Covered Entity Details

DSH260091BV SSM HEALTH ST MARY'S HOSPITAL-STL (Active) - information as of 4/24/2025 11:08:10 PM

Main Details

Name

SSM HEALTH ST MARY'S HOSPITAL-STL

Subdivision Name

Maternal Fetal Medicine - Shiloh

Type

Disproportionate Share Hospital

Rural

340B ID

DSH260091BV

Medicare Provider Number

260091

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/16/2022

Participating Start Date

1/1/2023

Participating Approval Date

10/31/2022

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

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

Primary Contact

SSM Health
Holly Herring, Director, 340B Center of Excellence
(580) 512-7188

Addresses

Street Address

1191 Fortune Ave
Shiloh, IL 62221

Billing Address

St. Mary's Hospital
6420 Clayton Road
St. Louis, MO 63117

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
MO	010326205,540326204	1962572396
IL	43065268100,43065268140	1962572396

Shipping Addresses

Shipping Address 1

St. Mary's Hospital
6420 Clayton Road
St. Louis, MO 63117

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
DSH260091A	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM CARDINAL GLENNON CHILDRENS HOSPITAL	1465 S GRAND BLVD	ST. LOUIS	MO	Active
DSH260091AA	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Pediatric GU	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AB	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Radiology-Diagnostic	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AC	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Ambulatory Surgery	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AD	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cardinal Glennon Children's Hospital Clinic / ED Nurse Practitioner	1465 South Grand Blvd.	St. Louis	MO	Terminated
DSH260091AE	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cardinal Glennon Children's Hospital Clinic / Illinois Subspecialty Services	1465 South Grand Blvd.	St. Louis	MO	Terminated
DSH260091AF	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Clinic / University Pediatrics	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AG	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Clinic / Knight of Columbus Center	3800 Park Avenue	St. Louis	MO	Active
DSH260091AH	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Clinic / Cardiology Clinic	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AJ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Clinic / ACC Section A	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AK	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Emergency	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091AL	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG ST MARY'S-INTERNAL MEDICINE	1035 Bellevue Avenue	RICHMOND HEIGHTS	MO	Active
DSH260091AM	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG Internal Medicine	1035 Bellevue Avenue	Richmond Heights	MO	Active
DSH260091AN	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Heart Institute Clayton	1027 Bellevue Avenue	St. Louis	MO	Active
DSH260091AP	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Neurology South	1035 Bellevue Avenue	Richmond Heights	MO	Active
DSH260091AQ	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSMMG ST. MARYS - GEN SURG	1035 Bellevue, Suite 500	Richmond Heights	MO	Terminated
DSH260091AR	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG Pulmonology & Sleep	1035 Bellevue Avenue	Richmond Heights	MO	Active
DSH260091AS	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cancer Care Radiation Oncology SMHC	6400 CLAYTON ROAD, SUITE 302	RICHMOND HEIGHTS	MO	Terminated
DSH260091AT	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM PAIN CARE	6420 Clayton Road	SAINT LOUIS	MO	Active
DSH260091AU	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Med Group Internal Medicine	8670 BIG BEND BLVD, SUITE A	ST. LOUIS	MO	Active
DSH260091AV	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cancer Care South SCHC	1011 Bowles Avenue	Fenton	MO	Active
DSH260091AW	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cancer Care South Radiation Oncology SCHC	1011 Bowles Avenue	Fenton	MO	Active
DSH260091AX	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM ST MARY'S MATERNAL FETAL MEDICINE	1027 BELLEVUE AVENUE, SUITE 205	ST. LOUIS	MO	Active
DSH260091AY	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM CANCER CENTER MEDICAL ONCOLOGY	6400 CLAYTON RD	Richmond Heights	MO	Active
DSH260091AZ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG ST MARYS RHEUM, Suite 500 / Rheumatology Clinic	1035 Bellevue Ave, Suite 500	St. Louis	MO	Active
DSH260091BA	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG Family Medicine Rock Hill	9759 Manchester Road	St. Louis	MO	Active
DSH260091BB	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cancer Care CCC, Suite 212 / Cancer Care Clinic	6400 Clayton Road, Suite 212	St. Louis	MO	Active
DSH260091BC	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG Breast Care Clinic	1031 Bellevue Avenue	St. Louis	MO	Active
DSH260091BD	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Maternal Fetal Medicine	1035 Bellevue Avenue	St. Louis	MO	Active
DSH260091BE	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Endocrinology	1035 Bellevue Avenue	St. Louis	MO	Active
