Covered Entity Details

RRC140223-18 ADVOCATE LUTHERAN GENERAL HOSPITAL (Active) - information as of 5/9/2025 10:39:34 PM

Main Details

Name

ADVOCATE LUTHERAN GENERAL HOSPITAL

Subdivision Name

Radiology - Diagnostic - CAC XRAY

Type

Rural Referral Center

Rural

Yes

340B ID

RRC140223-18

Medicare Provider Number

140223

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/9/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/13/2020

Last Recertification Date

8/14/2024

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

1700 Luther Lane
Suite 1320
Park Ridge, IL 60068

Billing Address

Advocate Lutheran General Hospital
1775 W. Dempster Street
Park Ridge, IL 60068

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	362169147025,362169147026,362169147408	1164539730
WI	362169147025,362169147026,362169147408	1164539730

Shipping Addresses

Shipping Address 1

Advocate Lutheran General Hospital
1775 W. Dempster Street
Park Ridge, IL 60068

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
RRC140223-01	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Pain Clinic - Pain Clinic	1875 Dempster Street	Park Ridge	IL	Active
RRC140223-02	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Outpatient Center - Outpatient Center	1875 Dempster Street	Park Ridge	IL	Active
RRC140223-03	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Apheresis Center - Apheresis Center	1875 Dempster Street	Park Ridge	IL	Active
RRC140223-04	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Occupational Therapy - O/P Rehab Nathanson	9375 W Church St	Des Plaines	IL	Terminated
RRC140223-05	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Occupational Therapy - O/P Wound Care	8816 Dempster Ave	Niles	IL	Active
RRC140223-06	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Ultrasound - Yacktman Ultrasound	1675 Dempster Ave	Park Ridge	IL	Terminated
RRC140223-07	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Outpatient Center - Pulmonary Rehab	1875 Dempster Street	Park Ridge	IL	Terminated
RRC140223-08	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Outpatient Center - ACH Behavioral Health Service	1675 Dempster Ave	Park Ridge	IL	Terminated
RRC140223-09	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Outpatient Center - Anticoagulation Clinic	8820 Dempster Ave	Niles	IL	Active
RRC140223-10	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Electrocardiology - Heart Station - Yacktman	1675 Dempster Ave	Park Ridge	IL	Terminated
RRC140223-11	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Rehab Medicine - Pediatric Neuropsych	1675 Dempster Ave	Park Ridge	IL	Active
RRC140223-12	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radiology - Radiology Yacktman	1675 Dempster Ave	Park Ridge	IL	Active
RRC140223-13	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	The Breast Program - The Breast Program	1700 Luther Lane 3rd Floor	Park Ridge	IL	Active
RRC140223-14	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Occupational Therapy - Pediatric Therapies	1675 Dempster Ave	Park Ridge	IL	Terminated
RRC140223-15	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Magnetic Resonance Imaging - MRI	1700 Luther Lane	Park Ridge	IL	Active
RRC140223-16	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	CT Scan - CAC PET	1700 Luther Lane	Park Ridge	IL	Active
RRC140223-17	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radiology - Therapeutic - CAC Radiation Oncology	1700 Luther Lane	Park Ridge	IL	Active
RRC140223-18	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radiology - Diagnostic - CAC XRAY	1700 Luther Lane	Park Ridge	IL	Active
RRC140223-19	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radioisotope - Vascular Lab	8816 W. Dempster Ave	Niles	IL	Terminated
RRC140223-20	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radiology - Diagnostic - Radiology USN	1700 Luther Lane	Park Ridge	IL	Terminated
RRC140223-21	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Outpatient Center - Pediatric Oncology Clinic	1675 Dempster Ave	Park Ridge	IL	Active
RRC140223-22	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Radiology - Therapeutic - CAC Cyberknife	1700 Luther Lane	Park Ridge	IL	Terminated
RRC140223-23	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Day Hospital - Child/Adult Day Treatment	1675 Dempster Ave	Park Ridge	IL	Active
RRC140223-24	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	CT Scan - CAC CT	1700 Luther Lane	Park Ridge	IL	Active
RRC140223-25	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Respiratory Therapy - Respiratory Therapy Peds	1675 Dempster Ave	Park Ridge	IL	Terminated
RRC140223-26	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Crystal Lake Infusion - Infusion	525 Congress Parkway	Crystal Lake	IL	Active
