Covered Entity Details

RRC140135-42 Decatur Memorial Hospital (Active) - information as of 4/25/2025 5:40:30 PM

Main Details

Name

Decatur Memorial Hospital

Subdivision Name

South Shores Imaging Center

Type

Rural Referral Center

Rural

340B ID

RRC140135-42

Medicare Provider Number

140135

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/5/2019

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Decatur Memorial Hospital
Drew Early, President CEO
(217) 876-2114

Primary Contact

Decatur Memorial Hospital
Paul William Robinson, 340B Coordinator
(217) 876-2031

Addresses

Street Address

1689 S FRANKLIN STREET RD
DECATUR, IL 62521-4018

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	370661199001,370661199401	1548357973

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
RRC140135-01	Child	RRC	Decatur Memorial Hospital	Forsyth Medical Center - Michael M. Wall, M.D	241 W. Weaver Road, Ste.145C	Forsyth	IL	Active
RRC140135-02	Child	RRC	Decatur Memorial Hospital	Scribner Family Practice	Forsyth Medical Center	Forsyth	IL	Terminated
RRC140135-03	Child	RRC	Decatur Memorial Hospital	Forsyth Medical Center - DMH Family Medicine Forsyth	241 W. Weaver Road, Ste. 145D	Forsyth	IL	Active
RRC140135-04	Child	RRC	Decatur Memorial Hospital	Forsyth Medical Center - Forsyth Family Medicine	241 W. Weaver Road, Ste. 145A	Forsyth	IL	Active
RRC140135-05	Child	RRC	Decatur Memorial Hospital	Barnes Family Practice	Forsyth Medical Center	Forsyth	IL	Terminated
RRC140135-06	Child	RRC	Decatur Memorial Hospital	DMG Internal Medicine 2	Forsyth Medical Center	Forsyth	IL	Active
RRC140135-07	Child	RRC	Decatur Memorial Hospital	Express Care North	3131 N. Water Street	Decatur	IL	Terminated
RRC140135-08	Child	RRC	Decatur Memorial Hospital	Express Care East	4455 US Rte 36 East	Decatur	IL	Terminated
RRC140135-09	Child	RRC	Decatur Memorial Hospital	DMH Lung Center	302 W Hay St, Ste. 110	Decatur	IL	Active
RRC140135-10	Child	RRC	Decatur Memorial Hospital	Arthur Medical Center	650 W. Columbia	Arthur	IL	Terminated
RRC140135-11	Child	RRC	Decatur Memorial Hospital	Urology Associates of Decatur	West Hay Medical Center	Decatur	IL	Terminated
RRC140135-12	Child	RRC	Decatur Memorial Hospital	Sullivan Medical Center	1220 W. Jackson Street	Sullivan	IL	Active
RRC140135-13	Child	RRC	Decatur Memorial Hospital	Dr. Marvin Derrick	2300 N. Edward St., Suite 2350	Decatur	IL	Terminated
RRC140135-14	Child	RRC	Decatur Memorial Hospital	Illinois Heart Specialists	Decatur memorial Hospital	Decatur	IL	Terminated
RRC140135-15	Child	RRC	Decatur Memorial Hospital	ENTA Allergy, Head & Neck Institute	101 W. McKinley Avenue	Decatur	IL	Active
RRC140135-16	Child	RRC	Decatur Memorial Hospital	Bailey & Gilman	West Hay Medical Center	Decatur	IL	Terminated
RRC140135-17	Child	RRC	Decatur Memorial Hospital	South Shores Medical Center	550 Southland Dr	Decatur	IL	Active
RRC140135-18	Child	RRC	Decatur Memorial Hospital	Decatur Neurosurgery Associates	2 Memorial Drive, Ste. 207	Decatur	IL	Active
RRC140135-19	Child	RRC	Decatur Memorial Hospital	Gowdar & Gowdar Family Practice	741 W. Pershing Road, Prov. Dept. 71938	Decatur	IL	Terminated
RRC140135-20	Child	RRC	Decatur Memorial Hospital	George Liu MD Surgery	West Hay Medical Center	Decatur	IL	Terminated
RRC140135-21	Child	RRC	Decatur Memorial Hospital	Jordan S Youngerman MD	1 Memorial Drive, Ste. 110	Decatur	IL	Active
RRC140135-22	Child	RRC	Decatur Memorial Hospital	Center for Advanced Surgery	West Hay Medical Center	Decatur	IL	Terminated
RRC140135-23	Child	RRC	Decatur Memorial Hospital	West Hay Family Medicine	West Hay Medical Center	Decatur	IL	Terminated
