Covered Entity Details

DSH260104BC SSM HEALTH DEPAUL HOSPITAL (Active) - information as of 4/27/2025 12:48:36 AM

Main Details

Name

SSM HEALTH DEPAUL HOSPITAL

Subdivision Name

Urgent Care - BHS

Type

Disproportionate Share Hospital

Rural

340B ID

DSH260104BC

Medicare Provider Number

260104

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/17/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/9/2022

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

12355 DePaul Drive
Suite 150
Bridgeton, MO 63044

Billing Address

DePaul Hospital
12303 DePaul Drive
Bridgeton, MO 63044

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	010494102	1598835308
IL	431704972001,43170497240	1598835308

Shipping Addresses

Shipping Address 1

DePaul Hospital
12303 DePaul Drive
Bridgeton, MO 63044

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
DSH260104A	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Heart Institute Cardiac Imaging	12266 DePaul Drive	Bridgeton	MO	Active
DSH260104AA	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG at Cross Keys / General	14021 New Halls Ferry Road	Florissant	MO	Active
DSH260104AB	Child	DSH	SSM DEPAUL HEALTH CENTER	DPMG Pediatrics - Cross Keys	14021 New Halls Ferry Road	Florissant	MO	Terminated
DSH260104AC	Child	DSH	SSM DEPAUL HEALTH CENTER	NSI DePaul Ste 100	12266 DePaul Drive	Bridgeton	MO	Terminated
DSH260104AD	Child	DSH	SSM DEPAUL HEALTH CENTER	CTSI Elec Phy DPHC	12266 DePaul Drive	Bridgeton	MO	Terminated
DSH260104AE	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	CTSI South LSL	400 Medical Plaza	Lake St. Louis	MO	Active
DSH260104AF	Child	DSH	SSM DEPAUL HEALTH CENTER	DPMG Spec DPHC Gen	12255 DePaul Drive	Bridgeton	MO	Terminated
DSH260104AG	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM CANCER CARE	12277 DePaul Drive	Bridgeton	MO	Active
DSH260104AH	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM CANCER CARE - Radiation Oncology	400 MEDICAL PLAZA	LAKE SAINT LOUIS	MO	Active
DSH260104AJ	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM CANCER CARE - Radiation Oncology	1475 KISKER ROAD	ST CHARLES	MO	Active
DSH260104AK	Child	DSH	SSM DEPAUL HEALTH CENTER	SSM DePaul MOB / SSM DePaul Pain Management	12255 DePaul Drive, Suite 120	Bridgeton	MO	Terminated
DSH260104AL	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DePaul Infusion	12277 DePaul Drive, Suite 100	Bridgeton	MO	Active
DSH260104AM	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Imaging Center	3440 DePaul Lane #100	Bridgeton	MO	Active
DSH260104AN	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM OB Care Clinic	12277 DePaul Drive, Suite 504	Bridgeton	MO	Active
DSH260104AP	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Ambulatory Surgery Center	12266 DePaul Drive, Suite 10	Bridgeton	MO	Active
DSH260104AQ	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Complex Care Clinic - Surgical Evaluation Center	12277 DePaul Dr	Bridgeton	MO	Active
DSH260104AR	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Shackelford Urgent Care	1120 Shackelford	Florissant	MO	Active
DSH260104AS	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSMMG GI	12277 DePaul Drive	Bridgeton	MO	Active
DSH260104AT	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DePaul Hospital - Adolescent Behavioral Health	12304 DePaul Drive	Bridgeton	MO	Active
DSH260104AU	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DePaul Hospital - Maternal Fetal Medicine	12277 DePaul Dr.	Bridgeton	MO	Active
DSH260104AV	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Radiation Oncology - Lake St. Louis	400 Medical Plaza	Lake St. Louis	MO	Active
DSH260104AW	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Infusion Center - Lake St. Louis	400 Medical Plaza	Lake St. Louis	MO	Active
DSH260104AX	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DePaul Hospital - Neuro Diagnostics	12266 DePaul Dr	Bridgeton	MO	Active
DSH260104B	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Cancer Care at St. Joseph Medical Park	1475 Kisker Road	St. Charles	MO	Active
