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DSH140276W LOYOLA UNIVERSITY MEDICAL CENTER (Terminated)
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Main Details
Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
LOYOLA CLINIC AT GOTTLIEB
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH140276W
Medicare Provider Number
140276
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/9/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/15/2010
Last Recertification Date
9/12/2023
Termination Date
Termination Reason
10/1/2024
Other
Contacts
Authorizing Official
Loyola Medicine
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723
Primary Contact
Loyola Medicine
Zohra Saleem, Regional 340B Manager
(708) 216-3875
Addresses
Street Address
675 W. NORTH AVENUE
SUITE 201
MELROSE PARK, IL 60160
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/3/2010- DOC. RECD. TO CONFIRM DSH ADJ. %.
03/09/2010
April 2025
April 2025
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