RRC140135-24	Child	RRC	Decatur Memorial Hospital	DMG Internal Medicine	241 W. Weaver Rd., Ste. 210	Forsyth	IL	Active
RRC140135-25	Child	RRC	Decatur Memorial Hospital	DMH Family Medicine	4775 E. Maryland Street, Prov. Dept. 71922	Decatur	IL	Terminated
RRC140135-26	Child	RRC	Decatur Memorial Hospital	DMH Family Medicine	4775 E Maryland St	Decatur	IL	Active
RRC140135-27	Child	RRC	Decatur Memorial Hospital	DMH Family Medicine	4775 E Maryland St Ste A	Decatur	IL	Terminated
RRC140135-28	Child	RRC	Decatur Memorial Hospital	DMH Millenium Pain Center	304 W Hay ST, STE 213	Decatur	IL	Active
RRC140135-29	Child	RRC	Decatur Memorial Hospital	Kidney Specialists of Central Illinois	301 W. Hay St.	Decatur	IL	Active
RRC140135-30	Child	RRC	Decatur Memorial Hospital	DMH Podiatry	2 Memorial Dr., Plaza West	Decatur	IL	Active
RRC140135-31	Child	RRC	Decatur Memorial Hospital	Shelbyville Medical Clinic - General Clinic	415 N. Cedar St.	Shelbyville	IL	Terminated
RRC140135-32	Child	RRC	Decatur Memorial Hospital	Hospice - Hospice	2870 N Main ST	Decatur	IL	Terminated
RRC140135-33	Child	RRC	Decatur Memorial Hospital	Infectious Disease Specialist of Central Illinois	304 W. Hay St.	Decatur	IL	Active
RRC140135-34	Child	RRC	Decatur Memorial Hospital	Home Health Care - Home Health	2870 N Main ST	Decatur	IL	Terminated
RRC140135-35	Child	RRC	Decatur Memorial Hospital	Cancer Care Center of Decatur	210 W. McKinley Ave.	Decatur	IL	Active
RRC140135-36	Child	RRC	Decatur Memorial Hospital	DMG Gastroenterology	2 Memorial Dr.	Decatur	IL	Active
RRC140135-37	Child	RRC	Decatur Memorial Hospital	DMH Rock Springs Medical Center	330 N. Wyckles Rd.	Decatur	IL	Active
RRC140135-38	Child	RRC	Decatur Memorial Hospital	DMH VEIN AND VASCULAR INSTITUTE - DMH VEIN AND VASCULAR INSTITUTE	1 MEMORIAL DR	DECATUR	IL	Terminated
RRC140135-39	Child	RRC	Decatur Memorial Hospital	DMH Family Medicine Associates	2975 N WATER ST	DECATUR	IL	Active
RRC140135-40	Child	RRC	Decatur Memorial Hospital	DMH MONTICELLO MEDICAL CENTER - DMH MONTICELLO MEDICAL CENTER	777 W BRIDGE ST	MONTICELLO	IL	Terminated
RRC140135-41	Child	RRC	Decatur Memorial Hospital	Memorial Surgery Center - Surgery	1 Memorial Drive, Ste. 300	Decatur	IL	Active
RRC140135-42	Child	RRC	Decatur Memorial Hospital	South Shores Imaging Center	1689 S FRANKLIN STREET RD	DECATUR	IL	Active
RRC140135-43	Child	RRC	Decatur Memorial Hospital	Forsyth Imaging Center	389 W WEAVER RD	FORSYTH	IL	Active
RRC140135-44	Child	RRC	Decatur Memorial Hospital	DMH Orthopaedic Associates	304 W. Hay St., Ste. 111	Decatur	IL	Active
RRC140135-45	Child	RRC	Decatur Memorial Hospital	Decatur Neurosurgery Associates 2 - Neurological Surgery	2 Memorial Drive, Ste. 202	Decatur	IL	Active
RRC140135-46	Child	RRC	Decatur Memorial Hospital	DMH Surgery Center - Surgery	304 W. Hay St., Ste 114	Decatur	IL	Active
RRC140135-47	Child	RRC	Decatur Memorial Hospital	DMH Endoscopy - Endoscopy	2 Memorial Dr., Ste. 102	Decatur	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 11:09:33 AM	8/21/2024 3:56:26 PM	8/21/2024 3:56 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 9:12:29 AM	8/23/2023 11:09:33 AM	8/23/2023 11:09 AM
Contacts	Authorizing Official	Update	AO Change Request	Bragg, Deborah L. Senior VP, Finance Decatur Memorial Hospital 2178762107	Early, Drew President CEO Decatur Memorial Hospital 2178762114	6/20/2023 7:29 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 5:44:12 PM	8/24/2022 9:12:29 AM	8/24/2022 9:12 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1942352273 (IL)		1/5/2022 2:58 PM
