Covered Entity Details

DSH140091EP The Carle Foundation Hospital (Active) - information as of 4/28/2025 12:42:46 AM

Main Details

Name

The Carle Foundation Hospital

Subdivision Name

Danville DEXA - Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140091EP

Medicare Provider Number

140091

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/26/2020

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Carle Foundation Hospital
Dennis P. Hesch, Executive VP and CFO
(217) 326-8231

Primary Contact

Carle Foundation Hospital
Katie Koch, Director of 340B and Retail Pharmacy Operations
(217) 904-7016

Addresses

Street Address

516 W. Madison
Suite 104
Danville, IL 61832

Billing Address

The Carle Foundation Hospital
611 West Park Street
Urbana, IL 61801

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	371119538001,371119538401,371119538027	1013071653,1083736177
IN	100069620A	1013071653,1083736177

Shipping Addresses

Shipping Address 1

The Carle Foundation Hospital
611 West Park Street
Urbana, IL 61801

Shipping Address 2

The Carle Foundation Hospital
502 N. Busey St.
Urbana, IL 61801

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
DSH140091A	Child	DSH	The Carle Foundation Hospital	Danville Surgicenter - Recovery Center	2300 North Vermillion Street	Danville	IL	Terminated
DSH140091AA	Child	DSH	The Carle Foundation Hospital	Danville - SurgerySpecialties	516 W. Madison	Danville	IL	Active
DSH140091AB	Child	DSH	The Carle Foundation Hospital	Danville – Cardiac Rehab	516 W. Madison	Danville	IL	Active
DSH140091AC	Child	DSH	The Carle Foundation Hospital	Danville - Orthopedics	516 W. Madison	Danville	IL	Active
DSH140091AD	Child	DSH	The Carle Foundation Hospital	Danville Vermillion - Infusion Center	2300 N. Vermillion St.	Danville	IL	Terminated
DSH140091AE	Child	DSH	The Carle Foundation Hospital	Danville – Oncology Physician Office	516 W. Madison	Danville	IL	Active
DSH140091AF	Child	DSH	The Carle Foundation Hospital	Danville – Occ Med	516 W. Madison	Danville	IL	Active
DSH140091AG	Child	DSH	The Carle Foundation Hospital	Danville Vermillion - Cardiology & Diag	516 W. Madison	Danville	IL	Active
DSH140091AH	Child	DSH	The Carle Foundation Hospital	Danville - X-Ray	516 W. Madison	Danville	IL	Active
DSH140091AJ	Child	DSH	The Carle Foundation Hospital	Danville - MRI	516 W. Madison	Danville	IL	Active
DSH140091AK	Child	DSH	The Carle Foundation Hospital	Danville – Nuclear Medicine	516 W. Madison	Danville	IL	Active
DSH140091AL	Child	DSH	The Carle Foundation Hospital	Monticello Clinic	1002 Medical Center Dr.	Monticello	IL	Active
DSH140091AM	Child	DSH	The Carle Foundation Hospital	Mahomet Clinic - Mahomet	1001 Heather Dr.	Mahomet	IL	Active
DSH140091AN	Child	DSH	The Carle Foundation Hospital	Mahomet Clinic - X-Ray	1001 Heather Dr.	Mahomet	IL	Active
DSH140091AP	Child	DSH	The Carle Foundation Hospital	North Annex - Sports Med Prof Srvcs	810 W. Anthony Dr.	Urbana	IL	Terminated
DSH140091AQ	Child	DSH	The Carle Foundation Hospital	OSM – Ortho SportMed Clinic	2300 S. First Street	Champaign	IL	Active
DSH140091AR	Child	DSH	The Carle Foundation Hospital	North Annex - X-Ray	810 W. Anthony Dr.	Urbana	IL	Active
DSH140091AS	Child	DSH	The Carle Foundation Hospital	Rantoul Clinic - Occ Med	1540 E. Grove Ave.	Rantoul	IL	Terminated
DSH140091AT	Child	DSH	The Carle Foundation Hospital	Rantoul Clinic - Rantoul	1540 E. Grove Ave.	Rantoul	IL	Active
DSH140091AU	Child	DSH	The Carle Foundation Hospital	Rantoul Clinic - X-Ray	1540 E. Grove Ave.	Rantoul	IL	Active
DSH140091AV	Child	DSH	The Carle Foundation Hospital	Spine Center - Surgery	610 N. Lincoln Ave.	Urbana	IL	Terminated
DSH140091AW	Child	DSH	The Carle Foundation Hospital	Spine Center - Injection Suite	610 N. Lincoln Ave.	Urbana	IL	Active
DSH140091AX	Child	DSH	The Carle Foundation Hospital	Brain & Spine	610 N. Lincoln Ave.	Urbana	IL	Active
