Covered Entity Details

DSH520177R FROEDTERT MEMORIAL LUTHERAN HOSPITAL (Active) - information as of 5/11/2025 11:46:01 PM

Main Details

Name

FROEDTERT MEMORIAL LUTHERAN HOSPITAL

Subdivision Name

FMLH INFUSION CLINIC DREXEL TOWN SQ - Drexel TSHC-General Infusion

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH520177R

Medicare Provider Number

520177

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/6/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/9/2019

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Froedtert Memorial Lutheran Hospital
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925

Primary Contact

Froedtert Memorial Lutheran Hospital
Casey Drake Spitzer, 340B Manager
(920) 319-6030

Addresses

Street Address

7901 S 6TH ST
2ND FLOOR STE 20403
OAK CREEK, WI 53154-2010

Billing Address

Froedtert Memorial Lutheran Hospital
9200 West Wisconsin Avenue
PO Box 26099
Milwaukee, WI 53226

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	11000400	1255334173
IL	396105970001	1255334173
IA	939538	1255334173
MI	40-4656061	1255334173
MN	923550700	1255334173

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
DSH520177D	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Tosa Health Center Radiology	1155 N. Mayfair Road	Wauwatosa	WI	Terminated
DSH520177E	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Sports Medicine Radiology	8700 Watertown Plank Road	Wauwatosa	WI	Terminated
DSH520177F	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Froedtert & Medical College of Wisconsin Reproductive Medicine Center	W129 N7055 Northfield Drive	Menomonee Falls	WI	Active
DSH520177G	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center - Infusion Clinic	4805 S. Moorland Road	New Berlin	WI	Active
DSH520177H	Child	DSH	FROEDTERT MEM. LUTHERAN HOSPT.	Plastic Surgery	8700 W. Watertown Plank Road	Milwaukee	WI	Terminated
DSH520177J	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center / Cancer Center Clinic	4805 South Moorland Road	New Berlin	WI	Active
DSH520177K	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Eye Institute	925 N. 87th Street	Milwaukee	WI	Active
DSH520177L	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Rheumatology Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177M	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Endocrine Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177N	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Infectious Disease Clinic	840 N 87th St	Milwaukee	WI	Active
DSH520177P	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Delivery Room & Labor Room	9000 West Wisconsin Avenue	Milwaukee	WI	Terminated
DSH520177Q	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER DREXEL TOWN SQUA - Drexel Cancer Center Clinic	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177R	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH INFUSION CLINIC DREXEL TOWN SQ - Drexel TSHC-General Infusion	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177S	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER MENOMONEE FALLS - Medical Oncology	W180N8085 TOWN HALL RD	MENOMONEE FALLS	WI	Active
DSH520177T	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER WEST BEND - Medical Oncology	3200 PLEASANT VALLEY RD	WEST BEND	WI	Active
DSH520177U	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH Clinic - Dermatology - Dermatology	601 N 99th Street	Milwaukee	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 7:42:37 PM	8/13/2024 10:58:17 AM	8/13/2024 10:58 AM
Contacts	Primary Contact	Update	Group Change Request	Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	Spitzer, Casey Drake 340B Manager Froedtert Memorial Lutheran Hospital 9203196030	5/7/2024 6:37 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 11:11:55 AM	8/29/2023 7:42:37 PM	8/29/2023 7:42 PM
Details	Last Recertification Date	Update	Recertification	8/20/2021 12:26:59 PM	8/24/2022 11:11:55 AM	8/24/2022 11:11 AM
Addresses	Billing Address	Update	Recertification	Froedtert Memorial Lutheran Hospital 9200 West Wisconsin Avenue Milwaukee, WI 53226	Froedtert Memorial Lutheran Hospital 9200 West Wisconsin Avenue PO Box 26099 Milwaukee, WI 53226	8/20/2021 12:26 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 9:17:52 AM	8/20/2021 12:26:59 PM	8/20/2021 12:26 PM