Details	Entity Subname	Update	Change Request	SOUTH SHORES IMAGING CENTER - Diagnostic Imaging Services	South Shores Imaging Center	1/5/2022 2:58 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 11:37:31 AM	8/17/2021 5:44:12 PM	8/17/2021 5:44 PM
Contacts	Primary Contact	Update	Change Request	Stice, Kristi Director, Pharmacy Decatur Memorial Hospital 2178766201	Robinson, Paul William 340B Coordinator Decatur Memorial Hospital 2178762031	3/3/2021 9:27 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/25/2020 11:37 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/25/2020 11:37 AM
Details	Last Recertification Date	Update	Recertification		8/25/2020 11:37:31 AM	8/25/2020 11:37 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Bragg, Deborah L. Senior VP, Finance Decatur Memorial Hospital 2178762107	11/5/2019 1:59 PM
Details	340B ID	Update	New Registration		RRC140135-42	11/5/2019 1:59 PM
Details	Entity Name	Update	New Registration	DECATUR MEMORIAL HOSPITAL	Decatur Memorial Hospital	11/5/2019 1:59 PM
Details	Entity Subname	Update	New Registration	SOUTH SHORES IMAGING CENTER	SOUTH SHORES IMAGING CENTER - Diagnostic Imaging Services	11/5/2019 1:59 PM
Dates	Participating Approval Date	Update	New Registration		11/5/2019 1:59:56 PM	11/5/2019 1:59 PM
Details	State	Update	New Registration	Pending	Approved	11/5/2019 1:59 PM
Dates	Signed By Date	Update	New Registration		10/14/2019 1:44:59 PM	11/5/2019 1:59 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/5/2019 1:59 PM
Addresses	Main Address	Insert	New Registration		1689 S FRANKLIN STREET RD DECATUR, IL 62521-4018	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370661199001	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370661199401	10/14/2019 12:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/14/2019 12:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548357973	10/14/2019 12:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942352273	10/14/2019 12:18 PM
Contacts	Primary Contact	Insert	New Registration		Stice, Kristi Director, Pharmacy Decatur Memorial Hospital 2178766201	10/14/2019 12:18 PM
Contacts	Authorizing Official	Insert	New Registration		Bragg, Deborah L. Senior VP, Finance Decatur Memorial Hospital 2178762107	10/14/2019 12:18 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2019 12:18 PM
Details	Grant Number	Insert	New Registration			10/14/2019 12:18 PM
Details	340B ID	Insert	New Registration			10/14/2019 12:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2019 12:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2019 12:18 PM
Details	Medicare Provider Number	Insert	New Registration		140135	10/14/2019 12:18 PM
Details	Entity Name	Insert	New Registration		DECATUR MEMORIAL HOSPITAL	10/14/2019 12:18 PM
Details	Program Code	Insert	New Registration		RRC	10/14/2019 12:18 PM
Details	Entity Subname	Insert	New Registration		SOUTH SHORES IMAGING CENTER	10/14/2019 12:18 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2019 12:18 PM
Details	State	Insert	New Registration		Pending	10/14/2019 12:18 PM
Dates	Registration Date	Insert	New Registration		10/14/2019 12:18:23 PM	10/14/2019 12:18 PM
Dates	Signed By Date	Insert	New Registration			10/14/2019 12:18 PM
Dates	Start Date	Insert	New Registration			10/14/2019 12:18 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2019 12:18 PM
Terminations	Termination Date	Insert	New Registration			10/14/2019 12:18 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2019 12:18 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2019 12:18 PM