HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo ›...

86
A Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracted Providers Ambulatory Surgicenters …………………………………………………………. 2 Durable Medical Equipment ……………………………………………………… 8 Durable Medical Equipment Blue Precision …………………………………… 18 Home Health Care ………………………………………………………………… 21 Home Infusion …………………………………………………………………….. 35 Hospice Facilities …………………………………………………………………. 37 Inpatient - Metro Hospitals ……………………………………………………….. 42 Inpatient - Boarder State Market Hospitals ……………………………………… 46 Long Term Acute Care ……………………………………………………………. 49 Mental Health IOP/PHP …………………………………………………………… 50 Orthotic & Prosthetic ……………………………………………………………… 51 Orthotic & Prosthetic Blue Precision……………………………………………….57 Hospital Based Outpatient Surgery Class I Providers …………………………………………………………. 59 Class II Providers ……………………………………………………….... 63 Renal Dialysis …………………………………………………………………….. 65 Skilled Nursing Facilities ………………………………………………………… 76 Substance Use Disorder ………………………………………………………….. 83

Transcript of HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo ›...

Page 1: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

A Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix D

HMO Illinois, Blue Advantage HMO and Blue Precision Contracted Providers

Ambulatory Surgicenters …………………………………………………………. 2 Durable Medical Equipment ……………………………………………………… 8 Durable Medical Equipment Blue Precision …………………………………… 18 Home Health Care ………………………………………………………………… 21 Home Infusion …………………………………………………………………….. 35 Hospice Facilities …………………………………………………………………. 37 Inpatient - Metro Hospitals ……………………………………………………….. 42 Inpatient - Boarder State Market Hospitals ……………………………………… 46 Long Term Acute Care ……………………………………………………………. 49 Mental Health IOP/PHP …………………………………………………………… 50 Orthotic & Prosthetic ……………………………………………………………… 51 Orthotic & Prosthetic Blue Precision……………………………………………….57 Hospital Based Outpatient Surgery Class I Providers …………………………………………………………. 59 Class II Providers ……………………………………………………….... 63 Renal Dialysis …………………………………………………………………….. 65 Skilled Nursing Facilities ………………………………………………………… 76 Substance Use Disorder ………………………………………………………….. 83

Page 2: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

1514 Surgicenter 03/08/06 25 East Same Day Surgicenter I 1 25 E. Washington Street Chicago IL 60602-1708 (312) 726-3329 R 10/16/071533 Surgicenter 02/01/99 900 N. Michigan Surgical Ctr. LLC I 1 60 E. Delaware Place Chicago IL 60611-1495 (312) 440-5152 A 12/01/99

50213 Surgicenter 05/01/03 Aanchor Health Center, Ltd. I 1 1186 Roosevelt Road Glen Ellyn IL 60137 (630) 495-4400 A 09/11/03591 Surgicenter 01/01/98 Access Health Center I 1 1700 75th Street Downers Grove IL 60516 (630) 964-0000

1546 Surgicenter 04/16/01 ACU Health Center, Ltd I 1 736 N. York Road Hinsdale IL 60521 (630) 794-0645 P 05/01/0151949 Surgicenter 09/01/12 Advanced Ambulatory Surg Center Inc. I 1 2333 N Harlem Ave. Chicago IL 60707-2718 (773) 637-1700 A 10/01/12

1535 Surgicenter 06/01/99 Advantage Health Care, Ltd. I 1 203 E. Irving Park Road Woodale IL 60191 (630) 595-1515 A 09/01/9952076 Surgicenter 06/01/13 Aiden Center For Day Surgery LLC I 1 1580 W Lake St. Addison IL 60101-1171 (630) 285-7000 A 08/01/1351441 Surgicenter 10/23/09 01/01/13 Aiden Center for Day Surgery LLC I 1 1580 W Lake ST Addison IL 60101-1171 (630) 928-1048 C 01/01/1350195 Surgicenter 04/01/03 Algonquin Road Surgery Center, LLC I 1 2550 Algonquin Lake in the Hill IL 60156 (847) 458-1246 A 07/10/0351522 Surgicenter 04/01/10 Ambulatory Surgicenter of Downers Grove I 1 4344 Main St. Downers Grove IL 60515-2869 (630) 322-9451 A 04/01/1056363 Surgicenter 01/01/14 American Medical Center I 1 110 S River Road Des Plaines IL 60016-3440 (847) 294-9614 N 05/01/14

523 Surgicenter 07/01/08 Amsurg Surgery Center I 1 998 129th Infantry Dr. Joliet IL 60435 (815) 744-3000 R 02/01/1051442 Surgicenter 10/23/09 01/01/13 Ashton Surgical Center Inc I 1 1800 McDonough Road Hoffman Estates IL 60192-4524 (630) 928-1048 C 01/01/1352077 Surgicenter 06/01/13 Ashton Surgical Center Inc I 1 1800 McDonough Road Hoffman Estates IL 60192-4524 (847) 742-7272 A 08/01/13

613 Surgicenter 04/08/13 Bel-Clair Ambulatory Surgery I 1 325 W. Lincoln St. Belleville IL 62220-1921 (618) 235-2299 A 09/01/13513 Surgicenter 01/01/14 Belleville Surgery Center I 1 28 N. 64th Street Belleville IL 62223 3808 (618) 398-5705 A 08/01/14

51042 Surgicenter 05/01/08 Belmont/Harlem Surgery Center, LLC I 1 3101 North Harlem Chicago IL 60634 (773) 889-2000 A 11/01/0850181 Surgicenter 04/01/03 Bloomington Normal Health Surgery Ct. I 1 2100 Ft. Jesse Road Normal IL 61761 (309) 834-4000 A 09/11/0351991 Surgicenter 11/01/12 Cadence Ambulatory Surgery Center, LLC I 1 27650 Ferry Road Warrenville IL 60555-3846 (630) 225-2700 PN 01/01/1351684 Surgicenter 01/01/11 Carle Surgicenter LLC I 1 1702 S Mattis Champaign IL 61821-5469 (217) 326-2030 A 03/01/1151034 Surgicenter 11/01/08 Castle Surgicenter, LLC d/b/a HWOV, LLC I 1 2111 Ogden Ave. Aurora IL 60504 (630) 978-3800 A 12/01/0851997 Surgicenter 09/01/12 Center for Ambulatory Surgery at Swedish I 1 5215 N. California Ave Chicago IL 60625-3513 (773) 649-5470 A 01/01/1350356 Surgicenter 04/01/05 Center for Digestive Health I 1 1615 N. Convent Street Boubonnais IL 60914 (815) 936-1700 A 08/03/0550598 Surgicenter 03/12/07 Center for Health Ambulatory I 1 8800 N. Route 91 Peoria Il 61615 (309) 683-4807 A 10/16/07

