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RRC140250-00 SOUTH SUBURBAN HOSPITAL (Terminated)
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Main Details
Name
SOUTH SUBURBAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC140250-00
Medicare Provider Number
140250
Additional Details
Current Program Status
Terminated
Registration Date
7/8/2020
Participating Start Date
10/1/2020
Participating Approval Date
7/21/2020
Last Recertification Date
Termination Date
Termination Reason
12/21/2020
Other
Contacts
Authorizing Official
Advocate Aurora Health Care
Nan Nelson, SVP-Finance
(414) 378-4765
Primary Contact
Advocate Aurora Health Care
Angela De Ianni, Vice President Pharmacy Supply Chain
(414) 630-1541
Addresses
Street Address
178TH STREET AND KEDZIE AVE
HAZELCREST, IL 60429
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating start date 7/1/2019. Terminated date 7/1/2019. Reinstated 10/1/2020.
07/09/2020
April 2025
April 2025
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