Covered Entity Details

DSH140304G UChicago Medicine AdventHealth Bolingbrook (Active) - information as of 4/27/2025 12:51:21 AM

Main Details

Name

UChicago Medicine AdventHealth Bolingbrook

Subdivision Name

UChicago Medicine AdventHealth Infusion Center Hinsdale

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140304G

Medicare Provider Number

140304

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/1/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/8/2020

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

UChicago Medicine AdventHealth Bolingbrook
Tristan R Shaw, CFO
(630) 312-6008

Primary Contact

UChicago Medicine AdventHealth Bolingbrook
DAVID TSANG, 340B PROGRAM DIRECTOR
(847) 372-8408

Addresses

Street Address

1 Salt Creek Ln, STE 100
HINSDALE, IL 60521-2936

Billing Address

UChicago Medicine AdventHealth Bolingbrook
c/o AdventHealth
902 Inspiration Avenue
Suite 9100
Altamonte Springs, FL 32714

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	651219504001	1164530465,1184923260,1013372440,1205120706,1336925817

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
DSH140304A	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Pain Management Bolingbrook	420 South Schmidt Road	Bolingbrook	IL	Active
DSH140304B	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Outpatient Women's Clinic	396 Remington Blvd	Bolingbrook	IL	Terminated
DSH140304C	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Plainfield Imaging and Outpatient Center	15720 S. Route 59	Plainfield	IL	Terminated
DSH140304D	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	PT Solutions at Adventist Bolingbrook Hospital	396 Remington Blvd	Bolingbrook	IL	Terminated
DSH140304E	Child	DSH	ADVENTIST BOLINGBROOK HOSPITAL	Wound Care Center	420 Schmidt Road	Bolingbrook	IL	Terminated
DSH140304F	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Infusion Center Bolingbrook	396 Remington Blvd	Bolingbrook	IL	Active
DSH140304G	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Infusion Center Hinsdale	1 Salt Creek Ln, STE 100	HINSDALE	IL	Active
DSH140304H	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Medication Therapy Management Clinic Bolingbrook	500 REMINGTON BLVD	BOLINGBROOK	IL	Active
DSH140304J	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Non-Chemo Infusion Hinsdale	1 SALT CREEK LN	HINSDALE	IL	Active
DSH140304K	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Ambulatory Clinic and Infusion Bolingbrook	420 South Schmidt Road	Bolingbrook	IL	Active
DSH140304L	Child	DSH	UChicago Medicine AdventHealth Bolingbrook	UChicago Medicine AdventHealth Bariatric Surgery Center Bolingbrook - Bariatric Surgery Center	420 S Schmidt Road	Bolingbrook	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	1 Salt Creek Ln, Room 1414 HINSDALE, IL 60521-2936	1 Salt Creek Ln, STE 100 HINSDALE, IL 60521-2936	1/27/2025 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1205120706	9/4/2024 2:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/4/2024 2:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336925817	9/4/2024 2:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/4/2024 2:10 PM
Details	Last Recertification Date	Update	Recertification	8/30/2023 9:43:53 AM	8/12/2024 9:19:47 AM	8/12/2024 9:19 AM
Contacts	Primary Contact	Update	Change Request	TSANG, DAVID PHARMACY DIRECTOR ADVENT HEALTH 8473728408	TSANG, DAVID 340B PROGRAM DIRECTOR UChicago Medicine AdventHealth Bolingbrook 8473728408	4/29/2024 8:33 AM
Contacts	Authorizing Official	Update	Change Request	Lee, Sun C Regional VP Ancillary & Oncology UChicago Medicine AdventHealth Bolingbrook 6308566518	Shaw, Tristan R CFO UChicago Medicine AdventHealth Bolingbrook 6303126008	4/19/2024 7:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1013372440	4/11/2024 2:49 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/11/2024 2:49 PM
Addresses	Main Address	Update	Change Request	UChicago Medicine AdventHealth Infusion Center Hinsdale 1 Salt Creek Ln, Room 1414 HINSDALE, IL 60521-2936	1 Salt Creek Ln, Room 1414 HINSDALE, IL 60521-2936	1/19/2024 9:02 AM
Details	Entity Subname	Update	Change Request	ACI - HINSDALE - cancer institute	UChicago Medicine AdventHealth Infusion Center Hinsdale	1/19/2024 9:02 AM
Details	Entity Name	Update	Recertification	ADVENTIST BOLINGBROOK HOSPITAL	UChicago Medicine AdventHealth Bolingbrook	9/5/2023 10:34 AM
Addresses	Main Address	Update	Recertification	1 SALT CREEK LN Room 1414 HINSDALE, IL 60521-2936	UChicago Medicine AdventHealth Infusion Center Hinsdale 1 Salt Creek Ln, Room 1414 HINSDALE, IL 60521-2936	8/30/2023 9:43 AM
Addresses	Billing Address	Update	Recertification	Adventist Bolingbrook Hospital c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	UChicago Medicine AdventHealth Bolingbrook c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	8/30/2023 9:43 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 10:30:35 AM	8/30/2023 9:43:53 AM	8/30/2023 9:43 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lee, Sun C Regional VP Ancillary & Oncology Adventist Bolingbrook Hospital 6308566518	Lee, Sun C Regional VP Ancillary & Oncology UChicago Medicine AdventHealth Bolingbrook 6308566518	8/17/2023 3:11 PM
Contacts	Authorizing Official	Update	AO Change Request	Brown, Jared Chief Financial Officer AdventHealth Bolingbrook 6303126003	Lee, Sun C Regional VP Ancillary & Oncology Adventist Bolingbrook Hospital 6308566518	7/26/2023 5:46 PM
