Covered Entity Details

DSH140224C PRESENCE SAINT JOSEPH HOSP-CHICAGO (Terminated) - information as of 6/16/2025 1:05:38 AM

Main Details

Name

PRESENCE SAINT JOSEPH HOSP-CHICAGO

Subdivision Name

SJHC PCAC Surgery - Surgery

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140224C

Medicare Provider Number

140224

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2021

Participating Start Date

1/1/2022

Participating Approval Date

10/27/2021

Last Recertification Date

8/16/2023

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Ascension St Joseph
Flavio Marin, CFO
(773) 665-6212

Primary Contact

Ascension
Rick Fischer, 340B Program Director
(630) 309-7828

Addresses

Street Address

331 W Surf Street
#5
Chicago, IL 60657

Billing Address

Ascension Health Ministry Service Center
PO Box 33902
Indianapolis, IN 46203

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	362235165015	1679659585

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
DSH140224A	Child	DSH	PRESENCE SAINT JOSEPH HOSP-CHICAGO	Infusion Services	2845 North Sheridan Road	Chicago	IL	Terminated
DSH140224B	Child	DSH	PRESENCE SAINT JOSEPH HOSP-CHICAGO	Oncology - Oncology	331 W Surf	Chicago	IL	Active
DSH140224C	Child	DSH	PRESENCE SAINT JOSEPH HOSP-CHICAGO	SJHC PCAC Surgery - Surgery	331 W Surf Street	Chicago	IL	Terminated
DSH140224D	Child	DSH	PRESENCE SAINT JOSEPH HOSP-CHICAGO	Anticoagulant Clinic - Cardiology	2845 N Sheridan	Chicago	IL	Active
DSH140224E	Child	DSH	PRESENCE SAINT JOSEPH HOSP-CHICAGO	Pain Center - Pain Management	2913 N Commonwealth Avenue	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		8/25/2023 12:00:00 AM	9/21/2023 7:41 AM
Details	State	Update	Termination Request	Active	To Be Terminated	9/21/2023 7:41 AM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	9/21/2023 7:41 AM
Terminations	Termination Effective Date	Update	Termination Request		9/1/2023 12:00:00 AM	9/21/2023 7:41 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	9/21/2023 7:41 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 4:36:48 PM	8/16/2023 4:56:19 PM	8/16/2023 4:56 PM
Contacts	Authorizing Official	Update	Change Request	Marin, Flavio CFO Presence St. Francis Hospital 8473164190	Marin, Flavio CFO Ascension St Joseph 7736656212	10/12/2022 10:02 AM
Contacts	Primary Contact	Update	Group Change Request	Fischer, Rick System Director, 340B Amita Health 6303097828	Fischer, Rick 340B Program Director Ascension 6303097828	9/28/2022 7:24 AM
Details	Last Recertification Date	Update	Recertification		8/29/2022 4:36:48 PM	8/29/2022 4:36 PM
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		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Marin, Flavio CFO Presence St. Francis Hospital 8473164190	10/27/2021 12:46 PM
Details	340B ID	Update	New Registration		DSH140224C	10/27/2021 12:46 PM
Details	Entity Subname	Update	New Registration	SJHC PCAC Surgery	SJHC PCAC Surgery - Surgery	10/27/2021 12:46 PM
Dates	Participating Approval Date	Update	New Registration		10/27/2021 12:46:47 PM	10/27/2021 12:46 PM
Details	State	Update	New Registration	Pending	Approved	10/27/2021 12:46 PM
Dates	Signed By Date	Update	New Registration		10/27/2021 10:22:34 AM	10/27/2021 12:46 PM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	10/27/2021 12:46 PM
Addresses	Main Address	Insert	New Registration		331 W Surf Street #5 Chicago, IL 60657	10/11/2021 12:41 PM
Addresses	Billing Address	Insert	New Registration		Ascension Health Ministry Service Center PO Box 33902 Indianapolis, IN 46203	10/11/2021 12:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2021 12:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		362235165015	10/11/2021 12:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/11/2021 12:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1679659585	10/11/2021 12:41 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/11/2021 12:41 PM
Contacts	Primary Contact	Insert	New Registration		Fischer, Rick System Director, 340B Amita Health 6309147828	10/11/2021 12:41 PM
Contacts	Authorizing Official	Insert	New Registration		Marin, Flavio CFO Presence St. Francis Hospital 8473164190	10/11/2021 12:41 PM
Details	Assistance Received From Date	Insert	New Registration			10/11/2021 12:41 PM
Details	Assistance Received To Date	Insert	New Registration			10/11/2021 12:41 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2021 12:41 PM
Details	Grant Number	Insert	New Registration			10/11/2021 12:41 PM
Details	340B ID	Insert	New Registration			10/11/2021 12:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2021 12:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2021 12:41 PM
Details	Medicare Provider Number	Insert	New Registration		140224	10/11/2021 12:41 PM
Details	Entity Name	Insert	New Registration		PRESENCE SAINT JOSEPH HOSP-CHICAGO	10/11/2021 12:41 PM
Details	NOFO Number	Insert	New Registration			10/11/2021 12:41 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2021 12:41 PM
Details	Entity Subname	Insert	New Registration		SJHC PCAC Surgery	10/11/2021 12:41 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2021 12:41 PM
Details	State	Insert	New Registration		Pending	10/11/2021 12:41 PM
Dates	Registration Date	Insert	New Registration		10/11/2021 12:41:58 PM	10/11/2021 12:41 PM
Dates	Signed By Date	Insert	New Registration			10/11/2021 12:41 PM
Dates	Start Date	Insert	New Registration			10/11/2021 12:41 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2021 12:41 PM
Terminations	Termination Date	Insert	New Registration			10/11/2021 12:41 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2021 12:41 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2021 12:41 PM