DSH260091BF	Child	DSH	SSM ST MARY'S HEALTH CENTER	Out Patient Behavioral Health Medicine	1027 Bellevue, 4th Floor	St. Louis	MO	Terminated
DSH260091BG	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Outpatient Neuro Diagnostics	1035 Bellevue Avenue	St. Louis	MO	Active
DSH260091BH	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Open MRI	6400 Clayton Rd	St. Louis	MO	Active
DSH260091BJ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Outpatient CT Scan	1031 Bellevue Avenue	St. Louis	MO	Active
DSH260091BK	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Radiology - South County	10296 Big Bend Rd	St. Louis	MO	Active
DSH260091BL	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Outpatient Imaging Diagnostics	1031 Bellevue Avenue	St. Louis	MO	Active
DSH260091BM	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Venous Access Center	1027 Bellevue Avenue	St. Louis	MO	Active
DSH260091BN	Child	DSH	SSM ST MARY'S HEALTH CENTER	2182-CG Peds Overland - 2182-CG Peds Overland	9553 Lackland Rd	Overland	MO	Terminated
DSH260091BP	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Maternal Fetal Medicine - St. Luke's	224 S Woods Mill Road	Chesterfield	MO	Active
DSH260091BQ	Child	DSH	SSM ST MARY'S HEALTH CENTER	2178-CG-SL South County STL - Pediatrics	10296 Big Bend Rd	St Louis	MO	Terminated
DSH260091BR	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Health Cardinal Glennon Perinatal Center - Maternal Fetal Medicine	226 S. Woods Mill Road	Chesterfield	MO	Terminated
DSH260091BS	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Specialty Clinic - Pediatrics	13000 Butler Crest Drive	St. Louis	MO	Active
DSH260091BT	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cardinal Glennon Children's Hospital South County Mobile MRI - Radiology	13000 Butler Crest Drive	St. Louis	MO	Terminated
DSH260091BU	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - CG Pediatric Urology - Butler Crest Dr	13000 Butler Crest Drive	Saint Louis	MO	Active
DSH260091BV	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Maternal Fetal Medicine - Shiloh	1191 Fortune Ave	Shiloh	IL	Active
DSH260091BW	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	St. Mary's - CTSI	1035 Bellevue Avenue	St. Louis	MO	Active
DSH260091BX	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SMHC - Breast Center	1031 BELLEVUE AVE	St Louis	MO	Active
DSH260091BY	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Nuclear Medicine	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091BZ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - CT Scan	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091C	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Heart Institute Cardiac Imaging	1027 Bellevue Avenue	Richmond Heights	MO	Active
DSH260091CA	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - MRI	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091CB	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Costas Center	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091CC	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Hemodialysis	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091CD	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Fetal Care Institute	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091CE	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Complex Medical Care	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091CF	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - DePaul Pediatrics	12255 DePaul Drive	Bridgeton	MO	Active
DSH260091CG	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - North County Specialty Care	3878 Pershall Rd.	Ferguson	MO	Active
DSH260091CH	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Danis Pediatrics Midtown	4100 Forest Park Avenue	St. Louis	MO	Active
DSH260091CJ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital - Florissant Pediatrics	4129 North Hwy 67	Florissant	MO	Active
DSH260091CK	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Maternal Fetal Medicine - Anderson	2133 Vadalabene Drive	Maryville	IL	Active
DSH260091CL	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Maternal Fetal Medicine - Carbondale	900 East Walnut Street	Carbondale	IL	Active
DSH260091CM	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG - General Surgery	1035 BELLEVUE AVE	St. Louis	MO	Active
DSH260091CN	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG - Pain Management	1031 Bellevue Ave	St. Louis	MO	Active
DSH260091CP	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG - Endo Rock Hill	9759 Manchester Road	Webster Groves	MO	Active
DSH260091CQ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSMMG - Family Medicine - The Boulevard	19 The Boulevard St. Louis	Richmond Heights	MO	Active
DSH260091CR	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Urgent Care - North County	3878 Pershall Road	Ferguson	MO	Active
DSH260091CS	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Urgent Care - South County	13000 Butler Crest Drive	St. Louis	MO	Active
DSH260091CT	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Health Medical Group- Pediatrics - Pediatrics	3878 Pershall Road	Ferguson	MO	Active
DSH260091CU	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare General Surgery STCLAR - SLUCare SUR STCLAR	1011 Bowles Avenue	Fenton	MO	Terminated