RRC140223-27	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Electroencephalography - Sleep Center - Sleep Center	1875 W Dempster St	Park Ridge	IL	Active
RRC140223-28	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Neurology Infusion - Infusion	1875 Dempster Street	Park Ridge	IL	Active
RRC140223-29	Child	RRC	ADVOCATE LUTHERAN GENERAL HOSPITAL	Elgin Infusion - Hematology	1425 N Randall Rd	Elgin	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	1700 Luther Lane Park Ridge, IL 60068	1700 Luther Lane Suite 1320 Park Ridge, IL 60068	5/2/2025 7:03 AM
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:42:08 PM	8/14/2024 8:39:35 PM	8/14/2024 8:39 PM
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	Last Recertification Date	Update	Recertification	9/2/2022 12:12:51 PM	8/23/2023 4:42:08 PM	8/23/2023 4:42 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 11:41:23 AM	9/2/2022 12:12:51 PM	9/2/2022 12:12 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	5/5/2022 10:51 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 2:10:44 PM	9/10/2021 11:41:23 AM	9/10/2021 11:41 AM
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
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147025	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147026	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		362169147408	9/8/2020 2:10 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 2:10 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	9/8/2020 2:10 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1164539730	9/8/2020 2:10 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 2:10 PM
Details	Last Recertification Date	Update	Recertification		9/8/2020 2:10:44 PM	9/8/2020 2:10 PM
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	7/16/2020 8:17 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
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 10:58 AM
Contacts	Signed By	Insert	New Registration		Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	4/13/2020 1:11 PM
Details	340B ID	Update	New Registration		RRC140223-18	4/13/2020 1:11 PM
Details	Entity Subname	Update	New Registration	Radiology - Diagnostic	Radiology - Diagnostic - CAC XRAY	4/13/2020 1:11 PM
Dates	Participating Approval Date	Update	New Registration		4/13/2020 1:11:38 PM	4/13/2020 1:11 PM
Details	State	Update	New Registration	Pending	Approved	4/13/2020 1:11 PM
Dates	Signed By Date	Update	New Registration		4/10/2020 10:56:38 AM	4/13/2020 1:11 PM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/13/2020 1:11 PM
Addresses	Main Address	Insert	New Registration		1700 Luther Lane Park Ridge, IL 60068	4/9/2020 10:10 PM
Addresses	Billing Address	Insert	New Registration		Advocate Lutheran General Hospital 1775 W. Dempster Street Park Ridge, IL 60068	4/9/2020 10:10 PM
Addresses	Shipping Address	Insert	New Registration		Advocate Lutheran General Hospital 1775 W. Dempster Street Park Ridge, IL 60068	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362169147025	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362169147026	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362169147408	4/9/2020 10:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/9/2020 10:10 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164539730	4/9/2020 10:10 PM
Contacts	Primary Contact	Insert	New Registration		De Ianni, Angela Director Supply Chain, Pharmacy Advocate Aurora Health Care 4143821854	4/9/2020 10:10 PM
Contacts	Authorizing Official	Insert	New Registration		Nelson, Nanine SVP-Finance Advocate Aurora Health Care 4142991610	4/9/2020 10:10 PM
Details	Last Recertification Date	Insert	New Registration			4/9/2020 10:10 PM
Details	Grant Number	Insert	New Registration			4/9/2020 10:10 PM
Details	340B ID	Insert	New Registration			4/9/2020 10:10 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2020 10:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2020 10:10 PM
Details	Medicare Provider Number	Insert	New Registration		140223	4/9/2020 10:10 PM
Details	Entity Name	Insert	New Registration		ADVOCATE LUTHERAN GENERAL HOSPITAL	4/9/2020 10:10 PM
Details	Program Code	Insert	New Registration		RRC	4/9/2020 10:10 PM
Details	Entity Subname	Insert	New Registration		Radiology - Diagnostic	4/9/2020 10:10 PM
Dates	Participating Approval Date	Insert	New Registration			4/9/2020 10:10 PM
Details	State	Insert	New Registration		Pending	4/9/2020 10:10 PM
Dates	Registration Date	Insert	New Registration		4/9/2020 10:10:37 PM	4/9/2020 10:10 PM
Dates	Signed By Date	Insert	New Registration			4/9/2020 10:10 PM
Dates	Start Date	Insert	New Registration			4/9/2020 10:10 PM
Terminations	Termination Comments	Insert	New Registration			4/9/2020 10:10 PM
Terminations	Termination Date	Insert	New Registration			4/9/2020 10:10 PM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2020 10:10 PM
Terminations	Termination Reason	Insert	New Registration			4/9/2020 10:10 PM