DSH260104BA	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SCC Endocrinology - Dorsett	2024 Dorsett Village	Maryland Heights	MO	Active
DSH260104BB	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSMMG OBGYN - Florissant	1120 Shackelford Road	Florissant	MO	Active
DSH260104BC	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Urgent Care - BHS	12355 DePaul Drive	Bridgeton	MO	Active
DSH260104BD	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM DEPAUL HEALTH CENTER - DPHC Anticoagulation Clinic	12277 DePaul Drive	Bridgeton	MO	Active
DSH260104BE	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Outpatient Behavioral Health Clinic - OP BHS LAI Clinic	12355 DePaul Dr	Bridgeton	MO	Active
DSH260104BF	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Wound Center - Wound Clinic	12266 DePaul Dr	Bridgeton	MO	Active
DSH260104BG	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Cancer Care Med Park RAD - Radiology	1475 Kisker Road	St. Peters	MO	Active
DSH260104C	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSM Cancer Care at Lake Saint Louis	400 Medical Plaza, Suite 100	Lake Saint Louis	MO	Active
DSH260104D	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPHC Rheumatology Infusion - Shackelford	1120 Shackelford Rd, Suite B	Florissant	MO	Active
DSH260104E	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPHC Rheumatology Infusion - DePaul	12255 DePaul Drive, Suite 501	Bridgeton	MO	Active
DSH260104F	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Dorsett Urgent Care	2022 Dorsett Village	Maryland Heights	MO	Active
DSH260104H	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	Vascular Institute	12266 DePaul Drive, Suite 315	Bridgeton	MO	Active
DSH260104J	Child	DSH	SSM DEPAUL HEALTH CENTER	SSMCC - North - LSL Ste 100 / SSM Cancer Care	400 Medical Plaza, Suite 100	Lake St. Louis	MO	Terminated
DSH260104K	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSMCC MP Infusion	1475 Kisker Road, Suite 180	Saint Peters	MO	Active
DSH260104L	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSMHI at DPMG Ste 205 / Heart Institute	12266 DePaul Drive	Bridgeton	MO	Active
DSH260104M	Child	DSH	SSM DEPAUL HEALTH CENTER	SSMHI at DePaul Ste 400 / Heart Institute	12255 DePaul Drive	Bridgeton	MO	Terminated
DSH260104N	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	SSMOI - Shackelford	1120 Shackelford Road	Florissant	MO	Active
DSH260104P	Child	DSH	SSM DEPAUL HEALTH CENTER	SSMOI - DPHC Ste 220	12266 DePaul Drive	Bridgeton	MO	Terminated
DSH260104Q	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPHC SSMOI	12349 DePaul Drive	Bridgeton	MO	Active
DSH260104R	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	NSI Neurology at DPHC Ste 100	12266 DePaul Drive	Bridgeton	MO	Active
DSH260104S	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Rheumatology at DPHC	12255 DePaul Drive	Bridgeton	MO	Active
DSH260104T	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Podiatry at DPHC	12255 DePaul Drive	Bridgeton	MO	Active
DSH260104U	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Pulmonary at DPHC	12255 DePaul Drive	Bridgeton	MO	Active
DSH260104V	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Rheumatology at DPHC	1120 Shackelford Road	Florissant	MO	Active
DSH260104W	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG at North County	1120 Shackelford Road	Florissant	MO	Active
DSH260104X	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Primary Care at DPHC	12255 DePaul Drive	Bridgeton	MO	Active
DSH260104Y	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG at Dorsett Village	2024 Dorsett Village Shopping Center	Maryland Heights	MO	Active
DSH260104Z	Child	DSH	SSM HEALTH DEPAUL HOSPITAL	DPMG Endocrinology at DPHC	12277 DePaul Drive	Bridgeton	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/11/2023 9:27:03 PM	8/15/2024 1:59:46 PM	8/15/2024 1:59 PM
Details	Entity Name	Update	Recertification	SSM DEPAUL HEALTH HOSPITAL	SSM HEALTH DEPAUL HOSPITAL	8/15/2024 1:46 PM