551 Surgicenter 04/01/98 Center for Orthopedic Medicine I 1 2502 B. East Empire Bloomington IL 61704-3630 (309) 662-612050296 Surgicenter 10/01/04 Center for Reconstructive Surgery I 1 6309 West 95th Street Oak Lawn IL 60453 (708) 499-3355 N 02/01/0851444 Surgicenter 12/18/12 Central Illinois Endoscopy Center, LLC I 1 1001 Main St Peoria IL 61606-2037 (309) 495-1144 R 12/01/12

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

1 Rev. 08-2014

Page 3: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50492 Surgicenter 11/01/06 Central Illinois Gastrointesintal Institute I 1 2200 Jacobsen Drive Normal Il 61761-5516 (309) 451-1123 A 03/30/0750340 Surgicenter 02/01/05 11/01/13 Central Illinois Surgery Center, LLC I 1 304 W. Hay Street Decatur IL 62526-6328 (217) 876-8201 C 12/01/1351153 Surgicenter 02/01/09 Chicago Endoscopy Center I 1 3536 W. Fullerton Ave. Chicago IL 60647 (773) 772-1269 A 03/01/0950513 Surgicenter 11/01/06 Chicago Prostate Cancer Surgical Center I 1 815 Pasquinelli Drive Westmont IL 60559 (630) 654-2515 A 03/30/0750402 Surgicenter 10/01/05 Decatur Digestive Disease Center, LLC I 1 2 Memorial Drive Decatur IL 62526 (217) 233-0030 A 01/13/0653281 Surgicenter 01/01/14 Deerpath Orthopedic Surgical Center I 1 1051 W US Route 6 Morris IL 60450-4200 (815) 318-5666 A 03/01/1451756 Surgicenter 04/01/11 Dialysis Access Center LLC I 1 400 John Deere Road Moline IL 61265 (309) 797-0594 A 08/01/11

622 Surgicenter 01/01/98 09/01/11 Dimensions Med. Ctr. I 1 1455 Golf Road Des Plaines IL 60016 (847) 390-9300 C 09/01/1151857 Surgicenter 04/01/13 DMG Pain Management Surgery Center I 1 2940 Rolling Ridge Road Naperville IL 60564-4226 (630) 303-5304 A 04/01/1350429 Surgicenter 02/01/06 DMG Surgical Center, LLC I 1 2725 S. Technology Drive Lombard IL 60148 (630) 942-7998 A 05/08/06

590 Surgicenter 01/01/98 Dreyer Amb. Surgi. Ctr. I 1 1221 N. Highland Aurora IL 60605 (630) 859-870050703 Surgicenter 01/01/08 DuPage Eye Surgery Center, LLC I 1 2015 North Main St. Wheaton IL 60187 (630) 665-3690 A 07/01/0851566 Surgicenter 07/01/10 10/31/12 DuPage Orthopaedic Surgery Center, LLC I 1 27650 Ferry Road Warrenville IL 60555-3846 (630) 225-2700 CP 01/01/13

1545 Surgicenter 01/01/01 Eastland Med. Plaza Surgicenter, LLC I 1 1505 Eastland Drive Bloomington IL 61701-3502 (309) 663-1997 A 08/01/011538 Surgicenter 08/01/99 Elmhurst Outpatient Surgery I 1 1200 S. York Road Elmhurst IL 60126-5626 (630) 758-8457 A 09/01/99

50405 Surgicenter 03/08/06 03/19/14 Elmwood Park Sameday Surgery I 1 1614 North Harlem Ave. Elmwood Park IL 60707-4302 (708) 452-5000 R 08/15/0750371 Surgicenter 06/01/05 Eye Surgery Center of Hinsdale I 1 950 N. York Road Hinsdale IL 60521-8609 (630) 789-6700 A 10/11/05

1502 Surgicenter 01/01/98 Eyes of Illinois Surgery Center I 1 #12 Professional Park Drive Maryville IL 62062 (618) 451-1780 N 11/01/11520 Surgicenter 01/22/04 Family Planning Mgt. Inc. dba Albany Med. Surg. I 1 5086 North Elston Ave Chicago IL 60630 (773) 725-0200 N 09/01/09

50437 Surgicenter 04/01/11 Forest Medical Surgical Center I 1 9050 W 81st Street Justice IL 60458 (708) 594-3500 A 04/01/1150420 Surgicenter 01/01/06 Forest View Medical Center, Ltd I 1 2750 S. River Road Des Plaines IL 60018-4103 (847) 375-1000 A 03/01/07

1530 Surgicenter 12/01/98 Fox Valley Orthopedic Inst. I 1 2525 Kaneville Road Geneva IL 60134 (630) 584-1400 A 02/01/9950732 Surgicenter 07/01/08 Fullerton Surgery Center I 1 4849 W. Fullerton Ave Chicago IL 60639 (773) 237-2900 A 07/01/0850348 Surgicenter 04/01/05 Glen Endoscopy Center, LLC I 1 2551 Compass Road Glenview IL 60026 (800) 590-2713 A 06/07/0551832 Surgicenter 12/01/11 10/01/13 Gold Coast Surgicenter LLC I 1 845 N. Michigan Ave Chicago IL 60611 (312) 521-5500 C 10/01/13

