Covered Entity Details

DSH140208B ADVOCATE CHRIST MEDICAL CENTER (Terminated) - information as of 6/11/2025 7:18:49 PM

Main Details

Name

ADVOCATE CHRIST MEDICAL CENTER

Subdivision Name

Physical Therapy - Tinley Park Rehab

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140208B

Medicare Provider Number

140208

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/3/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/31/2019

Last Recertification Date

9/2/2022

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Advocate Aurora Health Care
Nan Nelson, SVP-Finance
(414) 378-4765

Primary Contact

Advocate Aurora Health
Jason G Nowak, Director, Pharmacy 340B Program
(414) 640-8457

Addresses

Street Address

18210 S. La Grange Road
Tinley Park, IL 60487

Billing Address

Advocate Christ Medical Center
4440 W 95th Street
Oak Lawn, IL 60453

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	362169147001,362169147403,362169147065,362169147066,362169147074,362169147474	1508315516,1922542604,1548375082,1386188068
WI	362169147001,362169147065,362169147066,362169147074,362169147403,362169147474	1548375082,1386188068,1508315516,1922542604

Shipping Addresses

Shipping Address 1

Advocate Christ Medical Center
4440 W 95th Street
Oak Lawn, IL 60453

Shipping Address 2

Advocate Central Service Center
15-17 W. College Dr
Arlington Heights, IL 60004

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
DSH140208A	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Physical Therapy - Peds Rehab Outpatient Pavillion	12350 S. Harlem	Palos Heights	IL	Terminated
DSH140208B	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Physical Therapy - Tinley Park Rehab	18210 S. La Grange Road	Tinley Park	IL	Terminated
DSH140208C	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Electrocardiology - Cardiac Rehab Off-site	11800 Southwest Hwy	Palos Heights	IL	Terminated
DSH140208D	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Radiology - Breast Health	4545 W 103rd St	Oak Lawn	IL	Active
DSH140208E	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Ambulatory Care - ACH Behavioral Health Service	4700 W 95th st	Oak Lawn	IL	Active
DSH140208F	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Dreyer Infusion Clinic - Infusion services	1221 N Highland Avenue 1st Floor	Aurora	IL	Active
DSH140208G	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	Ambulatory Care - Wilmette Clinic	3232 Lake Ave	Wilmette	IL	Active
DSH140208H	Child	DSH	ADVOCATE CHRIST MEDICAL CENTER	CMC Transplant Clinic - Transplant	4400 W 95th St	Oak Lawn	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Change Request	Nowak, Jason Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	Nowak, Jason G Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	7/22/2024 3:54 PM
Contacts	Authorizing Official	Update	Profile Change Request	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4142991610	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4143784765	2/7/2024 11:14 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/30/2023 12:00:00 AM	7/13/2023 7:18 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/13/2023 7:18 AM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	7/13/2023 7:18 AM
Terminations	Termination Effective Date	Update	Termination Request		9/30/2023 12:00:00 AM	7/13/2023 7:18 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	7/13/2023 7:18 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 12:45:43 PM	9/2/2022 12:13:58 PM	9/2/2022 12:13 PM
Contacts	Primary Contact	Update	Group Change Request	De Ianni, Angela Vice President Pharmacy Supply Chain Advocate Aurora Health Care 4146301541	Nowak, Jason Director, Pharmacy 340B Program Advocate Aurora Health 4146408457	5/4/2022 11:16 AM
Contacts	Primary Contact	Update	Profile Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4146301541	De Ianni, Angela Vice President Pharmacy Supply Chain Advocate Aurora Health Care 4146301541	10/7/2021 12:57 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 1:31:22 PM	9/10/2021 12:45:43 PM	9/10/2021 12:45 PM
Contacts	Primary Contact	Update	Profile Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4146301541	9/1/2021 1:46 PM