Contacts	Authorizing Official	Update	Change Request	Radivojevic, Vladimir President & CEO AdventHealth GlenOaks 6305457258	Brown, Jared Chief Financial Officer AdventHealth Bolingbrook 6303126003	1/26/2023 12:21 PM
Contacts	Authorizing Official	Update	Profile Change Request	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	Radivojevic, Vladimir President & CEO AdventHealth GlenOaks 6305457258	10/19/2022 10:09 AM
Contacts	Signed By	Update	Profile Change Request	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	Radivojevic, Vladimir President & CEO AdventHealth GlenOaks 6305457258	10/19/2022 10:09 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1184923260	10/18/2022 8:28 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		IL	10/18/2022 8:28 PM
Addresses	Billing Address	Update	Recertification	Adventist Bolingbrook Hospital Accounts Payable 902 Inspiration Ave, Ste 9100 Altamonte Springs, FL 32714	Adventist Bolingbrook Hospital c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	9/16/2022 10:30 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 2:42:45 PM	9/16/2022 10:30:35 AM	9/16/2022 10:30 AM
Addresses	Billing Address	Update	Change Request	Adventist Bolingbrook Hospital c/o Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	Adventist Bolingbrook Hospital Accounts Payable 902 Inspiration Ave, Ste 9100 Altamonte Springs, FL 32714	7/5/2022 2:22 PM
Contacts	Authorizing Official	Update	Profile Change Request	Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	4/14/2022 12:31 PM
Contacts	Signed By	Update	Profile Change Request	Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	Radivojevic, Vladimir VP & COO AdventHealth Bolingbrook Hospital 6305457258	4/14/2022 12:31 PM
Contacts	Primary Contact	Update	Change Request	Fischer, Rick System Director, 340B Amita Health 6303097828	TSANG, DAVID PHARMACY DIRECTOR ADVENT HEALTH 8473728408	2/24/2022 9:29 AM
Contacts	Primary Contact	Update	Profile Change Request	Fischer, Rick System Director, 340B Amita Health 6309147828	Fischer, Rick System Director, 340B Amita Health 6303097828	1/20/2022 2:41 PM
Addresses	Main Address	Update	Change Request	1 SALT CREEK LN HINSDALE, IL 60521-2936	1 SALT CREEK LN Room 1414 HINSDALE, IL 60521-2936	9/24/2021 6:22 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 4:15:31 PM	8/20/2021 2:42:45 PM	8/20/2021 2:42 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/20/2020 4:15 PM
Details	Last Recertification Date	Update	Recertification		8/20/2020 4:15:31 PM	8/20/2020 4:15 PM
Contacts	Primary Contact	Update	Change Request	Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	Fischer, Rick System Director, 340B Amita Health 6309147828	8/7/2020 6:24 PM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	4/8/2020 10:21 AM
Details	340B ID	Update	New Registration		DSH140304G	4/8/2020 10:21 AM
Details	Entity Subname	Update	New Registration	ACI - HINSDALE	ACI - HINSDALE - cancer institute	4/8/2020 10:21 AM
Dates	Participating Approval Date	Update	New Registration		4/8/2020 10:21:06 AM	4/8/2020 10:21 AM
Details	State	Update	New Registration	Pending	Approved	4/8/2020 10:21 AM
Dates	Signed By Date	Update	New Registration		4/6/2020 2:30:08 PM	4/8/2020 10:21 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/8/2020 10:21 AM
Addresses	Main Address	Insert	New Registration		1 SALT CREEK LN HINSDALE, IL 60521-2936	4/1/2020 1:15 PM
Addresses	Billing Address	Insert	New Registration		Adventist Bolingbrook Hospital c/o Ascension Ministry Service Center PO Box 33902 Indianapolis, IN 46203	4/1/2020 1:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2020 1:15 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		651219504001	4/1/2020 1:15 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/1/2020 1:15 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164530465	4/1/2020 1:15 PM
Contacts	Primary Contact	Insert	New Registration		Whiteleather, Kim Pharmacy Data Analyst 340B Tallgrass Corporate Center 6309142438	4/1/2020 1:15 PM
Contacts	Authorizing Official	Insert	New Registration		Radivojevic, Vladimir VP & COO Amita Adventist Bolingbrook Hospital 6305457258	4/1/2020 1:15 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2020 1:15 PM
Details	Grant Number	Insert	New Registration			4/1/2020 1:15 PM
Details	340B ID	Insert	New Registration			4/1/2020 1:15 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2020 1:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2020 1:15 PM
Details	Medicare Provider Number	Insert	New Registration		140304	4/1/2020 1:15 PM
Details	Entity Name	Insert	New Registration		ADVENTIST BOLINGBROOK HOSPITAL	4/1/2020 1:15 PM
Details	Program Code	Insert	New Registration		DSH	4/1/2020 1:15 PM
Details	Entity Subname	Insert	New Registration		ACI - HINSDALE	4/1/2020 1:15 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2020 1:15 PM
Details	State	Insert	New Registration		Pending	4/1/2020 1:15 PM
Dates	Registration Date	Insert	New Registration		4/1/2020 1:15:27 PM	4/1/2020 1:15 PM
Dates	Signed By Date	Insert	New Registration			4/1/2020 1:15 PM
Dates	Start Date	Insert	New Registration			4/1/2020 1:15 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2020 1:15 PM
Terminations	Termination Date	Insert	New Registration			4/1/2020 1:15 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2020 1:15 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2020 1:15 PM