545 Surgicenter 01/01/98 Golf Surgery Center I 1 8901 Golf Road DesPlaines IL 60016 (847) 299-227353311 Surgicenter 12/01/13 Good Samaritan Surgery Center I 1 2 Good Samaritan Way Mount Vernon IL 62864 (618) 436-6542 A 01/01/14

517 Surgicenter 01/01/98 Hawthorn Surgery Center. I 1 240 Center Drive Vernon Hills IL 60061 (847) 367-8100 AD 05/01/14

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

2 Rev. 08-2014

Page 4: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

1532 Surgicenter 04/01/99 Hinsdale Surgical Center,LLC I 1 908 N. Elm Street Hinsdale Il 60521 (630) 325-5035 N 05/01/9950669 Surgicenter 02/01/08 Hoffman Estates Surgery Center, LLC I 1 1555 Barrington Road Hoffman Estates IL 60169-1019 (847) 519-1600 A 02/01/0851265 Surgicenter 06/01/09 Illinois Center for Foot & Ankle Surgery, LLC I 1 4650 Southwest Highway Oak Lawn IL 60453 (708) 424-6353 A 06/01/0951256 Surgicenter 06/01/09 Illinois Sports Medicine & Orthopedic Surgery I 1 9000 Waukegan Road Morton Grove IL 60053 (847) 213-5444 A 06/01/09

535 Surgicenter 01/01/98 Ingalls Same Day Surgery I 1 6701 W. 159th Street Tinley Park IL 60477 (708) 429-022250730 Surgicenter 06/01/09 Ireland Grove Center for Surgery I 1 3801 Ireland Grove Road Bloomington IL 61704 (309) 664-0101 A 06/01/0950075 Surgicenter 04/01/02 Kendall Pointe Surgery Center I 1 100 W. Fifth Street Oswego IL 60543 (630) 449-0085 A 09/19/02

1539 Surgicenter 09/13/99 02/08/14 Kishwaukee Community Hospital I 1 2240 Gateway Drive Sycamore IL 60178 (815) 756-8571 C 03/01/1451087 Surgicenter 11/01/08 Lake Forest Endoscopy Center, LLC I 1 1475 E. Belvidere Rd . Suite 303 Grayslake IL 60030 (847) 548-8715 A 01/01/0951904 Surgicenter 04/01/12 Lindenhurst Surgery Center LLC I 1 1050 Red Oak Lane Lindenhurst IL 60046-4998 (800) 826-3784 A 06/01/12

1524 Surgicenter 01/01/98 Loyola Ambulatory Surgery Ctr. I 1 1 S. 224 Summit Avenue Oakbrook Terrace IL 60181 (708) 216-3291539 Surgicenter 01/01/98 Magna Surgical Center I 1 7456 South State Road Bedford Park IL 60638 (773) 445-9696 AD 08/01/11

51524 Surgicenter 04/01/10 Marion Eye Surgery Center LLC I 1 2900 Broadway Mount Vernon IL 62864-2341 (618) 969-8700 A 04/01/10598 Surgicenter 04/06/99 Marion Surgery Center I 1 806 N. Treas Marion IL 62959 (618) 993-2113 N 07/01/99

50422 Surgicenter 01/01/06 Michigan Avenue Center of Health, Ltd. I 1 2415 S. Michigan Ave Chicago IL 60616 (312) 328-1200 A 03/30/0750463 Surgicenter 07/01/13 Midland Surgical Center I 1 2120 Midland Surgical Center Sycamore IL 60178-3172 (815) 748-0393 A 10/01/1350623 Surgicenter 04/01/07 Midwest Ctr. for Day Surgery I 1 3811 Highland Avenue Downers Grove IL 60515-1555 (630) 852-9300 A 02/01/0850736 Surgicenter 05/01/08 Midwest Endocopy Center, LLC I 1 1243 Ricket Road Naperville IL 60540 (630) 525-6450 A 07/01/08

549 Surgicenter 05/01/07 Midwest Eye Care Center, S.C. I 1 1700 E. West Road Calumet City IL 60409 (708) 891-3330 R 09/01/1052020 Surgicenter 03/01/13 Monroe County Surgical Center LLC I 1 501 Hamacher St Waterloo IL 62298 (618) 939-1001 A 03/01/1351825 Surgicenter 12/01/11 Musculoskeletal Surgery Center I 1 303 N. Kumpf Blvd. Peoria IL 61605 (309) 676-5546 A 01/01/12

555 Surgicenter 01/01/98 Naperville Surg. Centre I 1 1263 Rickert Drive Naperville IL 60540 (630) 305-3300519 Surgicenter 03/08/06 North Shore Same Day Surgery I 1 3725 W. Touhy Avenue Lincolnwood IL 60712 (847) 324-7770 TE 01/01/13544 Surgicenter 01/01/98 12/31/13 Northwest Community Day Surgery I 1 675 West Kirchoff Road Arlington Hgts. IL 60008 (847) 618-1000 CP 02/01/14

53466 Surgicenter 01/01/14 Northwest Community Day Surgery I 1 675 West Kirchoff Road Arlington Hgts. IL 60008 (847) 618-1000 P 02/01/1450143 Surgicenter 01/01/98 Northwest Surgicare Center I 1 1100 West Centeral Arlington Hgts IL 60005 (847) 259-3080 N 03/07/0350079 Surgicenter 01/01/98 Novamed Eye Surgery Ctr. I 1 7427 West Lake Street River Forest IL 60305 (708) 771-3334 P 09/19/0250153 Surgicenter 01/01/98 NovaMed EyeCare Mgt., LLC I 1 3034 West Peterson Avenue Chicago IL 60659 (773) 973-3223 P 05/01/03