DSH140091AY	Child	DSH	The Carle Foundation Hospital	Spine Center - Radiology	610 N. Lincoln Ave.	Urbana	IL	Active
DSH140091AZ	Child	DSH	The Carle Foundation Hospital	Spine Center - MRI	610 N. Lincoln Ave.	Urbana	IL	Active
DSH140091B	Child	DSH	The Carle Foundation Hospital	Danville Surgicenter - ASC	516 W. Madison	Danville	IL	Active
DSH140091BA	Child	DSH	The Carle Foundation Hospital	Plastic Surgery Center	3105 Fields South Drive	Champaign	IL	Active
DSH140091BB	Child	DSH	The Carle Foundation Hospital	Mattis Clinic - Cham Pain Clinic	1802 S. Mattis Ave.	Champaign	IL	Active
DSH140091BC	Child	DSH	The Carle Foundation Hospital	OSM – Orthopedics	2300 S. First Street	Champaign	IL	Active
DSH140091BD	Child	DSH	The Carle Foundation Hospital	Mattis Clinic - Champ Mattis X-Ray	1802 S. Mattis Ave.	Champaign	IL	Terminated
DSH140091BE	Child	DSH	The Carle Foundation Hospital	Curtis Clinic – SW Champ-Rheumatology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BF	Child	DSH	The Carle Foundation Hospital	Behavioral Health - Mattis	1802 S. Mattis Ave	Champaign	IL	Active
DSH140091BG	Child	DSH	The Carle Foundation Hospital	Curtis Clinic – SW Champ-Allergy	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BH	Child	DSH	The Carle Foundation Hospital	Curtis Clinic – SW Champ-Endocrinology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BJ	Child	DSH	The Carle Foundation Hospital	Curtis Clinic – SW Champ-DiabNutrSrvcs	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BK	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Visiting	1701 W. Curtis Rd.	Champaign	IL	Terminated
DSH140091BL	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Family Psychology	1701 W. Curtis Rd.	Champaign	IL	Terminated
DSH140091BM	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Pediatrics	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BN	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Gynecology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BP	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Family Medicine	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BQ	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Dermatology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BR	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Convenient Care	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BS	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Adult Medicine	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BT	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-AdultMed Residnts	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BU	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Sonography	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BV	Child	DSH	The Carle Foundation Hospital	Curtis Clinic - SW Champ-Radiology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091BW	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Gynecology	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091BX	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Visiting Provider	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091BY	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Reprod Med	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091BZ	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Psychology	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091C	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services at North Annex	810 West Anthony Drive	Urbana	IL	Active
