert	New Registration			4/5/2019 3:53 PM
Terminations	Termination Date	Insert	New Registration			4/5/2019 3:53 PM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2019 3:53 PM
Terminations	Termination Reason	Insert	New Registration			4/5/2019 3:53 PM