DSH260091CV	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Rheumatology - SLUCare Rheum DPMA	2315 Dougherty Ferry Rd	St. Louis	MO	Active
DSH260091CW	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Infusion at Des Peres - SLUCare Infusion DPMA	2325 Dougherty Ferry Road	St. Louis	MO	Active
DSH260091CX	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Colorectal Surgery - Surgery	1011 Bowles Avenue	Fenton	MO	Active
DSH260091CY	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare: Endocrinology, Diabetes, and Metabolism - Endocrinology, Diabetes, and Metabolism	2315 Dougherty Ferry Rd	St. Louis	MO	Active
DSH260091CZ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Hematology at Des Peres - SLUCare HEMONC DPMA	2325 Dougherty Ferry Road	St. Louis	MO	Active
DSH260091D	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM St. Mary's Infusion Center East	6400 Clayton Road	Richmond Heights	MO	Active
DSH260091DA	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Urology - SLUCare GU Clayton	6400 Clayton Road	St. Louis	MO	Active
DSH260091DB	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Pulmonology - SLUCare PULM DPMA	2315 Dougherty Ferry Rd	St. Louis	MO	Active
DSH260091DC	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Neurosurgery - SLUCare NSUR Clayton	6400 Clayton Road	St. Louis	MO	Active
DSH260091DD	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Orthopedic Surgery - SLUCare Ortho St Clare	1011 Bowles Avenue	Fenton	MO	Active
DSH260091DE	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare General Surgery - SLUCare CRS Clayton	6400 Clayton Road	St. Louis	MO	Active
DSH260091DF	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SMHC Radiology - SMHC Radiology at SLUCare Orthopedics	1031 Bellevue	St. Louis	MO	Active
DSH260091DG	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare Vascular Surgery - SLUCare VAS St Clare	1101 Bowles Avenue	Fenton	MO	Terminated
DSH260091DH	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	Women's Wellness Center - Wellness	1035 Bellevue	St. Louis	MO	Active
DSH260091DJ	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SLUCare GI DPMA - SLUCare Physicians Group- GI	2315 Dougherty Ferry Rd	St. Louis	MO	Active
DSH260091DK	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Health Cardinal Glennon IL Subspecialty Services - Pediatrics- Subspecialty IL	3403 Anderson Healthcare Drive	Edwardsville	IL	Active
DSH260091DL	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Health Cardinal Glennon Footprints - Pediatrics	1465 South Grand Blvd	St. Louis	MO	Active
DSH260091E	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM St. Mary's Infusion Center	1027 Bellevue Ave., Suite 103	Richmond Heights	MO	Active
DSH260091F	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cancer Care Fenton	1011 Bowles Avenue	Fenton	MO	Active
DSH260091G	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM St. Mary's Health Center Rheumatology Infusion	6400 Clayton Road, Suite 316	Richmond Heights	MO	Terminated
DSH260091H	Child	DSH	SSM ST MARY'S HEALTH CENTER	CGCMC Pediatric Specialists at Anderson	2133 Vadalabene Drive	Maryville	IL	Terminated
DSH260091J	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital at DePaul Health Center	12255 DePaul Drive	Bridgeton	MO	Active
DSH260091K	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cardinal Glennon at St. Anthony's	12700 Southfork Road, Suite 155D	St. Louis	MO	Terminated
DSH260091L	Child	DSH	SSM ST MARY'S HEALTH CENTER	SSM Cardinal Glennon at St. Luke's	224 South Woodsmill Road, Suite 640	Chesterfield	MO	Terminated
DSH260091M	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon at Lake St. Louis	301 Caledonia Parkway	O'Fallon	MO	Active
DSH260091N	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Brentwood Urgent Care	2341 S Brentwood Blvd	Brentwood	MO	Active
DSH260091P	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Recovery Room	1465 South Grand Blvd	St. Louis	MO	Active
DSH260091Q	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Operating Room	1465 South Grand Blvd	St. Louis	MO	Active
DSH260091R	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Special Procedures	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091S	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Endoscopy	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091T	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Electroencephalography	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091U	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Electrocardiology	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091V	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Sleep Disorder	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091W	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Respiratory Therapy	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091X	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Intravenous Therapy	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091Y	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Cardiac Catheterization	1465 South Grand Blvd.	St. Louis	MO	Active
DSH260091Z	Child	DSH	SSM HEALTH ST MARY'S HOSPITAL-STL	SSM Cardinal Glennon Children's Hospital Radiology-Therapeutic	1465 South Grand Blvd.	St. Louis	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Recertification	SSM ST MARY'S HOSPITAL-STL	SSM HEALTH ST MARY'S HOSPITAL-STL	8/15/2024 2:58 PM