Contacts	Primary Contact	Update	Profile Change Request	Olson, Jacob 340B Program Manager Froedtert and the Medical College of Wisconsin 2625325184	Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	5/17/2021 7:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		396105970001	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		939538	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		40-4656061	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		923550700	9/2/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1255334173 ( )		9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/2/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255334173	9/2/2020 9:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/2/2020 9:17 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 4:10:41 PM	9/2/2020 9:17:52 AM	9/2/2020 9:17 AM
Contacts	Primary Contact	Update	Change Request	Perhach, Kevin James Business Manager Froedtert Memorial Lutheran Hospital, Inc. 2625325163	Olson, Jacob 340B Program Manager Froedtert and the Medical College of Wisconsin 2625325184	12/13/2019 3:55 PM
Details	Last Recertification Date	Update	Recertification		8/20/2019 4:10:41 PM	8/20/2019 4:10 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	5/9/2019 9:35 AM
Details	340B ID	Update	New Registration		DSH520177R	5/9/2019 9:35 AM
Details	Entity Name	Update	New Registration	FROEDTERT MEM. LUTHERAN HOSPT.	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	5/9/2019 9:35 AM
Details	Entity Subname	Update	New Registration	FMLH INFUSION CLINIC DREXEL TOWN SQ	FMLH INFUSION CLINIC DREXEL TOWN SQ - Drexel TSHC-General Infusion	5/9/2019 9:35 AM
Dates	Participating Approval Date	Update	New Registration		5/9/2019 9:35:38 AM	5/9/2019 9:35 AM
Details	State	Update	New Registration	Pending	Approved	5/9/2019 9:35 AM
Dates	Signed By Date	Update	New Registration		5/6/2019 2:42:28 PM	5/9/2019 9:35 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	5/9/2019 9:35 AM
Addresses	Main Address	Insert	New Registration		7901 S 6TH ST 2ND FLOOR STE 20403 OAK CREEK, WI 53154-2010	5/6/2019 2:07 PM
Addresses	Billing Address	Insert	New Registration		Froedtert Memorial Lutheran Hospital 9200 West Wisconsin Avenue Milwaukee, WI 53226	5/6/2019 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	5/6/2019 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11000400	5/6/2019 2:07 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	5/6/2019 2:07 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	5/6/2019 2:07 PM
Contacts	Authorizing Official	Insert	New Registration		Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	5/6/2019 2:07 PM
Contacts	Primary Contact	Insert	New Registration		Perhach, Kevin James Business Manager Froedtert Memorial Lutheran Hospital, Inc. 2625325163	5/6/2019 2:07 PM
Details	Last Recertification Date	Insert	New Registration			5/6/2019 2:07 PM
Details	Grant Number	Insert	New Registration			5/6/2019 2:07 PM
Details	340B ID	Insert	New Registration			5/6/2019 2:07 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			5/6/2019 2:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			5/6/2019 2:07 PM
Details	Medicare Provider Number	Insert	New Registration		520177	5/6/2019 2:07 PM
Details	Entity Name	Insert	New Registration		FROEDTERT MEM. LUTHERAN HOSPT.	5/6/2019 2:07 PM
Details	Program Code	Insert	New Registration		DSH	5/6/2019 2:07 PM
Details	Entity Subname	Insert	New Registration		FMLH INFUSION CLINIC DREXEL TOWN SQ	5/6/2019 2:07 PM
Dates	Participating Approval Date	Insert	New Registration			5/6/2019 2:07 PM
Details	State	Insert	New Registration		Pending	5/6/2019 2:07 PM
Dates	Registration Date	Insert	New Registration		5/6/2019 2:07:30 PM	5/6/2019 2:07 PM
Dates	Signed By Date	Insert	New Registration			5/6/2019 2:07 PM
Dates	Start Date	Insert	New Registration			5/6/2019 2:07 PM
Terminations	Termination Comments	Insert	New Registration			5/6/2019 2:07 PM
Terminations	Termination Date	Insert	New Registration			5/6/2019 2:07 PM
Terminations	Termination Effective Date	Insert	New Registration			5/6/2019 2:07 PM
Terminations	Termination Reason	Insert	New Registration			5/6/2019 2:07 PM