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

3 Rev. 08-2014

Page 5: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50164 Surgicenter 04/01/98 Novamed Surgery Center/Merrillville I 1 8514 Broadway Street Merrillville IN 46410 (219) 756-5010 P 05/01/0352075 Surgicenter 06/01/13 Oak Brook Surgical Centre Inc. I 1 2425 W 22nd St. Oak Brook IL 60523-4642 (630) 990-2212 A 08/01/1350226 Surgicenter 08/01/03 06/01/13 Oak Lawn Endoscopy I 1 9921 Southwest Highway Oak Lawn IL 60453-3767 (708) 499-5687 CP 07/01/1352067 Surgicenter 06/01/13 Oak Lawn Endoscopy I 1 9921 Southwest Highway Oak Lawn IL 60453-3767 (708) 499-5678 P 07/01/1352106 Surgicenter 10/01/13 Oak Surgical Institute I 1 403 S Kennedy Drive Bradley IL 60915-2152 (815) 928-9999 A 12/01/1351440 Surgicenter 10/23/09 01/01/13 Oakbrook Surgical Center Inc. I 1 Oakbrook Surgical Center Inc. Oakbrook IL 60523-4641 (630) 990-2212 C 01/01/1351894 Surgicenter 05/01/12 Olympian Surgical Suites I 1 1002 Interstate Dr. Champaign IL 61822-1465 (217) 693-5700 A 05/01/1251598 Surgicenter 07/01/10 05/01/11 Olympian Surgical Suites I 1 1002 W. Interstate Drive Champaign IL 61822 (217) 693-5700 C 07/01/1150131 Surgicenter 11/01/02 Orland Park Surgical Center I 1 9550 W. 167th Street Orland Park IL 60467-5561 (708) 747-7960 A 03/07/03

1537 Surgicenter 10/20/00 Orthopaedic Surgery Center I 1 3136 Old Jacksonville Rd. Springfield IL 62704-6487 (217) 862-0500 A 11/01/0050032 Surgicenter 11/24/09 Palos SurgiCenter LLC I 1 7340 College Drive Palos Heights IL 60463 (708) 361-3223 R 12/01/09

1511 Surgicenter 01/01/98 Peoria Ambulatory Surgery Ctr. I 1 4909 N. Glen Park Place Peoria IL 61614 (309) 691-9069516 Surgicenter 01/01/98 Peoria Day Surgery Center I 1 7309 N. Knoxville Avenue Peoria IL 61614 (309) 692-9210 N 06/07/05

50935 Surgicenter 09/01/08 Physicians' Surgery Center, LLC I 1 2601 West Main St Carbondale IL 62901 (877) 377-1086 A 09/01/0851043 Surgicenter 11/01/08 Physicians Surgical Center Ltd. I 1 311 W. Lincoln St. Belleville IL 62220-1902 (618) 233-7077 P 01/01/0951092 Surgicenter 01/01/09 Plainfield Surgery Center, LLC I 1 24600 W 127th St. Plainfield IL 60585 (815) 436-0911 A 01/01/0950662 Surgicenter 11/01/07 06/30/11 Prairie Diagnostic Center LLC I 1 401 E. Carpenter Street Springfield IL 62702 (217) 527-3700 C 11/01/1151651 Surgicenter 12/01/10 Prairie Surgi Center Associates I 1 2020 W Iles Ave. Springfield IL 61704 (217) 698-3200 A 01/01/1150034 Surgicenter 11/05/01 Quad City Ambulatory Surg. Ctr. I 1 520 Valley View Drive Moline IL 61265 (309) 762-1952 P 01/23/0250139 Surgicenter 01/01/98 Quad City Endoscopy LLC I 1 2525 24th Street Rock Island IL 61201 (309) 788-5624 N 03/07/0351262 Surgicenter 05/01/09 Ravine Way Surgery Center LLC I 1 2350 Ravine Way Glenview IL 60025-7657 (847) 832-1555 A 06/01/0950416 Surgicenter 10/01/05 Renal Intervention Center, LLC I 1 430 Maxine Drive Morton IL 61550-2495 (309) 495-5420 A 08/01/10

1520 Surgicenter 01/01/99 04/24/13 Resurrection Health Care Surgery Center I 1 3115 N. Harlem Avenue Chicago IL 60634 (773) 889-2000 C 07/01/1351786 Surgicenter 09/01/11 Ritacca Laser Center Ltd. I 1 230 Center Drive Vernon Hills IL 60061-1584 (847) 367-8764 A 10/01/11

518 Surgicenter 03/08/06 River North Same Day Surgery Ctr. I 1 1 E. Erie Street Chicago IL 60611-3364 (312) 649-3939 R 10/16/071504 Surgicenter 01/01/98 Rockford Ambulatory Surgery Ctr. I 1 1016 Featherston Road Rockford IL 61107 (815) 226-3300

599 Surgicenter 01/01/98 Rockford Endoscopy Center I 1 401 Roxbury Road Rockford IL 61107 (815) 397-734051093 Surgicenter 01/01/09 Rockford Orthopedic Surgery Center, LLC I 1 346 Roxbury Rd Rockford IL 61107-5090 (815) 381-7400 A 01/01/09

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

4 Rev. 08-2014

Page 6: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51130 Surgicenter 12/29/08 RSC Illinois i 1 545 Valley View Drive Moline IL 61265-6138 (309) 762-0280 N 04/01/10602 Surgicenter 02/04/99 Rush Surgi Center, Ltd. I 1 1725 West Harrison Chicago IL 60612 (312) 563-2269 A 04/01/99

50179 Surgicenter 02/01/03 Salt Creek Surgery Center I 1 530 North Cass Avenue Westmont IL 60559 (630) 968-1800 A 05/01/0350245 Surgicenter 03/31/03 07/24/13 SCHCI, LLC (Cardivovascular) I 1 1200 Maple Road Joliet IL 60432-1439 (815) 740-1100 C 08/01/1352094 Surgicenter 09/01/13 South Loop Endoscopy and Wellness Center LLC I 1 2336 40 S Wabash Ave. Chicago IL 60616 (312) 808-0468 A 09/01/1350495 Surgicenter 11/01/06 Surgery Center of Joliet I 1 301 Madison Joliet IL 60435 (815) 744-1119 A 03/30/0750510 Surgicenter 11/01/06 Surgi Center of Greater Milwaukee I 1 3223 S. 103rd Street Milwaukee WI 53227 (414) 328-5800 A 03/30/0751606 Surgicenter 09/01/10 Surgicore, Inc I 1 10547 S. Ewing Avenue Chicago IL 60617 (708) 895-9000 A 10/01/10