DSH140091CA	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Pediatrics	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CB	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Geriatrics	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091CC	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Family Medicine	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CD	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Dermatology	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091CE	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Convenient Care	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CF	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Adult/Geriatric	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CG	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-ReprdMed Ultrsnd	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091CH	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Sonography	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CJ	Child	DSH	The Carle Foundation Hospital	Windsor Clinic - SE Urbana-Radiology	1818 E. Windsor Rd.	Urbana	IL	Active
DSH140091CK	Child	DSH	The Carle Foundation Hospital	Echo Program - Echo	805 West Park St.	Urbana	IL	Terminated
DSH140091CL	Child	DSH	The Carle Foundation Hospital	Echo Program	805 West Park St.	Urbana	IL	Terminated
DSH140091CM	Child	DSH	The Carle Foundation Hospital	HVI - Pacemaker Service	611 West Park Street	Urbana	IL	Active
DSH140091CN	Child	DSH	The Carle Foundation Hospital	Curtis Clinic-SW Champ-Cardiac Rehab	1701 W. Curtis Rd	Champaign	IL	Active
DSH140091CP	Child	DSH	The Carle Foundation Hospital	HVI - Congestive Heart Failure	611 West Park Street	Urbana	IL	Active
DSH140091CQ	Child	DSH	The Carle Foundation Hospital	Curtis Clinic – SW Champ-Cardiology	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091CR	Child	DSH	The Carle Foundation Hospital	HVI - C/Vascular Surgery	611 West Park Street	Urbana	IL	Active
DSH140091CS	Child	DSH	The Carle Foundation Hospital	HVI - Echocardiography	611 West Park Street	Urbana	IL	Active
DSH140091CT	Child	DSH	The Carle Foundation Hospital	HVI - Vascular Lab	611 West Park Street	Urbana	IL	Active
DSH140091CU	Child	DSH	The Carle Foundation Hospital	HVI - Interventional Radiology	611 West Park Street	Urbana	IL	Active
DSH140091CV	Child	DSH	The Carle Foundation Hospital	Lower Level & Center - Maternal Fetal Medicine	611 West Park Street	Urbana	IL	Active
DSH140091CW	Child	DSH	The Carle Foundation Hospital	Lower Level & Center - MFM OB Sono	611 West Park Street	Urbana	IL	Active
DSH140091CX	Child	DSH	The Carle Foundation Hospital	North Clinic - Physical Med & Rehab	611 West Park Street	Urbana	IL	Active
DSH140091CY	Child	DSH	The Carle Foundation Hospital	North Clinic - Pulmonary Function	611 West Park Street	Urbana	IL	Active
DSH140091CZ	Child	DSH	The Carle Foundation Hospital	Carle at the Fields - Head and Neck (ENT)	3105 Fields South Drive	Champaign	IL	Active
DSH140091D	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - South Mattis Avenue	1802 South Mattis Avenue	Champaign	IL	Terminated
DSH140091DA	Child	DSH	The Carle Foundation Hospital	North Clinic - Gastro	611 West Park Street	Urbana	IL	Terminated
DSH140091DB	Child	DSH	The Carle Foundation Hospital	North Clinic - NC6 Psych	611 West Park Street	Urbana	IL	Active
DSH140091DC	Child	DSH	The Carle Foundation Hospital	DHC Ambulatory	611 West Park Street	Urbana	IL	Active
DSh140091DD	Child	DSH	The Carle Foundation Hospital	North Clinic - Chest Medicine	611 West Park Street	Urbana	IL	Active
DSH140091DE	Child	DSH	The Carle Foundation Hospital	South Clinic - Urology	611 West Park Street	Urbana	IL	Active
DSH140091DF	Child	DSH	The Carle Foundation Hospital	South Clinic - Pediatrics Specialties	611 West Park Street	Urbana	IL	Active
DSH140091DG	Child	DSH	The Carle Foundation Hospital	Carle at the Fields - General Surgery	3105 Fields South Drive	Champaign	IL	Active
DSH140091DH	Child	DSH	The Carle Foundation Hospital	Ophthalmology	3105 Fields South Drive	Champaign	IL	Active
DSH140091DJ	Child	DSH	The Carle Foundation Hospital	South Clinic - OB/GYN	611 West Park Street	Urbana	IL	Active
