Covered Entity Details

DSH140164D MEMORIAL HOSPITAL OF CARBONDALE (Active) - information as of 5/13/2025 11:04:16 PM

Main Details

Name

MEMORIAL HOSPITAL OF CARBONDALE

Subdivision Name

D.B.A SIH Prairie Heart Institute - OP Cardiovascular Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140164D

Medicare Provider Number

140164

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/1/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/31/2019

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

SIH
Warren Ladner, CFO
(618) 457-5200 Ext: 67130

Primary Contact

Southern Illinois Healthcare - Carbondale, IL
Katelyn Morgan, 340B Coordinator
(618) 457-5200 Ext: 67205

Addresses

Street Address

409 West Oak Street
Carbondale, IL 62901

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	370618939001	1093801797

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
DSH140164A	Child	DSH	MEMORIAL HOSPITAL OF CARBONDALE	D.B.A. WEST FRANKFORT FAMILY MEDICI	2553 KEN GRAY BLVD	WEST FRANKFORT	IL	Active
DSH140164B	Child	DSH	MEMORIAL HOSPITAL OF CARBONDALE	Cancer Treatment Center - Infusion	1400 Pin Oak Drive	Carterville	IL	Active
DSH140164C	Child	DSH	MEMORIAL HOSPITAL OF CARBONDALE	Cancer Treatment Center - Oncology	1400 Pin Oak Drive	Carterville	IL	Active
DSH140164D	Child	DSH	MEMORIAL HOSPITAL OF CARBONDALE	D.B.A SIH Prairie Heart Institute - OP Cardiovascular Center	409 West Oak Street	Carbondale	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Patrick, Katelyn 340B Coordinator Southern Illinois Healthcare - Carbondale, IL 6184575200-67205	Morgan, Katelyn 340B Coordinator Southern Illinois Healthcare - Carbondale, IL 6184575200-67205	4/9/2025 2:55 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 6:09:35 PM	9/5/2024 12:34:00 PM	9/5/2024 12:34 PM
Contacts	Authorizing Official	Update	Profile Change Request	Ladner, Warren CFO SIH 6018701228-67130	Ladner, Warren CFO SIH 6184575200-67130	7/25/2024 12:07 PM
Contacts	Primary Contact	Update	Group Change Request	Lovett, Michelle Financial Analyst-340B/Pharmacy SIH 6184575200	Patrick, Katelyn 340B Coordinator Southern Illinois Healthcare - Carbondale, IL 6184575200-67205	2/9/2024 2:12 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 9:50:05 AM	9/7/2023 6:09:35 PM	9/7/2023 6:09 PM
Contacts	Primary Contact	Update	PC Change Request	Wright, Greg Corporate Director of Finance Southern Illinois Healthcare 6184575200-67200	Lovett, Michelle Financial Analyst-340B/Pharmacy SIH 6184575200	9/1/2023 1:59 PM
Contacts	Authorizing Official	Update	AO Change Request	BUDDE, REX CEO Southern Illinois Healthcare 6184575200	Ladner, Warren CFO SIH 6018701228-67130	2/21/2023 7:31 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 9:40:38 AM	9/6/2022 9:50:05 AM	9/6/2022 9:50 AM
Contacts	Primary Contact	Update	Change Request	Lovett, Michelle Financial Analyst-340B/Pharmacy SIH 6184575200	Wright, Greg Corporate Director of Finance Southern Illinois Healthcare 6184575200-67200	8/17/2022 10:29 AM
Details	Last Recertification Date	Update	Recertification	8/31/2020 4:01:04 PM	8/31/2021 9:40:38 AM	8/31/2021 9:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1093801797 ( )		8/31/2020 4:01 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1093801797	8/31/2020 4:01 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2020 4:01 PM
Details	Last Recertification Date	Update	Recertification		8/31/2020 4:01:04 PM	8/31/2020 4:01 PM
Contacts	Primary Contact	Update	Profile Change Request	Lovett, Michelle Property Manager/Analyst SIH 6184575200	Lovett, Michelle Financial Analyst-340B/Pharmacy SIH 6184575200	8/26/2020 11:10 AM
Contacts	Primary Contact	Update	Change Request	Grace, Christopher Financial Analyst, 340B/Pharmacy SIH 6184575200-67205	Lovett, Michelle Property Manager/Analyst SIH 6184575200	3/24/2020 10:55 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		BUDDE, REX CEO Southern Illinois Healthcare 6184575200	10/31/2019 9:25 AM
Details	340B ID	Update	New Registration		DSH140164D	10/31/2019 9:25 AM
Details	Entity Subname	Update	New Registration	D.B.A SIH Prairie Heart Institute	D.B.A SIH Prairie Heart Institute - OP Cardiovascular Center	10/31/2019 9:25 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2019 9:25:48 AM	10/31/2019 9:25 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2019 9:25 AM
Dates	Signed By Date	Update	New Registration		10/9/2019 10:04:22 AM	10/31/2019 9:25 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/31/2019 9:25 AM
Addresses	Main Address	Insert	New Registration		409 West Oak Street Carbondale, IL 62901	10/1/2019 12:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/1/2019 12:29 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370618939001	10/1/2019 12:29 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/1/2019 12:29 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093801797	10/1/2019 12:29 PM
Contacts	Authorizing Official	Insert	New Registration		BUDDE, REX CEO Southern Illinois Healthcare 6184575200	10/1/2019 12:29 PM
Contacts	Primary Contact	Insert	New Registration		Grace, Christopher Financial Analyst, 340B/Pharmacy SIH 6184575200-67205	10/1/2019 12:29 PM
Details	Last Recertification Date	Insert	New Registration			10/1/2019 12:29 PM
Details	Grant Number	Insert	New Registration			10/1/2019 12:29 PM
Details	340B ID	Insert	New Registration			10/1/2019 12:29 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/1/2019 12:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/1/2019 12:29 PM
Details	Medicare Provider Number	Insert	New Registration		140164	10/1/2019 12:29 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HOSPITAL OF CARBONDALE	10/1/2019 12:29 PM
Details	Program Code	Insert	New Registration		DSH	10/1/2019 12:29 PM
Details	Entity Subname	Insert	New Registration		D.B.A SIH Prairie Heart Institute	10/1/2019 12:29 PM
Dates	Participating Approval Date	Insert	New Registration			10/1/2019 12:29 PM
Details	State	Insert	New Registration		Pending	10/1/2019 12:29 PM
Dates	Registration Date	Insert	New Registration		10/1/2019 12:29:42 PM	10/1/2019 12:29 PM
Dates	Signed By Date	Insert	New Registration			10/1/2019 12:29 PM
Dates	Start Date	Insert	New Registration			10/1/2019 12:29 PM
Terminations	Termination Comments	Insert	New Registration			10/1/2019 12:29 PM
Terminations	Termination Date	Insert	New Registration			10/1/2019 12:29 PM
Terminations	Termination Effective Date	Insert	New Registration			10/1/2019 12:29 PM
Terminations	Termination Reason	Insert	New Registration			10/1/2019 12:29 PM