605 Surgicenter 01/01/98 The Center For Surgery I 1 475 E. Diehl Road Naperville IL 60563 (630) 505-773350438 Surgicenter 12/19/07 The Endo Center for Elgin Gastroenterology I 1 745 Fletcher Drive Elgin IL 60123 (847) 888-1300 A 02/01/08

582 Surgicenter 01/01/98 The Eye Surgery Center I 1 3990 N. Illinois Street Belleville IL 62231 (618) 277-113050315 Surgicenter 01/01/05 The Lake Bluff IL Endoscopy SC d/b/a No. Shore I 1 101 S. Waukegan Road Lake Bluff IL 60044 (847) 604-8700 P 03/08/0550193 Surgicenter 03/01/03 Tinley Woods Surgery Center I 1 18200 S. LaGrange Tinley Park IL 60477 (708) 570-2490 A 07/10/0350648 Surgicenter 09/01/07 Tri-Cities Surgery Center, LLC I 1 345 Delnore Drive Geneva IL 60134 (630) 262-8111 A 02/01/08

630 Surgicenter 01/01/98 United Shockwave Therapies-North I 1 1875 W. Dempster Street Park Ridge IL 60068 (847) 696-2210 N 12/18/02546 Surgicenter 01/01/98 Valley Ambulatory Surgery Ctr. I 1 2210 Dean Street St. Charles IL 60175 (630) 548-9800

50447 Surgicenter 07/01/06 Vista Surgery & Treatment Center I 1 1050 Red Oak Lane Lindenhurst IL 60046 (847) 356-4700 PN 12/28/06

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

5 Rev. 08-2014

Page 7: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

58414 Surgicenter 01/01/14 Western Diversey Surgical Center I 1 2744 N Western Ave. Chicago IL 60647-2017 (772) 772-7726 A 03/01/1450122 Surgicenter 05/01/02 Williams Eye Institute I 1 6836 Hohman Avenue Hammond IN 46324-1410 (219) 937-5063 N 01/13/03

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelD: Eff DateN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone Number

6 Rev. 08-2014

Page 8: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

1604073 DME 02/01/14 Absolute Medical X 0 328 Jefferson Street Chicago IL 60661 (312) 233-2207 A 01/01/142207274 DME 05/01/98 Achieve Mobility X 0 17W620 14th Street Terrace IL 60181 (630) 268-8670 N 04/01/089932649 DME 12/01/07 Advanced Respiratory X 0 2443 W. 16th Street Chicago IL 60608 (800) 426-4224 AD 02/01/131617625 DME 01/01/98 Advocate Home Care Products X 0 2311 W. 22nd Street Oak Brook IL 60523 (630) 572-59991632168 DME 04/18/02 Alverno Home Medical Equipment X 0 16149 S. Clinton Street Harvey IL 60426 (708) 331-4615 P 09/19/027270224 DME 10/01/99 American Home Patient X 0 1724 W. Chanute Rd Peoria IL 61615 (309) 691-7200 AD 07/01/118415051 DME 10/01/99 American Home Patient X 0 Road Springfield IL 62703 (217) 753-1525 A 03/01/004929926 DME 08/01/01 Animas Diabetes Care X 0 184 Shuman Blvd Naperville IL 60563 (877) 937-7867 AD 09/01/092220487 DME 01/01/96 Apria Health Care X 0 4055 Steele Dr. Machesney Pk IL 61115 (847) 252-2000 AD & TE 07/01/118423184 DME 01/01/06 Apria Health Care X 0 775 E. Linton Ave. Springfield IL 62703 (217) 789-0461 A 12/28/06723183 DME 01/01/06 Apria Health Care X 0 Drive Peoria IL 61615 (309) 691-1012 A 12/28/06

90001158 DME 01/01/06 Apria Health Care X 0 1581 E. 90th Place Merrillville IN 46410 (219) 736-1302 A 12/28/062220487 DME 01/01/13 Apria Healthcare X 0 2020 Glen Park Champaign IL 61821 (271) 876-9025 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 1912 W Rendelman Marion IL 62959 (618) 997-6469 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 19 ABC PKWY Collinsville IL 62234 (618) 343-3700 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 4711 W 135th ST Crestwood IL 60445 (708) 597-7079 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 10910 N 2nd St. Machesney Park IL 61115 (815) 633-7778 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 1016 NorthPoint Blvd Waukegan IL 60085 (847) 473-0739 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 1103 M L King Dr Bloomington IL 61701 (309) 828-9047 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 500 W Jaycee Ave Effingham IL 62401 (217) 347-5212 AL 08/01/13

HMO Illinois/Blue Advantage HMO Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev.08-2014

Page 9: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

2220487 DME 01/01/13 Apria Healthcare X 0 1300 W Ogden Ave Naperville IL 60563 (630) 369-6500 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 3453 Rupp Pkwy Decatur IL 62526 (217) 876-9025 AL 08/01/132220487 DME 01/01/13 Apria Healthcare X 0 Industrial Streator IL 61364 (815) 673-3751 AL 08/01/139932364 DME 11/01/09 Baar Home Medical Equipment X 0 24760 W Eames Street Channahon IL 60410 (815) 467-0072 A 11/01/092232523 DME 01/01/06 Bari Care, Inc. X 0 8404 S. Wilmette Ave Darien IL 60561 (630) 964-6528 A 01/13/069971517 DME 08/01/06 Basinger's Pharmacy X 0 2130 W. Jefferson Street Joliet IL 60435 (815) 725-1102 A 12/28/06

80001621 DME 07/01/12Bioventus, LLC (new name for Smith Nephew) X 0 1450 E Brooks Rd Memphis TN 38116 (800) 396-4325 A 07/01/12

