Covered Entity Details

DSH140046P SSM HEALTH GOOD SAMARITAN HOSPITAL (Terminated) - information as of 6/16/2025 1:06:59 AM

Main Details

Name

SSM HEALTH GOOD SAMARITAN HOSPITAL

Subdivision Name

SMGS - - Infectious Disease

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140046P

Medicare Provider Number

140046

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/6/2023

Participating Start Date

7/1/2023

Participating Approval Date

6/5/2023

Last Recertification Date

8/15/2024

Termination Date
Termination Reason

1/1/2025
Site closure

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

2 Good Samaritan Way
Suite 420
Mt. Vernon, IL 62864

Billing Address

Good Samaritan Hospital
1 Good Samaritan Way
Mt. Vernon, IL 62864

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	430653587002,430653587402	1043270424,1487758801,1609897339,1316282163

Shipping Addresses

Shipping Address 1

Good Samaritan Hospital
1 Good Samaritan Way
Mt. Vernon, IL 62864

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
DSH140046A	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Medical Plaza Urology [CC-746100]	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046B	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Pulmonary Care	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046C	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SSM HEALTH GOOD SAMARITAN HOSPITAL- - SMGS - Oncology	4117 VETERANS MEMORIAL DR	MOUNT VERNON	IL	ToBeTerminated
DSH140046D	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	GOOD SAMARITAN REGIONAL HEALTH CENT - SMGS - Wound Healing Center	4106 S WATER TOWER PL	MOUNT VERNON	IL	ToBeTerminated
DSH140046E	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - General Surgery	5 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046F	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Heart and Vascular	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046G	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Rheumatology	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
DSH140046H	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Nephrology	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046J	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Medical Plaza Vascular Surgery	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046K	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Weight Management	5 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046L	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Medical Plaza Urology [CC-74600]	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
DSH140046M	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SSM HEALTH GOOD SAMARITAN HOSPITAL- - SMGS - Oncology Infusion	4117 VETERANS MEMORIAL DR	MOUNT VERNON	IL	ToBeTerminated
DSH140046N	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - GI	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046P	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Infectious Disease	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
DSH140046Q	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Endocrinology 5GS	5 Good Samaritan Way	Mt. Vernon	IL	Terminated
DSH140046R	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Endocrinology 2GS	2 Good Samaritan Way	Mount Vernon	IL	ToBeTerminated
DSH140046S	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Physical Medicine and Rehab	2 Good Samaritan Way	Mt. Vernon	IL	Terminated
DSH140046T	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	SMGS - - Medical Plaza Podiatry	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046U	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	Behavioral Health Clinic - MV Behavioral Health	2 Good Samaritan Way	Mt. Vernon	IL	ToBeTerminated
DSH140046V	Child	DSH	SSM HEALTH GOOD SAMARITAN HOSPITAL	Good Samaritan Infusion Centralia - Infusion	400 North Pleasant Avenue	Centralia	IL	ToBeTerminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/21/2024 12:00:00 AM	10/29/2024 12:43 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/29/2024 12:43 PM
Terminations	Termination Comments	Update	Termination Request		Department closed	10/29/2024 12:43 PM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	10/29/2024 12:43 PM
Terminations	Termination Effective Date	Update	Termination Request		10/21/2024 12:00:00 AM	10/29/2024 12:43 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/29/2024 12:43 PM
Details	Last Recertification Date	Update	Recertification	9/11/2023 10:51:58 PM	8/15/2024 1:37:16 PM	8/15/2024 1:37 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 7:35 AM
Details	Last Recertification Date	Update	Recertification		9/11/2023 10:51:58 PM	9/11/2023 10:51 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Addresses	Main Address	Insert	New Registration		2 Good Samaritan Way Suite 420 Mt. Vernon, IL 62864	6/5/2023 11:48 AM
Addresses	Billing Address	Insert	New Registration		Good Samaritan Hospital 1 Good Samaritan Way Mt. Vernon, IL 62864	6/5/2023 11:48 AM
Contacts	Signed By	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	6/5/2023 11:48 AM
Details	340B ID	Update	New Registration		DSH140046P	6/5/2023 11:48 AM
Details	Entity Subname	Update	New Registration	SSM Health Good Samaritan Hospital	SMGS - - Infectious Disease	6/5/2023 11:48 AM
Dates	Participating Approval Date	Update	New Registration		6/5/2023 11:48:54 AM	6/5/2023 11:48 AM
Details	State	Update	New Registration	Pending	Approved	6/5/2023 11:48 AM
Dates	Signed By Date	Update	New Registration		4/17/2023 11:42:14 PM	6/5/2023 11:48 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	6/5/2023 11:48 AM
Addresses	Main Address	Insert	New Registration		2 Good Samaritan Way Suite 420 Mt. Vernon, IL 62864	4/6/2023 10:14 PM
Addresses	Billing Address	Insert	New Registration		Good Samaritan Hospital 1 Good Samaritan Way Mt. Vernon, IL 62864	4/6/2023 10:14 PM
Addresses	Shipping Address	Insert	New Registration		Good Samaritan Hospital 1 Good Samaritan Way Mt. Vernon, IL 62864	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		430653587002	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		430653587402	4/6/2023 10:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1043270424	4/6/2023 10:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1487758801	4/6/2023 10:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609897339	4/6/2023 10:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316282163	4/6/2023 10:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/6/2023 10:14 PM
Contacts	Authorizing Official	Insert	New Registration		Lamm, Eileen Regional Vice President-Finance SSM Health 3149946219	4/6/2023 10:14 PM
Contacts	Primary Contact	Insert	New Registration		McAllister, Anita System Director of 340B Operations SSM Health 3149896778	4/6/2023 10:14 PM
Details	Assistance Received From Date	Insert	New Registration			4/6/2023 10:14 PM
Details	Assistance Received To Date	Insert	New Registration			4/6/2023 10:14 PM
Details	Last Recertification Date	Insert	New Registration			4/6/2023 10:14 PM
Details	Grant Number	Insert	New Registration			4/6/2023 10:14 PM
Details	340B ID	Insert	New Registration			4/6/2023 10:14 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/6/2023 10:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/6/2023 10:14 PM
Details	Medicare Provider Number	Insert	New Registration		140046	4/6/2023 10:14 PM
Details	Entity Name	Insert	New Registration		SSM HEALTH GOOD SAMARITAN HOSPITAL	4/6/2023 10:14 PM
Details	NOFO Number	Insert	New Registration			4/6/2023 10:14 PM
Details	Program Code	Insert	New Registration		DSH	4/6/2023 10:14 PM
Details	Entity Subname	Insert	New Registration		SSM Health Good Samaritan Hospital	4/6/2023 10:14 PM
Dates	Participating Approval Date	Insert	New Registration			4/6/2023 10:14 PM
Details	State	Insert	New Registration		Pending	4/6/2023 10:14 PM
Dates	Registration Date	Insert	New Registration		4/6/2023 10:14:54 PM	4/6/2023 10:14 PM
Dates	Signed By Date	Insert	New Registration			4/6/2023 10:14 PM
Dates	Start Date	Insert	New Registration			4/6/2023 10:14 PM
Terminations	Termination Comments	Insert	New Registration			4/6/2023 10:14 PM
Terminations	Termination Date	Insert	New Registration			4/6/2023 10:14 PM
Terminations	Termination Effective Date	Insert	New Registration			4/6/2023 10:14 PM
Terminations	Termination Reason	Insert	New Registration			4/6/2023 10:14 PM