Details	Last Recertification Date	Update	Recertification	9/11/2023 9:58:15 PM	8/15/2024 1:45:50 PM	8/15/2024 1:45 PM
Details	Entity Name	Update	Change Request	SSM ST MARY'S HEALTH CENTER	SSM ST MARY'S HOSPITAL-STL	7/16/2024 7:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2024 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		43065268100	6/13/2024 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/13/2024 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2024 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		43065268140	6/13/2024 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/13/2024 4:20 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1962572396	6/13/2024 4:20 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/13/2024 4:20 PM
Contacts	Primary Contact	Update	PC Change Request	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	Herring, Holly Director, 340B Center of Excellence SSM Health 5805127188	10/2/2023 7:01 AM
Details	Last Recertification Date	Update	Recertification		9/11/2023 9:58:15 PM	9/11/2023 9:58 PM
Contacts	Primary Contact	Update	PC Change Request	McAllister, Anita System Director of 340B Operations SSM Health 3149896778	Schmitt, Michelle Nicole Director of Business Operations SSM Health 6082846203	8/23/2023 9:49 AM
Details	Entity Subname	Update	Change Request	Maternal Fetal Medicine - - Shiloh	Maternal Fetal Medicine - Shiloh	1/19/2023 9:20 AM
Contacts	Primary Contact	Update	Profile Change Request	McAllister, Anita System Director of 340B Operations SSM Health 9193576357	McAllister, Anita System Director of 340B Operations SSM Health 3149896778	1/10/2023 9:39 AM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Primary Contact	Update	Group Change Request	Violette, Chelsea Director of Optimization Spendmend 8452066019	McAllister, Anita System Director of 340B Operations SSM Health 9193576357	11/28/2022 12:35 PM
Contacts	Signed By	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	10/31/2022 7:06 AM
Details	340B ID	Update	New Registration		DSH260091BV	10/31/2022 7:06 AM
Details	Entity Name	Update	New Registration	SSM HEALTH ST. MARYS HOSPITAL - STL	SSM ST MARY'S HEALTH CENTER	10/31/2022 7:06 AM
Details	Entity Subname	Update	New Registration	Maternal Fetal Medicine -	Maternal Fetal Medicine - - Shiloh	10/31/2022 7:06 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2022 7:06:36 AM	10/31/2022 7:06 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2022 7:06 AM
Dates	Signed By Date	Update	New Registration		10/17/2022 8:43:15 PM	10/31/2022 7:06 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	10/31/2022 7:06 AM
Addresses	Main Address	Insert	New Registration		1191 Fortune Ave Shiloh, IL 62221	10/16/2022 8:35 PM
Addresses	Billing Address	Insert	New Registration		St. Mary's Hospital 6420 Clayton Road St. Louis, MO 63117	10/16/2022 8:35 PM
Addresses	Shipping Address	Insert	New Registration		St. Mary's Hospital 6420 Clayton Road St. Louis, MO 63117	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010326205	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		540326204	10/16/2022 8:35 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/16/2022 8:35 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1962572396	10/16/2022 8:35 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/16/2022 8:35 PM
Contacts	Authorizing Official	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	10/16/2022 8:35 PM
Contacts	Primary Contact	Insert	New Registration		Violette, Chelsea Director of Optimization Spendmend 8452066019	10/16/2022 8:35 PM
Details	Assistance Received From Date	Insert	New Registration			10/16/2022 8:35 PM
Details	Assistance Received To Date	Insert	New Registration			10/16/2022 8:35 PM
Details	Last Recertification Date	Insert	New Registration			10/16/2022 8:35 PM
Details	Grant Number	Insert	New Registration			10/16/2022 8:35 PM
Details	340B ID	Insert	New Registration			10/16/2022 8:35 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/16/2022 8:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/16/2022 8:35 PM
Details	Medicare Provider Number	Insert	New Registration		260091	10/16/2022 8:35 PM
Details	Entity Name	Insert	New Registration		SSM HEALTH ST. MARYS HOSPITAL - STL	10/16/2022 8:35 PM
Details	NOFO Number	Insert	New Registration			10/16/2022 8:35 PM
Details	Program Code	Insert	New Registration		DSH	10/16/2022 8:35 PM
Details	Entity Subname	Insert	New Registration		Maternal Fetal Medicine -	10/16/2022 8:35 PM
Dates	Participating Approval Date	Insert	New Registration			10/16/2022 8:35 PM
Details	State	Insert	New Registration		Pending	10/16/2022 8:35 PM
Dates	Registration Date	Insert	New Registration		10/16/2022 8:35:26 PM	10/16/2022 8:35 PM
Dates	Signed By Date	Insert	New Registration			10/16/2022 8:35 PM
Dates	Start Date	Insert	New Registration			10/16/2022 8:35 PM
Terminations	Termination Comments	Insert	New Registration			10/16/2022 8:35 PM
Terminations	Termination Date	Insert	New Registration			10/16/2022 8:35 PM
Terminations	Termination Effective Date	Insert	New Registration			10/16/2022 8:35 PM
Terminations	Termination Reason	Insert	New Registration			10/16/2022 8:35 PM