1629993 DME 04/01/02 Byram Healthcare X 0 3010 Woodcreek Drive Downers Grove IL 60515 (800) 681-1395 A 07/09/0234140288 DME 11/01/05 Care Medical Supplies Inc. X 0 4201 IIberry Road Mt. Vernon IL 62864 (618) 244-4949 P 08/01/1111642527 DME 11/01/05 Care Medical Supplies Inc. X 0 6500 W Main Street Belleville IL 62223 (618) 398-3762 P & AD 08/01/111670187 DME 11/01/05 Care Medical Supplies Inc. X 0 333 W Hintz Road Wheeling IL 60090 (847) 947-4160 P 05/01/105632525 DME 01/01/13 Centegra Home Medical Equipment X 0 213 N Front Street McHenry IL 60050 (815) 759-4444 A 12/01/122232502 DME 09/15/09 Classic Medical Inc. X 0 2000 Bloomingdale Road Heights IL 60139 (866) 261-2179 A 10/01/092233029 DME 12/01/06 CNS Home Infusion & Pharmacy X 0 690 E. North Ave. Carol Stream IL 60188 (630) 933-7777 TE 07/21/117232275 DME 01/01/13 Complete Home Respiratory Care X 0 1605 W Chanute Rd Peoria IL 61615 (309) 689-5038 A 12/01/122234595 DME 02/01/13 Compliant Sleep Solutions X 0 7501 Lemont Rd Woodridge IL 60517 (630) 324-5370 A 02/01/134521209 DME 07/01/98 Delnor Comm. Hosp. Home Hlth X 0 300 Randall Road Geneva IL 4200 (630) 513-0370 TE 07/01/112233260 DME 01/01/13 Delta Sleep, Inc X 0 3510 Hobson Road Woodridge IL 60517 (630) 960-2727 A 12/01/122270097 DME 01/01/95 Denson Shops Inc. X 0 509 S. Carlton Street Wheaton IL 60187 (630) 665-1488

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev.08-2014

Page 10: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

80001617 DME 03/01/13 Dexcom, Inc X 0 6340 Sequence Dr San Diego CA 92121 (888) 738-3646 A 04/01/131627524 DME 08/01/01 DJ O LLC X 0 1308 Lakeview Drive Palatine IL 60067 (877) 406-9676 TE 06/01/091617040 DME 01/01/06 Doubek Medical Supply X 0 11350 S. Cicero Ave. Alsip IL 60803 (773) 581-1122 A 01/13/06

2234829 DME 11/01/11Dupage Medical Group dba Premier Medical Equipment X 0 428 Pennsylvania Ave Glen Ellyn IL 60137 (630) 545-7770 A 12/01/11

5022926 DME 06/01/06 Dwight Drugs, Inc. X 0 109 E. Main Street Streator IL 61364 (815) 672-2968 A 12/28/0680001664 DME 12/01/12 Dynasplint Systems, Inc X 0 770 Ritchie Hwy Severna Park MD 21146 (800) 638-6771 A 12/01/124932133 DME 12/01/02 EBI LLC X 0

gCircle Elburn IL 60119 (800) 526-2579 N & AD 09/01/10

5632003 DME 05/01/10 Edgepark Medical Supplies X 0 1360 Madeline Lane Elgin IL 60124 (800) 307-5930 A 06/01/10

2232463 DME 01/01/06Elmhurst Memorial Home Health DME dba Action Medical Equipment X 0 855 N. Church Center Elmhurst IL 60126 (630) 758-7000 N 09/01/09

82015000 DME 01/01/95 EMPI, Inc X 0 599 Cardigan Road St. Paul MN 55126 (800) 328-25364921058 DME 09/15/09 Fair Haven Medical Supply X 0 608 E Hawley Street Mundelein IL 60060 (847) 566-5801 A 10/01/09

90001059 DME 03/01/02 Fairmeadows Home Health Center, Inc. X 0 400 Kennedy Ave. Schererville IN 46375 (219) 865-5960 A 07/09/027230214 DME 04/01/07 Family Medical Equipment X 0 1837 N. Knoxville Ave. Peoria IL 61603 (309) 682-1900 A 02/01/081670010 DME 01/01/95 Fitzsimmons Surgical Supply X 0 6428 N. Milwaukee Chicago IL 60631 (773) 881-87001670010 DME 01/01/95 Fitzsimmons Surgical Supply X 0 2600 Beverly Dr. Aurora IL 60502 (630) 851-88511670010 DME 03/01/14 Fitzsimmons Surgical Supply X 0 6177 Broadway Merrillville IN 46410 (219) 887-7719 AL 05/01/141670010 DME 03/01/14 Fitzsimmons Surgical Supply X 0 8000 W 186th St Tinley Park IL 60487 (708) 532-1199 AL 05/01/141670010 DME 01/01/95 03/01/14 Fitzsimmons Surgical Supply X 0 1906 N. Halsted Chicago IL 60614 (773) 665-0080 C 05/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev.08-2014

Page 11: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

1670010 DME 01/01/95 03/01/14 Fitzsimmons Surgical Supply X 0 6442 W. Cermak Berwyn IL 60402 (708) 795-6300 C 05/01/141670010 DME 01/01/95 03/01/14 Fitzsimmons Surgical Supply X 0 11925 S. Harlem Palos Heights IL 60463 (708) 361-3500 C 05/01/141670010 DME 01/01/95 03/01/14 Fitzsimmons Surgical Supply X 0 2747 W. 95th Street Evergreen Park IL 60805 (773) 881-8700 C 05/01/141670010 DME 01/01/95 03/01/14 Fitzsimmons Surgical Supply X 0 17660 S. Kedzie Hazel Crest IL 60429 (708) 957-9500 C 05/01/148215183 DME 06/01/06 Fox Medical Equipment Services X 0 1832 Vandalia Street Collinsville IL 62234 (618) 345-0649 A 12/28/06

