Covered Entity Details

RRC140281-23 NORTHWESTERN MEMORIAL HOSPITAL (Active) - information as of 5/20/2025 11:33:43 PM

Main Details

Name

NORTHWESTERN MEMORIAL HOSPITAL

Subdivision Name

NORTHWESTERN MEMORIAL HOSPITAL - Lavin Pavilion Pain Clinic

Type

Rural Referral Center

Rural

Yes

340B ID

RRC140281-23

Medicare Provider Number

140281

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2020

Participating Start Date

8/7/2020

Participating Approval Date

7/31/2020

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Northwestern Memorial Hospital
Matthew Joseph Flynn, VP, Finance, NMHC
(312) 926-5236

Primary Contact

Northwestern Memorial Hospital
Richard Jacobson, Director of Pharmacy
(312) 926-3024

Addresses

Street Address

259 East Erie Street
Suite 1400
Chicago, IL 60611

Billing Address

Northwestern Memorial Healthcare
Accounts Payable - PO Box 13776
Philadelphia, PA 19101-3776

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	370960170001	1497859649,1831298926,1902238645

Shipping Addresses

Shipping Address 1

NORTHWESTERN MEM HOSP SPEC LC704 STORE ROM
251 E HURON ST LC 704
Chicago, IL 60611-3232

Shipping Address 2

Northwestern Medicine Specialty Pharmacy
676 N St Clair St Suite 560
Chicago, IL 60611

