Covered Entity Details

CAH141305-09 Memorial Hospital Association (Active) - information as of 4/28/2025 1:44:34 AM

Main Details

Name

Memorial Hospital Association

Subdivision Name

MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC - PROVIDER BASED CLINIC-Rhuematology

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141305-09

Medicare Provider Number

141305

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/18/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/7/2019

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Memorial Hospital Assoication
Teresa Smith, CFO
(217) 357-8573

Primary Contact

Memorial Hospital
Ada Bair, CEO
(217) 357-8566

Addresses

Street Address

1450 N County Road 2050
Carthage, IL 62321

Billing Address

MEMORIAL HOSPITAL ASSOCIATION
PO Box 160
Carthage, IL 62321

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?
No

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
CAH141305-01	Child	CAH	Memorial Hospital Association	Bowen Family Clinic	209 E 5th Street	Bowen	IL	Active
CAH141305-02	Child	CAH	Memorial Hospital Association	Women & Family Group	630 Locust St	Carthage	IL	Active
CAH141305-03	Child	CAH	Memorial Hospital Association	Carthage Clinic	1450 North County Road 2050	Carthage	IL	Active
CAH141305-04	Child	CAH	Memorial Hospital Association	RHC-NAUVOO CLINIC	1370 MULLHOLLAND ST	NAUVOO	IL	Active
CAH141305-05	Child	CAH	Memorial Hospital Association	Memorial Medical Clinic LaHarpe	501 E Main	LaHarpe	IL	Active
CAH141305-06	Child	CAH	Memorial Hospital Association	D/B/A MEMORIAL MEDICAL CLINICS CARTHAGE / Gero Psych - Outpatient Geriatric Counceling	D/B/A MEMORIAL MEDICAL CLINICS CARTHAGE	CARTHAGE	IL	Active
CAH141305-07	Child	CAH	Memorial Hospital Association	Colchester Clinic	110 E MARKET ST	COLCHESTER	IL	Active
CAH141305-08	Child	CAH	Memorial Hospital Association	Memorial Hospital Association-Provider Based - Provider Based Specialty-Neurology	1450 North County Road 2050	Carthage	IL	Active
CAH141305-09	Child	CAH	Memorial Hospital Association	MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC - PROVIDER BASED CLINIC-Rhuematology	1450 N County Road 2050	Carthage	IL	Active
CAH141305-10	Child	CAH	Memorial Hospital Association	MEMORIAL HOSPITAL ASSOICATION-PROVIDER BASED - PROVIDER BASED SPECIALTY-ENDOCRINOLOGY	1450 N County Road 2050	Carthage	IL	Active
CAH141305-11	Child	CAH	Memorial Hospital Association	MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC - PROVIDER BASED CLINIC - UROLOGY	1450 North County Road 2050	Carthage	IL	Active
CAH141305-12	Child	CAH	Memorial Hospital Association	MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC - ORTHOPEDIC	1450 North County Road 2050	Carthage	IL	Active
CAH141305-13	Child	CAH	Memorial Hospital Association	Memorial Hospital Association Provider Based Specialty - Dermatology	1450 North County 2050	Carthage	IL	Active
CAH141305-14	Child	CAH	Memorial Hospital Association	Memorial Hospital Association Medical Based Clinic-Pulmonary - Pulmonary	1450 North County 2050	Carthage	IL	Active
CAH141305-15	Child	CAH	Memorial Hospital Association	Memorial Hospital Association Medical Based Clinic-Cardio - Cardiology	1450 North County 2050	Carthage	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 2:17:49 PM	8/19/2024 3:18:33 PM	8/19/2024 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 2:23:26 PM	8/15/2023 2:17:49 PM	8/15/2023 2:17 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 5:01:43 PM	8/29/2022 2:23:26 PM	8/29/2022 2:23 PM
Details	Last Recertification Date	Update	Recertification	9/2/2020 5:21:03 PM	8/23/2021 5:01:43 PM	8/23/2021 5:01 PM
Details	Last Recertification Date	Update	Recertification		9/2/2020 5:21:03 PM	9/2/2020 5:21 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Smith, Teresa CFO Memorial Hospital Assoication 2173578573	11/7/2019 2:10 PM
Details	340B ID	Update	New Registration		CAH141305-09	11/7/2019 2:10 PM
Details	Entity Name	Update	New Registration	MEMORIAL HOSPITAL ASSOCIATION	Memorial Hospital Association	11/7/2019 2:10 PM
Details	Entity Subname	Update	New Registration	MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC	MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC - PROVIDER BASED CLINIC-Rhuematology	11/7/2019 2:10 PM
Dates	Participating Approval Date	Update	New Registration		11/7/2019 2:10:40 PM	11/7/2019 2:10 PM
Details	State	Update	New Registration	Pending	Approved	11/7/2019 2:10 PM
Dates	Signed By Date	Update	New Registration		10/18/2019 5:46:05 PM	11/7/2019 2:10 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/7/2019 2:10 PM
Addresses	Main Address	Insert	New Registration		1450 N County Road 2050 Carthage, IL 62321	10/18/2019 5:46 PM
Addresses	Billing Address	Insert	New Registration		MEMORIAL HOSPITAL ASSOCIATION PO Box 160 Carthage, IL 62321	10/18/2019 5:46 PM
Contacts	Primary Contact	Insert	New Registration		Bair, Ada CEO Memorial Hospital 2173578566	10/18/2019 5:46 PM
Contacts	Authorizing Official	Insert	New Registration		Smith, Teresa CFO Memorial Hospital Assoication 2173578573	10/18/2019 5:46 PM
Details	Last Recertification Date	Insert	New Registration			10/18/2019 5:46 PM
Details	Grant Number	Insert	New Registration			10/18/2019 5:46 PM
Details	340B ID	Insert	New Registration			10/18/2019 5:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/18/2019 5:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/18/2019 5:46 PM
Details	Medicare Provider Number	Insert	New Registration		141305	10/18/2019 5:46 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HOSPITAL ASSOCIATION	10/18/2019 5:46 PM
Details	Program Code	Insert	New Registration		CAH	10/18/2019 5:46 PM
Details	Entity Subname	Insert	New Registration		MEMORIAL HOSPITAL ASSOCIATION-PROVIDER BASED CLINIC	10/18/2019 5:46 PM
Dates	Participating Approval Date	Insert	New Registration			10/18/2019 5:46 PM
Details	State	Insert	New Registration		Pending	10/18/2019 5:46 PM
Dates	Registration Date	Insert	New Registration		10/18/2019 5:46:02 PM	10/18/2019 5:46 PM
Dates	Signed By Date	Insert	New Registration			10/18/2019 5:46 PM
Dates	Start Date	Insert	New Registration			10/18/2019 5:46 PM
Terminations	Termination Comments	Insert	New Registration			10/18/2019 5:46 PM
Terminations	Termination Date	Insert	New Registration			10/18/2019 5:46 PM
Terminations	Termination Effective Date	Insert	New Registration			10/18/2019 5:46 PM
Terminations	Termination Reason	Insert	New Registration			10/18/2019 5:46 PM