90001306 DME 03/01/07 Genesis Medical X 0 1164 E. 86th Place Merrillville IN 46410 (317) 347-2000 A 10/16/071671535 DME 07/01/08 Gottlieb Prof Building Pharmacy X 0 675 W. North Avenue Melrose Park IL 60160 (708) 450-4941 A 08/01/081670200 DME 03/01/01 07/01/11 Health Link Services Inc. X 0 16135 New Ave. Lemont IL 60439 (708) 594-2244 C 07/01/112223252 DME 02/01/01 Health Technology Resources, LLC X 0 600 Academy Drive Northbrook IL 60062 (847) 291-2637 A 03/01/011671073 DME 01/01/95 High Street Pharmacy X 0 2320 High Street Blue Island IL 60406 (708) 388-00331618960 DME 01/01/98 Hill-Rom Company X 0 8500 185th Street Tinley Park IL 60487 (800) 638-2546 AD, TE 04/01/142233148 DME 10/15/09 Home Medical Express X 0 650 W Grand Ave. Elmhurst IL 60126 (630) 530-9777 A 10/01/091632492 DME 09/01/02 Hoveround Corporation X 0 241 S. Frontage Road Burr Ridge IL 60527 (800) 701-5781 A 12/18/029222357 DME 01/01/05 Illiana Medical Equipment X 0 912 N. Vermilion Street Danville IL 61832 (217) 442-0654 PN 01/10/052233765 DME 10/15/09 Independence Plus X 0 720 Enterprise Drive Oak Brook IL 60523 (630) 463-4400 A 11/01/092233787 DME 01/01/12 Integra HealthCare Equipment X 0 747 N Church Rd Elmhurst IL 60126 (630) 834-3700 A 02/01/12

10170824 DME 01/01/95 Integrated HomeCare Services X 0 5027 Harrison Ave. Rockford IL 61108 (815) 227-0202 TE 06/01/094532183 DME 10/01/04 Integrated Homecare Services X 0 2000 Bloomingdale Road Heights IL 60139 (877) 426-0202 TE 07/01/118232389 DME 08/17/09 IV Care LLC X 0 65 S. 65th Street Belleville IL 62223 (618) 398-2720 P 08/01/092571346 DME 03/01/05 Joint Active Systems X 0 2600 S. Raney Street Effingham IL 62401 (217) 342-3412 A 06/07/05

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4 Rev.08-2014

Page 12: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

7221211 DME 10/01/04 KCI USA Inc. X 0 4105 N. Becker Drive Bartonville IL 61607 (309) 633-2281 AD 02/01/102221210 DME 07/01/05 KCI USA Inc. X 0 1193 N Ellsworth Villa Park IL 60181 (800) 275-4524 AD 08/01/149921295 DME 01/01/03 Kramer Enterprises, Ltd X 0 3077 W. Jefferson Street Joliet IL 5264 (815) 773-9028 TE 07/01/111621096 DME 09/01/02 Kreg Therapeutic Inc. X 0 2240 W. Walnut Chicago IL 60612 (866) 760-5734 TE 07/01/111932093 DME 07/01/11 Lehan Drugs, Inc X 0 1407 So 4th St DeKalb IL 60115 (815) 758-0911 A 08/01/119222398 DME 11/01/01 01/01/13 Lincare, dba Patients First Pulmonary X 0 270 W. North Ave. Villa Park IL 60181 C 08/01/139222398 DME 11/01/01 Lincare, dba Patients First Pulmonary X 0 270 W. North Ave. Villa Park IL 60181 A 04/29/029222398 DME 11/01/01 Lincare, dba Pediatric Specialists X 0 2755 B Cirtoss Street Downers Grove IL 60515 (630) 960-9933 A 04/29/029222398 DME 11/01/01 01/01/13 Lincare, dba Pediatric Specialists X 0 2755 B Cirtoss Street Downers Grove IL 60515 (630) 960-9933 C 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 1701 Howard St. Elk Groove IL 60007 (847) 806-8080 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 271 N Industrial Dr. Bradley IL 60915 (815) 932-1392 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 2218 E Logan St. Decature IL 62526 (217) 422-4140 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 Rd. Muphysboro IL 62966 (618) 687-9229 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 7101 S Adams St. WillowBrook IL 60527 (630) 850-7296 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 1613 Commerce PKWY Bloomington IL 61704 (309) 661-7349 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 4808 N Sheridan Rd. Peoria IL 61614 (309) 679-2093 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 602 S Staley Rd Champaign IL 61822 (217) 398-8191 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 825 E Golf Rd Arlington Hts IL 60005 (847) 952-1579 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 53 E Simmons St. GalesBurg IL 61401 (309) 343-2776 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 2349 W. Grand Chicago IL 606012 (312) 733-7157 AL 08/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5 Rev.08-2014

Page 13: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

2523825 DME 01/01/13 Lincare, Inc. X 0 935 Maine St. Qunicy IL 62301 (217) 222-1983 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 1150 N BradFordton Rd Springfield IL 62711 (217) 793-6029 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 1000 Brown St. Wauconda IL 60084 (847) 526-1357 AL 08/01/139222398 DME 11/01/01 Lincare, Inc. X 0 839 E. Voorhess Danville IL 61832 (217) 431-1524 TE 08/01/112523825 DME 04/01/05 Lincare, Inc. X 0 700 N. Henerietta Effingham IL 62401 (217) 347-7002 TE 07/01/112523825 DME 01/01/13 Lincare, Inc. X 0 8910 W. 192nd St. Mokena IL 60448 (708) 478-3941 AL 08/01/132523825 DME 01/01/13 Lincare, Inc. X 0 1128 Royal Heights Rd Belleville IL 62226 (618) 235-4458 AL 08/01/131670691 DME 01/01/95 Little Co. of Mary Home Health Equip. X 0 5610 W. 95th Street Oak Lawn IL 2343 (708) 499-00711633478 DME 10/01/06 Loyola University DME X 0