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
RRC140281-02	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - NMH Cardiac Rehab	1030 N CLARK ST	CHICAGO	IL	Active
RRC140281-03	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - NMH Lakeview Radiology-Diagnostic	1333 W BELMONT AVE	CHICAGO	IL	Terminated
RRC140281-05	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - NMH Bucktown - Radiology-Diagnostic	1776 N MILWAUKEE AVE	CHICAGO	IL	Terminated
RRC140281-06	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Operating Room	250 E SUPERIOR ST	CHICAGO	IL	Active
RRC140281-07	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Delivery Room & Labor Room	250 E SUPERIOR ST	CHICAGO	IL	Active
RRC140281-08	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice MRI	250 E SUPERIOR ST	CHICAGO	IL	Terminated
RRC140281-09	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Recovery Room	250 E SUPERIOR ST	CHICAGO	IL	Active
RRC140281-10	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Anesthesiology	250 E SUPERIOR ST	CHICAGO	IL	Active
RRC140281-11	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Laboratory	250 E SUPERIOR ST	CHICAGO	IL	Terminated
RRC140281-12	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Radiology-Diagnostic	250 E SUPERIOR ST	CHICAGO	IL	Terminated
RRC140281-13	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Prentice Radiology-Therapeutic	250 E SUPERIOR ST	CHICAGO	IL	Terminated
RRC140281-14	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Laboratory	259 E ERIE ST	CHICAGO	IL	Terminated
RRC140281-15	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Radiology-Diagnostic	259 E ERIE ST	CHICAGO	IL	Terminated
RRC140281-16	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Recovery Room	259 E ERIE ST	CHICAGO	IL	Active
RRC140281-17	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Non-Invasive Cardiac Testing	259 E ERIE ST	CHICAGO	IL	Active
RRC140281-18	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Operating Room	259 E ERIE ST	CHICAGO	IL	Active
RRC140281-19	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion CT Scan	259 E ERIE ST	CHICAGO	IL	Terminated
RRC140281-20	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion MRI	259 E ERIE ST	CHICAGO	IL	Terminated
RRC140281-21	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion Anesthesiology	259 E ERIE ST	CHICAGO	IL	Active
RRC140281-22	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Family Pavilion GI	259 E ERIE ST	CHICAGO	IL	Active
RRC140281-23	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Pavilion Pain Clinic	259 East Erie Street	Chicago	IL	Active
RRC140281-24	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Pavilion PreOp Clinic	259 East Erie Street	Chicago	IL	Active
RRC140281-25	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Pavilion Digestive Health Clinic	259 East Erie Street	Chicago	IL	Active
RRC140281-26	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion Radiology-Diagnostic	676 N SAINT CLAIR ST	CHICAGO	IL	Terminated
RRC140281-27	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion Radioisotope	676 N SAINT CLAIR ST	CHICAGO	IL	Terminated
RRC140281-28	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion CT Scan	676 N SAINT CLAIR ST	CHICAGO	IL	Terminated
RRC140281-29	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion MRI	676 N SAINT CLAIR ST	CHICAGO	IL	Terminated
RRC140281-30	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion Laboratory	676 N SAINT CLAIR ST	CHICAGO	IL	Terminated
RRC140281-31	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion Transplant Clinic	676 North St. Clair Street	Chicago	IL	Active
RRC140281-32	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Arkes Pavilion Infectious Disease Clinic	676 North St. Clair Street	Chicago	IL	Active
RRC140281-33	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Olson Pavilion Laboratory	710 N FAIRBANKS CT	CHICAGO	IL	Terminated
RRC140281-34	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Olson Pavilion Radiology-Therapeutic	710 N FAIRBANKS CT	CHICAGO	IL	Terminated
RRC140281-35	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	Northwestern Memorial Hospital Galter Interventional GI - Galter Interventional GI	675 N Saint Clair St	Chicago	IL	Active
RRC140281-36	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	Northwestern Memorial Hospital NMH Rube Walker - NMH Rube Walker	250 E Superior Street	Chicago	IL	Active
RRC140281-37	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	Northwestern Memorial Hospital NMH Developmental Therapeutics - NMH Developmental Therapeutics	233 E Superior St	Chicago	IL	Active
RRC140281-38	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	Northwestern Memorial Hospital Galter GI Post-Op Recovery - Galter GI Post-Op Recovery	675 N Saint Clair St	Chicago	IL	Active
RRC140281-39	Child	RRC	NORTHWESTERN MEMORIAL HOSPITAL	Medicine Therapy Management - Medication Therapy Management	676 N St Clair St	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 1:45:06 PM	8/27/2024 2:12:08 PM	8/27/2024 2:12 PM
Contacts	Authorizing Official	Update	Profile Change Request	Flynn, Matthew Joseph Chief Financial Officer Northwestern Memorial Hospital 3129265236	Flynn, Matthew Joseph VP, Finance, NMHC Northwestern Memorial Hospital 3129265236	11/15/2023 1:08 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 10:39:13 AM	8/18/2023 1:45:06 PM	8/18/2023 1:45 PM
Addresses	Billing Address	Insert	Group Change Request		Northwestern Memorial Healthcare Accounts Payable - PO Box 13776 Philadelphia, PA 19101-3776	1/10/2023 1:54 PM