Addresses	Main Address	Update	Change Request	1821 S. La Grange Road Tinley Park, IL 60487	18210 S. La Grange Road Tinley Park, IL 60487	10/20/2020 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147474	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147001	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147065	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147066	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147074	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147403	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147474	9/8/2020 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 1:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1386188068	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1508315516	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548375082	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1922542604	9/8/2020 1:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 1:31 PM
Details	Last Recertification Date	Update	Recertification		9/8/2020 1:31:22 PM	9/8/2020 1:31 PM
Contacts	Authorizing Official	Update	Change Request	Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	Nelson, Nan SVP-Finance Advocate Aurora Health Care 4142991610	6/17/2020 10:23 AM
Contacts	Primary Contact	Update	Change Request	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	6/3/2020 8:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362169147001	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362169147403	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362169147065	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362169147066	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362169147074	3/2/2020 11:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/2/2020 11:54 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	10/31/2019 8:33 AM
Details	340B ID	Update	New Registration		DSH140208B	10/31/2019 8:33 AM
Details	Entity Name	Update	New Registration	ADVOCATE CHRIST HOSPITAL	ADVOCATE CHRIST MEDICAL CENTER	10/31/2019 8:33 AM
Details	Entity Subname	Update	New Registration	Physical Therapy	Physical Therapy - Tinley Park Rehab	10/31/2019 8:33 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2019 8:33:15 AM	10/31/2019 8:33 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2019 8:33 AM
Dates	Signed By Date	Update	New Registration		10/9/2019 5:34:37 PM	10/31/2019 8:33 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/31/2019 8:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1922542604	10/9/2019 9:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1386188068	10/9/2019 9:34 PM
Addresses	Main Address	Insert	New Registration		1821 S. La Grange Road Tinley Park, IL 60487	10/3/2019 1:16 PM
Addresses	Billing Address	Insert	New Registration		Advocate Christ Medical Center 4440 W 95th Street Oak Lawn, IL 60453	10/3/2019 1:16 PM
Addresses	Shipping Address	Insert	New Registration		Advocate Christ Medical Center 4440 W 95th Street Oak Lawn, IL 60453	10/3/2019 1:16 PM
Addresses	Shipping Address	Insert	New Registration		Advocate Central Service Center 15-17 W. College Dr Arlington Heights, IL 60004	10/3/2019 1:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1508315516	10/3/2019 1:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548375082	10/3/2019 1:16 PM
Contacts	Primary Contact	Insert	New Registration		De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	10/3/2019 1:16 PM
Contacts	Authorizing Official	Insert	New Registration		Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	10/3/2019 1:16 PM
Details	Last Recertification Date	Insert	New Registration			10/3/2019 1:16 PM
Details	Grant Number	Insert	New Registration			10/3/2019 1:16 PM
Details	340B ID	Insert	New Registration			10/3/2019 1:16 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/3/2019 1:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/3/2019 1:16 PM
Details	Medicare Provider Number	Insert	New Registration		140208	10/3/2019 1:16 PM
Details	Entity Name	Insert	New Registration		ADVOCATE CHRIST HOSPITAL	10/3/2019 1:16 PM
Details	Program Code	Insert	New Registration		DSH	10/3/2019 1:16 PM
Details	Entity Subname	Insert	New Registration		Physical Therapy	10/3/2019 1:16 PM
Dates	Participating Approval Date	Insert	New Registration			10/3/2019 1:16 PM
Details	State	Insert	New Registration		Pending	10/3/2019 1:16 PM
Dates	Registration Date	Insert	New Registration		10/3/2019 1:16:05 PM	10/3/2019 1:16 PM
Dates	Signed By Date	Insert	New Registration			10/3/2019 1:16 PM
Dates	Start Date	Insert	New Registration			10/3/2019 1:16 PM
Terminations	Termination Comments	Insert	New Registration			10/3/2019 1:16 PM
Terminations	Termination Date	Insert	New Registration			10/3/2019 1:16 PM
Terminations	Termination Effective Date	Insert	New Registration			10/3/2019 1:16 PM
Terminations	Termination Reason	Insert	New Registration			10/3/2019 1:16 PM