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DSH140276AD LOYOLA UNIVERSITY MEDICAL CENTER (Terminated)
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Main Details
Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Loyola Center for Health at Norridge
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH140276AD
Medicare Provider Number
140276
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/9/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/11/2015
Last Recertification Date
8/25/2016
Termination Date
Termination Reason
7/1/2017
Site closure
Contacts
Authorizing Official
Loyola University Medical Center
Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252
Primary Contact
Loyola University Medical Center
William Pong, Administrative Director, Pharmacy Services
(708) 216-0399
Addresses
Street Address
8307 W Lawrence Ave
Norridge, IL 60706
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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