Covered Entity Details

RRC140034-08 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS (Terminated) - information as of 4/27/2025 12:55:40 AM

Main Details

Name

ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Subdivision Name

SMGS Centralia Pulmonology - Pulmonology

Type

Rural Referral Center

Rural

Yes

340B ID

RRC140034-08

Medicare Provider Number

140034

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/13/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/24/2020

Last Recertification Date

9/16/2022

Termination Date
Termination Reason

1/1/2023
Site closure

Contacts

Authorizing Official

SSM Health
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219

Primary Contact

Spendmend
Chelsea Violette, Director of Optimization
(845) 206-6019

Addresses

Street Address

1054 Martin Luther King Drive Suite 222
Centralia, IL 62801

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	370662580401,370662580001	1083617245,1255391611,1629003074,1710105192,1770687196

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
RRC140034-01	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	Behavioral Health - Angela Center	444 N. Pleasant Avenue	Centralia	IL	Terminated
RRC140034-02	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	ST MARYS HOSPTIAL Work Safety Institute - Physical Therapy	1250 W WHITTAKER ST	SALEM	IL	Terminated
RRC140034-03	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	CENTRALIA WORK SAFETY INSTITUTE - Physical Therapy	1441 W BROADWAY	CENTRALIA	IL	Terminated
RRC140034-04	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	Weight Management Clinic	432 N Pleasant Avenue	Centralia	IL	Terminated
RRC140034-05	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Surgery	1054 Martin Luther King Jr. Drive, Suite 125	Centralia	IL	Terminated
RRC140034-06	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMGS Centralia ENT	1054 Martin Luther King Jr. Drive, Suite 105	Centralia	IL	Terminated
RRC140034-07	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Cardiology	1054 Martin Luther King Jr. Dr, Suite 222	Centralia	IL	Terminated
RRC140034-08	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMGS Centralia Pulmonology - Pulmonology	1054 Martin Luther King Drive Suite 222	Centralia	IL	Terminated
RRC140034-09	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Infusion Center	1052 Martin Luther King Jr Drive Suite 100	Centralia	IL	Terminated
RRC140034-10	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Podiatry General Surgery	402 N PLEASANT AVE	CENTRALIA	IL	Terminated
RRC140034-11	Child	RRC	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	SMC - Podiatry	402 N PLEASANT AVE	CENTRALIA	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/31/2022 12:00:00 AM	10/19/2022 2:03 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/19/2022 2:03 PM
Terminations	Termination Comments	Update	Termination Request		Clinic closed 8/1/22, no 340B drugs purchased for site after 7/31/22.	10/19/2022 2:03 PM
Terminations	Termination Date	Update	Termination Request		1/1/2023 12:00:00 AM	10/19/2022 2:03 PM
Terminations	Termination Effective Date	Update	Termination Request		8/1/2022 12:00:00 AM	10/19/2022 2:03 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/19/2022 2:03 PM
Contacts	Primary Contact	Update	Group Change Request	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	Violette, Chelsea Director of Optimization Spendmend 8452066019	10/10/2022 5:34 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 4:42:04 PM	9/16/2022 1:10:57 PM	9/16/2022 1:10 PM
Contacts	Primary Contact	Update	Profile Change Request	Sharrow, Nicholas Director of Pharmacy SSM Health 9203246757	Sharrow, Nicholas Director of 340B Operations SSM Health 6087075611	8/17/2022 5:26 PM
Contacts	Primary Contact	Update	Group Change Request	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	Sharrow, Nicholas Director of Pharmacy SSM Health 9203246757	8/16/2022 11:32 AM
Contacts	Authorizing Official	Update	AO Change Request	Harbison, Damon President SSM Health - St. Mary's Hospital Centralia, IL 6184368000	Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	4/15/2022 9:24 AM
Contacts	Primary Contact	Update	Group Change Request	White, Tamika Senior Financial Analyst SSM Health 3149892320	Coultrip, Susan 340B Program Director SSM of Oklahoma 4058123230	2/14/2022 11:59 AM
Contacts	Primary Contact	Update	Change Request	Coffer, Denise Sr. Financial Analysit SSM Health 3149892289	White, Tamika Senior Financial Analyst SSM Health 3149892320	12/3/2021 7:46 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 10:40:20 AM	9/8/2021 4:42:04 PM	9/8/2021 4:42 PM
Contacts	Primary Contact	Update	Group Change Request	Peine, Jeffrey Finance Director SSM Health 3149893532	Coffer, Denise Sr. Financial Analysit SSM Health 3149892289	7/8/2021 4:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1083617245 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1770687196 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1629003074 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1255391611 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1710105192 ( )		9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1083617245	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255391611	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1629003074	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1710105192	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1770687196	9/11/2020 10:40 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:40 AM
Details	Last Recertification Date	Update	Recertification		9/11/2020 10:40:20 AM	9/11/2020 10:40 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Harbison, Damon President SSM Health - St. Mary's Hospital Centralia, IL 6184368000	4/24/2020 11:45 AM
Details	340B ID	Update	New Registration		RRC140034-08	4/24/2020 11:45 AM
Details	Entity Name	Update	New Registration	SSM HEALTH ST. MARYS HOSPITAL	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS	4/24/2020 11:45 AM
Details	Entity Subname	Update	New Registration	SMGS Centralia Pulmonology	SMGS Centralia Pulmonology - Pulmonology	4/24/2020 11:45 AM
Dates	Participating Approval Date	Update	New Registration		4/24/2020 11:45:03 AM	4/24/2020 11:45 AM
Details	State	Update	New Registration	Pending	Approved	4/24/2020 11:45 AM
Dates	Signed By Date	Update	New Registration		4/13/2020 5:13:50 PM	4/24/2020 11:45 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/24/2020 11:45 AM
Addresses	Main Address	Insert	New Registration		1054 Martin Luther King Drive Suite 222 Centralia, IL 62801	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370662580401	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370662580001	4/13/2020 1:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/13/2020 1:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083617245	4/13/2020 1:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770687196	4/13/2020 1:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629003074	4/13/2020 1:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255391611	4/13/2020 1:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710105192	4/13/2020 1:34 PM
Contacts	Primary Contact	Insert	New Registration		Peine, Jeffrey Finance Director SSM Health 3149893532	4/13/2020 1:34 PM
Contacts	Authorizing Official	Insert	New Registration		Harbison, Damon President SSM Health - St. Mary's Hospital Centralia, IL 6184368000	4/13/2020 1:34 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2020 1:34 PM
Details	Grant Number	Insert	New Registration			4/13/2020 1:34 PM
Details	340B ID	Insert	New Registration			4/13/2020 1:34 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2020 1:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2020 1:34 PM
Details	Medicare Provider Number	Insert	New Registration		140034	4/13/2020 1:34 PM
Details	Entity Name	Insert	New Registration		SSM HEALTH ST. MARYS HOSPITAL	4/13/2020 1:34 PM
Details	Program Code	Insert	New Registration		RRC	4/13/2020 1:34 PM
Details	Entity Subname	Insert	New Registration		SMGS Centralia Pulmonology	4/13/2020 1:34 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2020 1:34 PM
Details	State	Insert	New Registration		Pending	4/13/2020 1:34 PM
Dates	Registration Date	Insert	New Registration		4/13/2020 1:34:55 PM	4/13/2020 1:34 PM
Dates	Signed By Date	Insert	New Registration			4/13/2020 1:34 PM
Dates	Start Date	Insert	New Registration			4/13/2020 1:34 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2020 1:34 PM
Terminations	Termination Date	Insert	New Registration			4/13/2020 1:34 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2020 1:34 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2020 1:34 PM