DSH140091DK	Child	DSH	The Carle Foundation Hospital	Neurosciences Non-invasive	611 West Park Street	Urbana	IL	Active
DSH140091DL	Child	DSH	The Carle Foundation Hospital	Windsor Clinic – SE Urbana – Neurology	1818 E. Windsor Rd.	Urbana	IL	Terminated
DSH140091DM	Child	DSH	The Carle Foundation Hospital	North Clinic - Nephrology	611 West Park Street	Urbana	IL	Active
DSH140091DN	Child	DSH	The Carle Foundation Hospital	North Clinic - Infectious Disease	611 West Park Street	Urbana	IL	Active
DSH140091DP	Child	DSH	The Carle Foundation Hospital	South Clinic - Head & Neck Cancer Clinic	611 West Park Street	Urbana	IL	Terminated
DSH140091DR	Child	DSH	The Carle Foundation Hospital	South Clinic - Family Practice	611 West Park Street	Urbana	IL	Active
DSH140091DS	Child	DSH	The Carle Foundation Hospital	South Clinic - Fam Pract Residency Clinic	611 West Park Street	Urbana	IL	Terminated
DSH140091DT	Child	DSH	The Carle Foundation Hospital	Carle at the Fields - Audiology	3105 Fields South Drive	Champaign	IL	Active
DSH140091DV	Child	DSH	The Carle Foundation Hospital	Carle at the Fields - Optometry	3105 Fields South Drive	Champaign	IL	Active
DSH140091DW	Child	DSH	The Carle Foundation Hospital	Sleep Clinic	611 West Park Street	Urbana	IL	Active
DSH140091DX	Child	DSH	The Carle Foundation Hospital	South Clinic / Gynecologic Oncology	611W PARK ST	URBANA	IL	Active
DSH140091DY	Child	DSH	The Carle Foundation Hospital	North Annex / Occ Med	810 W ANTHONY DR	URBANA	IL	Active
DSH140091DZ	Child	DSH	The Carle Foundation Hospital	THE CARLE FOUNDATION HOSPITAL / Windsor Clinic - SE Urbana-Allergy	1818 E WINDSOR RD	URBANA	IL	Active
DSH140091E	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - Southwest Champaign	3402 Mission Drive	Champaign	IL	Active
DSH140091EA	Child	DSH	The Carle Foundation Hospital	Wound Healing - Danville	516 W. Madison	Danville	IL	Active
DSH140091EB	Child	DSH	The Carle Foundation Hospital	Wound Healing Center	611 West Park Street	Urbana	IL	Active
DSH140091EC	Child	DSH	The Carle Foundation Hospital	Pulmonary Rehab	810 WEST UNIVERSITY AVENUE	Urbana	IL	Active
DSH140091ED	Child	DSH	The Carle Foundation Hospital	Pulmonary Rehab - Danville	516 W. Madison	Danville	IL	Active
DSH140091EF	Child	DSH	The Carle Foundation Hospital	Southwest Champaign-Dermatology MOHS	1701 W. Curtis Rd.	Champaign	IL	Active
DSH140091EG	Child	DSH	The Carle Foundation Hospital	SW Champ-Developmentl Peds	1701 W. Curtis Road	Champaign	IL	Active
DSH140091EH	Child	DSH	The Carle Foundation Hospital	Transitional Care Clinic	611 West Park Street	Urbana	IL	Active
DSH140091EJ	Child	DSH	The Carle Foundation Hospital	Ortho/Sports Med Radiology	2300 S. First Street	Champaign	IL	Active
DSH140091EK	Child	DSH	The Carle Foundation Hospital	Therapy - Ortho/Sports Med - Physical Therapy	2300 S. First Street	Champaign	IL	Active
DSH140091EL	Child	DSH	The Carle Foundation Hospital	Sleep Lab - Sleep Lab	1702 S. Mattis	Champaign	IL	Active
DSH140091EM	Child	DSH	The Carle Foundation Hospital	Danville - Ophthalmology	516 W. Madison	Danville	IL	Active
DSH140091EN	Child	DSH	The Carle Foundation Hospital	CICOM Student Clinic - Clinic	1701 W. Curtis Rd	Champaign	IL	Active
DSH140091EP	Child	DSH	The Carle Foundation Hospital	Danville DEXA - Clinic	516 W. Madison	Danville	IL	Active
DSH140091EQ	Child	DSH	The Carle Foundation Hospital	Carle Foundation Hospital - IVF - Clinic	611 West Park Street	Urbana	IL	Terminated
DSH140091ER	Child	DSH	The Carle Foundation Hospital	Ambulatory Phlebotomy - Phlebotomy	1540 E. Grove Ave.	Rantoul	IL	Active
DSH140091ES	Child	DSH	The Carle Foundation Hospital	Windsor Genetics - Genetics	1818 E Windsor Rd.	Urbana	IL	Active
DSH140091ET	Child	DSH	The Carle Foundation Hospital	CATR Radiology Nursing Svc - Infusions	516 W Madison St Suite 104	Danville	IL	Active
