Covered Entity Details

DSH520177U FROEDTERT MEMORIAL LUTHERAN HOSPITAL (Active) - information as of 4/29/2025 12:30:50 AM

Main Details

Name

FROEDTERT MEMORIAL LUTHERAN HOSPITAL

Subdivision Name

FMLH Clinic - Dermatology - Dermatology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH520177U

Medicare Provider Number

520177

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/17/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/16/2022

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Froedtert Memorial Lutheran Hospital
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925

Primary Contact

Froedtert Memorial Lutheran Hospital
Casey Drake Spitzer, 340B Manager
(920) 319-6030

Addresses

Street Address

601 N 99th Street
Milwaukee, WI 53226

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
WI	11000400	1255334173
IL	396105970001	1255334173
IA	939538	1255334173
MI	40-4656061	1255334173
MN	923550700	1255334173

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
DSH520177D	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Tosa Health Center Radiology	1155 N. Mayfair Road	Wauwatosa	WI	Terminated
DSH520177E	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Sports Medicine Radiology	8700 Watertown Plank Road	Wauwatosa	WI	Terminated
DSH520177F	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Froedtert & Medical College of Wisconsin Reproductive Medicine Center	W129 N7055 Northfield Drive	Menomonee Falls	WI	Active
DSH520177G	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center - Infusion Clinic	4805 S. Moorland Road	New Berlin	WI	Active
DSH520177H	Child	DSH	FROEDTERT MEM. LUTHERAN HOSPT.	Plastic Surgery	8700 W. Watertown Plank Road	Milwaukee	WI	Terminated
DSH520177J	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Moorland Reserve Health Center / Cancer Center Clinic	4805 South Moorland Road	New Berlin	WI	Active
DSH520177K	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Eye Institute	925 N. 87th Street	Milwaukee	WI	Active
DSH520177L	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Rheumatology Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177M	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Endocrine Clinic	9200W WISCONSIN AVE	MILWAUKEE	WI	Terminated
DSH520177N	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FROEDTERT MEMORIAL LUTHERAN HOSPITAL / Infectious Disease Clinic	840 N 87th St	Milwaukee	WI	Active
DSH520177P	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	Delivery Room & Labor Room	9000 West Wisconsin Avenue	Milwaukee	WI	Terminated
DSH520177Q	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER DREXEL TOWN SQUA - Drexel Cancer Center Clinic	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177R	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH INFUSION CLINIC DREXEL TOWN SQ - Drexel TSHC-General Infusion	7901 S 6TH ST	OAK CREEK	WI	Active
DSH520177S	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER MENOMONEE FALLS - Medical Oncology	W180N8085 TOWN HALL RD	MENOMONEE FALLS	WI	Active
DSH520177T	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH CANCER CENTER WEST BEND - Medical Oncology	3200 PLEASANT VALLEY RD	WEST BEND	WI	Active
DSH520177U	Child	DSH	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	FMLH Clinic - Dermatology - Dermatology	601 N 99th Street	Milwaukee	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 7:41:50 PM	8/13/2024 10:56:40 AM	8/13/2024 10:56 AM
Contacts	Primary Contact	Update	Group Change Request	Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	Spitzer, Casey Drake 340B Manager Froedtert Memorial Lutheran Hospital 9203196030	5/7/2024 6:37 AM
Details	Last Recertification Date	Update	Recertification		8/29/2023 7:41:50 PM	8/29/2023 7:41 PM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	11/16/2022 12:40 PM
Details	340B ID	Update	New Registration		DSH520177U	11/16/2022 12:40 PM
Details	Entity Name	Update	New Registration	FROEDTERT MEM. LUTHERAN HOSPT.	FROEDTERT MEMORIAL LUTHERAN HOSPITAL	11/16/2022 12:40 PM
Details	Entity Subname	Update	New Registration	FMLH Clinic - Dermatology	FMLH Clinic - Dermatology - Dermatology	11/16/2022 12:40 PM
Dates	Participating Approval Date	Update	New Registration		11/16/2022 12:40:20 PM	11/16/2022 12:40 PM
Details	State	Update	New Registration	Pending	Approved	11/16/2022 12:40 PM
Dates	Signed By Date	Update	New Registration		10/17/2022 2:25:58 PM	11/16/2022 12:40 PM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/16/2022 12:40 PM
Addresses	Main Address	Insert	New Registration		601 N 99th Street Milwaukee, WI 53226	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11000400	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		396105970001	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		939538	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		40-4656061	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		923550700	10/17/2022 10:04 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	10/17/2022 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	10/17/2022 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/17/2022 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	10/17/2022 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/17/2022 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	10/17/2022 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		IA	10/17/2022 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	10/17/2022 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	10/17/2022 10:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255334173	10/17/2022 10:04 AM
Medicaid Billing	NPI: State	Insert	New Registration		MN	10/17/2022 10:04 AM
Contacts	Authorizing Official	Insert	New Registration		Klauck, James Senior Vice President, Ancillary Services Froedtert Memorial Lutheran Hospital 4147771925	10/17/2022 10:04 AM
Contacts	Primary Contact	Insert	New Registration		Olson, Jacob 340B Program Manager Froedtert Memorial Lutheran Hospital 2625325184	10/17/2022 10:04 AM
Details	Assistance Received From Date	Insert	New Registration			10/17/2022 10:04 AM
Details	Assistance Received To Date	Insert	New Registration			10/17/2022 10:04 AM
Details	Last Recertification Date	Insert	New Registration			10/17/2022 10:04 AM
Details	Grant Number	Insert	New Registration			10/17/2022 10:04 AM
Details	340B ID	Insert	New Registration			10/17/2022 10:04 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/17/2022 10:04 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/17/2022 10:04 AM
Details	Medicare Provider Number	Insert	New Registration		520177	10/17/2022 10:04 AM
Details	Entity Name	Insert	New Registration		FROEDTERT MEM. LUTHERAN HOSPT.	10/17/2022 10:04 AM
Details	NOFO Number	Insert	New Registration			10/17/2022 10:04 AM
Details	Program Code	Insert	New Registration		DSH	10/17/2022 10:04 AM
Details	Entity Subname	Insert	New Registration		FMLH Clinic - Dermatology	10/17/2022 10:04 AM
Dates	Participating Approval Date	Insert	New Registration			10/17/2022 10:04 AM
Details	State	Insert	New Registration		Pending	10/17/2022 10:04 AM
Dates	Registration Date	Insert	New Registration		10/17/2022 10:04:54 AM	10/17/2022 10:04 AM
Dates	Signed By Date	Insert	New Registration			10/17/2022 10:04 AM
Dates	Start Date	Insert	New Registration			10/17/2022 10:04 AM
Terminations	Termination Comments	Insert	New Registration			10/17/2022 10:04 AM
Terminations	Termination Date	Insert	New Registration			10/17/2022 10:04 AM
Terminations	Termination Effective Date	Insert	New Registration			10/17/2022 10:04 AM
Terminations	Termination Reason	Insert	New Registration			10/17/2022 10:04 AM