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DSH140155D Presence St. Mary's Hospital (Terminated)
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Main Details
Name
Presence St. Mary's Hospital
Subdivision Name
Bourbonnais Campus - Radiation Therapy
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140155D
Medicare Provider Number
140155
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/15/2014
Participating Start Date
10/1/2014
Participating Approval Date
5/8/2014
Last Recertification Date
Termination Date
Termination Reason
7/1/2015
Site closure
Contacts
Authorizing Official
AMITA Health
Yuesha Chen, Regional Chief Financial Officer
(815) 741-7667
Primary Contact
Ken Kuczero, pharmacy operations manager
(815) 937-2175
Addresses
Street Address
100 Provena Way
Bourbonnais, IL 60914
Billing Address
Presence St. Mary's Hospital
500 West Court Street
Kankakee, IL 60901
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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9/16/14 originally registered for a 7/1/14 start date then, prior to start date, terminated because hospital was not ready to implement 340B. Subsequently re-registered during July registration period and so the old record was re-instated effective 10/1/14
09/16/2014
April 2025
April 2025
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