Contacts	Authorizing Official	Update	AO Change Request	Fraher, Francis Donald CFO Northwestern Memorial Hospital 3129265236	Flynn, Matthew Joseph Chief Financial Officer Northwestern Memorial Hospital 3129265236	12/15/2022 4:31 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 2:05:19 PM	9/7/2022 10:39:13 AM	9/7/2022 10:39 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 10:24:31 AM	8/30/2021 2:05:19 PM	8/30/2021 2:05 PM
Addresses	Shipping Address	Insert	Change Request		NORTHWESTERN MEM HOSP SPEC LC704 STORE ROM 251 E HURON ST LC 704 Chicago, IL 60611-3232	3/22/2021 8:47 AM
Addresses	Shipping Address	Insert	Change Request		Northwestern Medicine Specialty Pharmacy 676 N St Clair St Suite 560 Chicago, IL 60611	3/22/2021 8:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1902238645	3/22/2021 8:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	3/22/2021 8:47 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300031230 (IN)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	80489200 (WI)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1011906 (WA)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	358232 (OH)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q44890 (TN)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	11631207 (MO)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	7001572810 (KY)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000170376 (CO)		9/11/2020 10:24 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	930458 (FL)		9/11/2020 10:24 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1497859649 ( )		9/11/2020 10:24 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1831298926 ( )		9/11/2020 10:24 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497859649	9/11/2020 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:24 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1831298926	9/11/2020 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 10:24 AM
Details	Last Recertification Date	Update	Recertification		9/11/2020 10:24:31 AM	9/11/2020 10:24 AM
Details	State	Update	OPA Edit	Approved	Active	8/7/2020 6:50 AM
Dates	Start Date	Update	OPA Edit	10/1/2020 12:00:00 AM	8/7/2020 12:00:00 AM	8/7/2020 6:50 AM
Contacts	Signed By	Insert	New Registration		Fraher, Francis Donald CFO Northwestern Memorial Hospital 3129265236	7/31/2020 2:30 PM
Details	340B ID	Update	New Registration		RRC140281-23	7/31/2020 2:30 PM
Details	Entity Subname	Update	New Registration	NORTHWESTERN MEMORIAL HOSPITAL	NORTHWESTERN MEMORIAL HOSPITAL - Lavin Pavilion Pain Clinic	7/31/2020 2:30 PM
Dates	Participating Approval Date	Update	New Registration		7/31/2020 2:30:33 PM	7/31/2020 2:30 PM
Details	State	Update	New Registration	Pending	Approved	7/31/2020 2:30 PM
Dates	Signed By Date	Update	New Registration		7/15/2020 5:55:56 PM	7/31/2020 2:30 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	7/31/2020 2:30 PM
Addresses	Main Address	Insert	New Registration		259 East Erie Street Suite 1400 Chicago, IL 60611	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370960170001	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300031230	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		80489200	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1011906	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		358232	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q44890	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11631207	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7001572810	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000170376	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		930458	7/15/2020 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	7/15/2020 5:55 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1497859649	7/15/2020 5:55 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831298926	7/15/2020 5:55 PM
Contacts	Authorizing Official	Insert	New Registration		Fraher, Francis Donald CFO Northwestern Memorial Hospital 3129265236	7/15/2020 5:55 PM
Contacts	Primary Contact	Insert	New Registration		Jacobson, Richard Director of Pharmacy Northwestern Memorial Hospital 3129263024	7/15/2020 5:55 PM
Details	Last Recertification Date	Insert	New Registration			7/15/2020 5:55 PM
Details	Grant Number	Insert	New Registration			7/15/2020 5:55 PM
Details	340B ID	Insert	New Registration			7/15/2020 5:55 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/15/2020 5:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/15/2020 5:55 PM
Details	Medicare Provider Number	Insert	New Registration		140281	7/15/2020 5:55 PM
Details	Entity Name	Insert	New Registration		NORTHWESTERN MEMORIAL HOSPITAL	7/15/2020 5:55 PM
Details	Program Code	Insert	New Registration		RRC	7/15/2020 5:55 PM
Details	Entity Subname	Insert	New Registration		NORTHWESTERN MEMORIAL HOSPITAL	7/15/2020 5:55 PM
Dates	Participating Approval Date	Insert	New Registration			7/15/2020 5:55 PM
Details	State	Insert	New Registration		Pending	7/15/2020 5:55 PM
Dates	Registration Date	Insert	New Registration		7/15/2020 5:55:53 PM	7/15/2020 5:55 PM
Dates	Signed By Date	Insert	New Registration			7/15/2020 5:55 PM
Dates	Start Date	Insert	New Registration			7/15/2020 5:55 PM
Terminations	Termination Comments	Insert	New Registration			7/15/2020 5:55 PM
Terminations	Termination Date	Insert	New Registration			7/15/2020 5:55 PM
Terminations	Termination Effective Date	Insert	New Registration			7/15/2020 5:55 PM
Terminations	Termination Reason	Insert	New Registration			7/15/2020 5:55 PM