DSH140091EU	Child	DSH	The Carle Foundation Hospital	CATR Audiology & Hearing - Audiology	516 W Madison St	Danville	IL	Active
DSH140091F	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - Rantoul	1540 East Grove Avenue	Rantoul	IL	Active
DSH140091G	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - Mahomet	1001 Heather Drive	Mahomet	IL	Active
DSH140091H	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - Danville	516 W. Madison	Danville	IL	Active
DSH140091J	Child	DSH	The Carle Foundation Hospital	Carle Therapy Services - Spine Institute	610 North Lincoln Avenue	Urbana	IL	Active
DSH140091K	Child	DSH	The Carle Foundation Hospital	Cancer Center - MBCI DEXA	509 West University Avenue	Urbana	IL	Active
DSH140091L	Child	DSH	The Carle Foundation Hospital	Cancer Center - MBCI Sonography	509 West University Avenue	Urbana	IL	Active
DSH140091M	Child	DSH	The Carle Foundation Hospital	Cancer Center - Breast Imaging	509 West University Avenue	Urbana	IL	Active
DSH140091N	Child	DSH	The Carle Foundation Hospital	Cancer Center - Breast Center	509 West University Avenue	Urbana	IL	Active
DSH140091P	Child	DSH	The Carle Foundation Hospital	Cancer Center - Med Oncol	509 West University Avenue	Urbana	IL	Active
DSH140091Q	Child	DSH	The Carle Foundation Hospital	Cancer Center - Oncology Administrat	509 West University Avenue	Urbana	IL	Terminated
DSH140091R	Child	DSH	The Carle Foundation Hospital	Cancer Center - Rad Oncology & Physi	509 West University Avenue	Urbana	IL	Active
DSH140091S	Child	DSH	The Carle Foundation Hospital	Cancer Center - CT Scans-Cancer Center	509 West University Avenue	Urbana	IL	Terminated
DSH140091T	Child	DSH	The Carle Foundation Hospital	Cancer Center - Chemo	509 West University Avenue	Urbana	IL	Active
DSH140091U	Child	DSH	The Carle Foundation Hospital	Cancer Center - MBCI MRI	509 West University Avenue	Urbana	IL	Active
DSH140091V	Child	DSH	The Carle Foundation Hospital	South Clinic - Phlebotomy	611 West Park Street	Urbana	IL	Active
DSH140091W	Child	DSH	The Carle Foundation Hospital	Danville Fairchild - X-Ray	311 W. Fairchild St.	Danville	IL	Terminated
DSH140091X	Child	DSH	The Carle Foundation Hospital	Danville - Sono	516 W. Madison	Danville	IL	Active
DSH140091Y	Child	DSH	The Carle Foundation Hospital	Danville - CT Scan	516 W. Madison	Danville	IL	Active
DSH140091Z	Child	DSH	The Carle Foundation Hospital	Danville Vermillion - Pacemaker Clinic	2300 N. Vermillion St.	Danville	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/11/2023 5:59:49 PM	9/3/2024 5:41:11 PM	9/3/2024 5:41 PM
Details	Last Recertification Date	Update	Recertification	9/19/2022 10:44:09 AM	9/11/2023 5:59:49 PM	9/11/2023 5:59 PM
Addresses	Main Address	Update	Change Request	2300 N. Vermillion Street Danville, IL 61832	516 W. Madison Suite 104 Danville, IL 61832	3/15/2023 2:18 PM
Contacts	Primary Contact	Update	Recertification	Fred, Linda Vice President of Pharmacy Services Carle Health 2179025803	Koch, Katie Director of 340B and Retail Pharmacy Operations Carle Foundation Hospital 2179047016	9/19/2022 10:44 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 12:34:43 PM	9/19/2022 10:44:09 AM	9/19/2022 10:44 AM
Details	Last Recertification Date	Update	Recertification		8/27/2021 12:34:43 PM	8/27/2021 12:34 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Hesch, Dennis P. Executive VP and CFO Carle Foundation Hospital 2173268231	10/26/2020 8:35 AM
Details	340B ID	Update	New Registration		DSH140091EP	10/26/2020 8:35 AM
Details	Entity Name	Update	New Registration	CARLE FOUNDATION HOSPITAL	The Carle Foundation Hospital	10/26/2020 8:35 AM
Details	Entity Subname	Update	New Registration	Danville DEXA	Danville DEXA - Clinic	10/26/2020 8:35 AM
Dates	Participating Approval Date	Update	New Registration		10/26/2020 8:35:10 AM	10/26/2020 8:35 AM