Details	Entity Name	Update	Change Request	SSM DEPAUL HEALTH CENTER	SSM DEPAUL HEALTH HOSPITAL	7/17/2024 12:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2024 3:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		431704972001	6/13/2024 3:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/13/2024 3:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2024 3:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		43170497240	6/13/2024 3:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/13/2024 3:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598835308	6/13/2024 3:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/13/2024 3:37 PM
Contacts	Primary Contact	Update	PC Change Request	McAllister, Anita System Director of 340B Operations SSM Health 3149896778	Herring, Holly Director, 340B Center of Excellence SSM Health 5805127188	10/2/2023 6:49 AM
Details	Last Recertification Date	Update	Recertification		9/11/2023 9:27:03 PM	9/11/2023 9:27 PM
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	12/22/2022 12:07 PM
Contacts	Signed By	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	11/9/2022 1:22 PM
Details	340B ID	Update	New Registration		DSH260104BC	11/9/2022 1:22 PM
Details	Entity Name	Update	New Registration	SSM HEALTH DEPAUL HOSPITAL	SSM DEPAUL HEALTH CENTER	11/9/2022 1:22 PM
Details	Entity Subname	Update	New Registration	Urgent Care	Urgent Care - BHS	11/9/2022 1:22 PM
Dates	Participating Approval Date	Update	New Registration		11/9/2022 1:22:18 PM	11/9/2022 1:22 PM
Details	State	Update	New Registration	Pending	Approved	11/9/2022 1:22 PM
Dates	Signed By Date	Update	New Registration		10/21/2022 1:59:59 PM	11/9/2022 1:22 PM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/9/2022 1:22 PM
Addresses	Main Address	Insert	New Registration		12355 DePaul Drive Suite 150 Bridgeton, MO 63044	10/17/2022 12:46 AM
Addresses	Billing Address	Insert	New Registration		DePaul Hospital 12303 DePaul Drive Bridgeton, MO 63044	10/17/2022 12:46 AM
Addresses	Shipping Address	Insert	New Registration		DePaul Hospital 12303 DePaul Drive Bridgeton, MO 63044	10/17/2022 12:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 12:46 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010494102	10/17/2022 12:46 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/17/2022 12:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1598835308	10/17/2022 12:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/17/2022 12:46 AM
Contacts	Authorizing Official	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	10/17/2022 12:46 AM
Contacts	Primary Contact	Insert	New Registration		Violette, Chelsea Director of Optimization Spendmend 8452066019	10/17/2022 12:46 AM
Details	Assistance Received From Date	Insert	New Registration			10/17/2022 12:46 AM
Details	Assistance Received To Date	Insert	New Registration			10/17/2022 12:46 AM
Details	Last Recertification Date	Insert	New Registration			10/17/2022 12:46 AM
Details	Grant Number	Insert	New Registration			10/17/2022 12:46 AM
Details	340B ID	Insert	New Registration			10/17/2022 12:46 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/17/2022 12:46 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/17/2022 12:46 AM
Details	Medicare Provider Number	Insert	New Registration		260104	10/17/2022 12:46 AM
Details	Entity Name	Insert	New Registration		SSM HEALTH DEPAUL HOSPITAL	10/17/2022 12:46 AM
Details	NOFO Number	Insert	New Registration			10/17/2022 12:46 AM
Details	Program Code	Insert	New Registration		DSH	10/17/2022 12:46 AM
Details	Entity Subname	Insert	New Registration		Urgent Care	10/17/2022 12:46 AM
Dates	Participating Approval Date	Insert	New Registration			10/17/2022 12:46 AM
Details	State	Insert	New Registration		Pending	10/17/2022 12:46 AM
Dates	Registration Date	Insert	New Registration		10/17/2022 12:46:01 AM	10/17/2022 12:46 AM
Dates	Signed By Date	Insert	New Registration			10/17/2022 12:46 AM
Dates	Start Date	Insert	New Registration			10/17/2022 12:46 AM
Terminations	Termination Comments	Insert	New Registration			10/17/2022 12:46 AM
Terminations	Termination Date	Insert	New Registration			10/17/2022 12:46 AM
Terminations	Termination Effective Date	Insert	New Registration			10/17/2022 12:46 AM
Terminations	Termination Reason	Insert	New Registration			10/17/2022 12:46 AM