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DSH140054E MACNEAL HOSPITAL (Terminated)
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Main Details
Name
MACNEAL HOSPITAL
Subdivision Name
MACNEAL PAIN CENTER - Pain Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140054E
Medicare Provider Number
140054
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/26/2018
Participating Start Date
1/1/2019
Participating Approval Date
11/5/2018
Last Recertification Date
9/11/2020
Termination Date
Termination Reason
10/1/2021
Site closure
Contacts
Authorizing Official
Loyola University Medical Center
Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252
Primary Contact
Loyola Medicine
Joe Vadakara, Regional Pharmacy Director
(708) 216-0399
Addresses
Street Address
2550 SOUTH OAK PARK AVE
Berwyn, IL 60402-4661
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 10/1/2018; terminated 10/1/2018; Reinstated 1/1/2019.
11/01/2018
May 2025
May 2025
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