Covered Entity Details

DSH140180G Presence Saints Mary and Elizabeth Medical Center (Terminated) - information as of 6/26/2025 12:22:31 AM

Main Details

Name

Presence Saints Mary and Elizabeth Medical Center

Subdivision Name

Rheumatology - Rheumatology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140180G

Medicare Provider Number

140180

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/1/2021

Participating Start Date

7/1/2021

Participating Approval Date

4/7/2021

Last Recertification Date

Termination Date
Termination Reason

10/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Saints Mary and Elizabeth Medical Center
Eric M Zornow, CFO
(312) 770-2105

Primary Contact

Amita Health
Rick Fischer, System Director, 340B
(630) 309-7828

Addresses

Street Address

1431 N. Claremont Ave
Chicago, IL 60622

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	362235165018	1922177229

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
DSH140180A	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Oncology Infusion Center: A service of Saints Mary and Elizabeth Medical Center	ST JOSEPH HOSP CHEMO DOP 340B	Chicago	IL	Terminated
DSH140180B	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC d/b/a Presence Saint Elizabeth Hospital - Surgery	1431 N. Claremont	Chicago	IL	Terminated
DSH140180C	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC d/b/a Saint Elizabeth Hospital - OP Oncology	2216 West Thomas Street	Chicago	IL	Terminated
DSH140180D	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	OP Behavioral Health	1431 N. Claremont	Chicago	IL	Terminated
DSH140180E	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	OP Behavioral Health	1127 N. OAKLEY BLVD	Chicago	IL	Terminated
DSH140180F	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC Infusion	5600 West Addison Street	Chicago	IL	Terminated
DSH140180G	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Rheumatology - Rheumatology	1431 N. Claremont Ave	Chicago	IL	Terminated
DSH140180H	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Rheumatology - Rheumatology	2222 W. Division Street	Chicago	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2021 12:00:00 AM	8/17/2021 8:23 AM
Details	State	Update	Termination Request	Active	To Be Terminated	8/17/2021 8:23 AM
Terminations	Termination Comments	Update	Termination Request		340B drugs were never purchased for this location. Clinic has relocated.	8/17/2021 8:23 AM
Terminations	Termination Date	Update	Termination Request		10/1/2021 12:00:00 AM	8/17/2021 8:23 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	8/17/2021 8:23 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	8/17/2021 8:23 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Zornow, Eric M CFO Saints Mary and Elizabeth Medical Center 3127702105	4/7/2021 7:38 AM
Details	340B ID	Update	New Registration		DSH140180G	4/7/2021 7:38 AM
Details	Entity Name	Update	New Registration	PRESENCE SAINTS MARY & ELIZABETH MED	Presence Saints Mary and Elizabeth Medical Center	4/7/2021 7:38 AM
Details	Entity Subname	Update	New Registration	Rheumatology	Rheumatology - Rheumatology	4/7/2021 7:38 AM
Dates	Participating Approval Date	Update	New Registration		4/7/2021 7:38:19 AM	4/7/2021 7:38 AM
Details	State	Update	New Registration	Pending	Approved	4/7/2021 7:38 AM
Dates	Signed By Date	Update	New Registration		4/5/2021 5:07:32 PM	4/7/2021 7:38 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/7/2021 7:38 AM
Addresses	Main Address	Insert	New Registration		1431 N. Claremont Ave Chicago, IL 60622	4/1/2021 3:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2021 3:30 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362235165018	4/1/2021 3:30 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/1/2021 3:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922177229	4/1/2021 3:30 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/1/2021 3:30 PM
Contacts	Primary Contact	Insert	New Registration		Fischer, Rick System Director, 340B Amita Health 6309147828	4/1/2021 3:30 PM
Contacts	Authorizing Official	Insert	New Registration		Zornow, Eric M CFO Saints Mary and Elizabeth Medical Center 3127702105	4/1/2021 3:30 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2021 3:30 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2021 3:30 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2021 3:30 PM
Details	Grant Number	Insert	New Registration			4/1/2021 3:30 PM
Details	340B ID	Insert	New Registration			4/1/2021 3:30 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2021 3:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2021 3:30 PM
Details	Medicare Provider Number	Insert	New Registration		140180	4/1/2021 3:30 PM
Details	Entity Name	Insert	New Registration		PRESENCE SAINTS MARY & ELIZABETH MED	4/1/2021 3:30 PM
Details	NOFO Number	Insert	New Registration			4/1/2021 3:30 PM
Details	Program Code	Insert	New Registration		DSH	4/1/2021 3:30 PM
Details	Entity Subname	Insert	New Registration		Rheumatology	4/1/2021 3:30 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2021 3:30 PM
Details	State	Insert	New Registration		Pending	4/1/2021 3:30 PM
Dates	Registration Date	Insert	New Registration		4/1/2021 3:30:14 PM	4/1/2021 3:30 PM
Dates	Signed By Date	Insert	New Registration			4/1/2021 3:30 PM
Dates	Start Date	Insert	New Registration			4/1/2021 3:30 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2021 3:30 PM
Terminations	Termination Date	Insert	New Registration			4/1/2021 3:30 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2021 3:30 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2021 3:30 PM