Details	State	Update	New Registration	Pending	Approved	10/26/2020 8:35 AM
Dates	Signed By Date	Update	New Registration		10/14/2020 11:31:16 AM	10/26/2020 8:35 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/26/2020 8:35 AM
Contacts	Primary Contact	Update	Profile Change Request	Fred, Linda Pharmacy Director Carle Foundation Hospital 2179047001	Fred, Linda Vice President of Pharmacy Services Carle Health 2179025803	10/15/2020 1:21 PM
Addresses	Main Address	Insert	New Registration		2300 N. Vermillion Street Danville, IL 61832	10/14/2020 11:31 AM
Addresses	Billing Address	Insert	New Registration		The Carle Foundation Hospital 611 West Park Street Urbana, IL 61801	10/14/2020 11:31 AM
Addresses	Shipping Address	Insert	New Registration		The Carle Foundation Hospital 611 West Park Street Urbana, IL 61801	10/14/2020 11:31 AM
Addresses	Shipping Address	Insert	New Registration		The Carle Foundation Hospital 502 N. Busey St. Urbana, IL 61801	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		371119538001	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		371119538401	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		371119538027	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100069620A	10/14/2020 11:31 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	10/14/2020 11:31 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1013071653	10/14/2020 11:31 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/14/2020 11:31 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083736177	10/14/2020 11:31 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/14/2020 11:31 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1013071653	10/14/2020 11:31 AM
Medicaid Billing	NPI: State	Insert	New Registration		IN	10/14/2020 11:31 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083736177	10/14/2020 11:31 AM
Medicaid Billing	NPI: State	Insert	New Registration		IN	10/14/2020 11:31 AM
Contacts	Primary Contact	Insert	New Registration		Fred, Linda Pharmacy Director Carle Foundation Hospital 2179047001	10/14/2020 11:31 AM
Contacts	Authorizing Official	Insert	New Registration		Hesch, Dennis P. Executive VP and CFO Carle Foundation Hospital 2173268231	10/14/2020 11:31 AM
Details	Assistance Received From Date	Insert	New Registration			10/14/2020 11:31 AM
Details	Assistance Received To Date	Insert	New Registration			10/14/2020 11:31 AM
Details	Last Recertification Date	Insert	New Registration			10/14/2020 11:31 AM
Details	Grant Number	Insert	New Registration			10/14/2020 11:31 AM
Details	340B ID	Insert	New Registration			10/14/2020 11:31 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2020 11:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2020 11:31 AM
Details	Medicare Provider Number	Insert	New Registration		140091	10/14/2020 11:31 AM
Details	Entity Name	Insert	New Registration		CARLE FOUNDATION HOSPITAL	10/14/2020 11:31 AM
Details	NOFO Number	Insert	New Registration			10/14/2020 11:31 AM
Details	Program Code	Insert	New Registration		DSH	10/14/2020 11:31 AM
Details	Entity Subname	Insert	New Registration		Danville DEXA	10/14/2020 11:31 AM
Dates	Participating Approval Date	Insert	New Registration			10/14/2020 11:31 AM
Details	State	Insert	New Registration		Pending	10/14/2020 11:31 AM
Dates	Registration Date	Insert	New Registration		10/14/2020 11:31:08 AM	10/14/2020 11:31 AM
Dates	Signed By Date	Insert	New Registration			10/14/2020 11:31 AM
Dates	Start Date	Insert	New Registration			10/14/2020 11:31 AM
Terminations	Termination Comments	Insert	New Registration			10/14/2020 11:31 AM
Terminations	Termination Date	Insert	New Registration			10/14/2020 11:31 AM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2020 11:31 AM
Terminations	Termination Reason	Insert	New Registration			10/14/2020 11:31 AM