g54 Maywood IL 60153 (708) 216-0435 TE 07/01/11

1617237 DME 11/01/05 Mark Drug X 0 548A W. Dundee Road Wheeling IL 60090 (847) 537-8500 TE 07/01/11

1670876 DME 01/01/96 12/01/11Mark Drug Home Health dba Pinnacle Rehab Solutions X 0

1457 W. Schaumburg Rd Schaumburg IL

60194-4051 (847) 895-0011 C 01/01/12

4915218 DME 02/01/14 Medline Industries X 0 1 Medline Place Mundelein IL 60060 (847) 837-2753 A 02/01/141621940 DME 09/21/09 Medsource, LLC X 0 700 N Sacramento Blvd Chicago Il 60612 (888) 510-5100 P, AD 10/01/091621940 DME 03/01/05 Medsource, LLC X 0 3002 Gill Street Bloomington IL 61704 (309) 664-7930 A 06/07/054932943 DME 06/01/13 Medtech Medical X 0 1602 Barclay Blvd Buffalo Grove IL 60089 (847) 520-3000 A 06/01/138421746 DME 04/01/98 Memorial Homecare X 0 644 N. Second Street Springfield IL 62702 (217) 788-46635632486 DME 10/01/10 Mercy Assisted Care X 0 1819 N Division St Harvard IL 60033 (815) 943-2071 A 11/01/102232948 DME 06/01/06 Merit Sleep Technologies X 0 1300 S. Main Street Lombard IL 60148 (630) 652-7900 A 02/01/081670603 DME 11/01/05 Metro Rehab Serv. Inc. X 0 11551 S. Ridgeland Ave. Alsip IL 60803 (708) 361-7060

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6 Rev.08-2014

Page 14: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

1634992 DME 10/15/09Midwest Medical Equipment Solutions dba Neb Medical Services X 0 7646 W 159th Street Orland Park IL 60462 (708) 633-1560 N 06/01/11

2225704 DME 02/02/02 Minimed Distribution Corp. X 0 3725 25th Ave Schiller Park IL 60176 (800) 341-3849 AD 02/01/1321622172 DME 09/01/07 Mobility Systems & Solutions X 0 9755 S. 78th Ave. Hickory Hills IL 60457 (708) 599-3500 TE 09/01/0880001659 DME 11/01/12 National Biological Corporation X 0 23700 Merchantile Rd Beechwood OH 44122 (216) 831-0600 A 12/01/129920264 DME 05/20/13 National Seating & Mobility X 0 11551 S Ridgeland Ave Alsip IL 60803 (708) 361-7060 AL 06/01/139920264 DME 04/01/09 National Seating & Mobility X 0 South Lombard IL 60148 (630) 495-3751 AD & TE 06/01/134570084 DME 01/01/95 Neumann's Home Medical Equip. X 0 821 W. Illinois Ave Aurora IL 60506 (630) 897-6444 AD 07/01/111600454 DME 07/09/09 NorthShore University Health System X 0 4901 Searle Parkway Skokie IL 60077 (847) 475-2001 TE 07/01/11

1623638 DME 02/01/01 05/01/14Ophthalmic Support Systems - (Vitectomy equip) X 0 1942 W. Wolfram Street Chicago IL 60657 (773) 404-2148 C 06/01/14

8123498 DME 08/01/00 Optioncare of the Quad Cities X 0 5111 22nd Avenue Moline IL 61265 (309) 762-7979 A 09/01/001618646 DME 01/01/95 Orsini Home Medical Equipment X 0 1111 Nicholas Blvd Villiage IL 60007 (847) 860-0240 AD & TE 07/01/111621072 DME 08/01/00 Orthofix Inc. X 0 875 N Michigan Ave Chicago IL 60611 (800) 527-0404 AD 02/01/124632003 DME 01/01/05 OrthoRx, Inc. X 0 1306 Gemini Circle Ottawa IL 61350 (815) 936-6040 A 03/08/054632003 DME 01/01/05 07/01/11 OrthoRx, Inc. X 0 1051 W. US Route 6 Morris IL 60450 (815) 941-1879 CL 08/01/114632003 DME 01/01/05 OrthoRx, Inc. X 0 400 S. Kennedy Drive Bradley IL 60915 (815) 936-60404632003 DME 01/01/05 OrthoRx, Inc. X 0 1405 W. Park Street Urbana IL 61801 (217) 384-6913 CL 08/01/115732277 DME 07/01/13 OSF Home Medical Equipment X 0 1505 Eastland Dr Bloomington IL 61701 (309) 665-4765 A 08/01/13

10120714 DME 07/01/13 OSF Home Medical Equipment X 0 5668 E State St Rockford IL 61108 (815) 227-2079 A 08/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 7 Rev.08-2014

Page 15: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

3732061 DME 07/01/13 OSF Home Medical Equipment X 0 125 N Tremont St Kewanee IL 61443 (309) 854-6980 A 08/01/135332047 DME 07/01/13 OSF Home Medical Equipment X 0 608 N Ladd St Pontiac IL 61764 (815) 844-4906 A 08/01/132234394 DME 01/01/10 Otto Bock Orthopedic Services X 0 764 Burr Oak Dr Westmont IL 60559 (800) 736-8276 A 04/01/10432001 DME 05/01/12 Pacific Pulmonary Services X 0 3384 N Publishers Dr Rockford IL 61109 (818) 874-1314 A 05/01/12432001 DME 05/01/12 Pacific Pulmonary Services X 0 2201 W Townline Rd Peoria IL 61615 (309) 693-0375 A 05/01/12432001 DME 05/01/12 Pacific Pulmonary Services X 0 1551 E. 91st Street Dr Merrillville IL 46410 (219) 736-5828 A 05/01/12432001 DME 05/01/12 Pacific Pulmonary Services X 0 4511 N. Kedzie Ave Chicago IL 60625 (773) 477-8802 A 05/01/12432001 DME 05/01/12 Pacific Pulmonary Services X 0 1521 Wright Blvd Schaumburg IL 60193 (847) 895-4834 A 05/01/12432001 DME 05/01/12 Pacific Pulmonary Services X 0 9935 S 76th Ave Bridgeview IL 60455 (708) 599-7339 A 05/01/12

6921724 DME 07/01/98 Passavant Home Care X 0 306 N. Westgate Ave. Jacksonville IL 62650 (217) 245-8365 A 09/01/982270918 DME 01/01/95 Premier Medical Products, Inc. X 0 708 W. Fifth Ave. Naperville IL 60563 (630) 420-0308

80001666 DME 10/29/12 Prentke Romich Company X 0 1022 Heyl Rd Wooster OH 44691 (330) 262-1984 A 12/01/127220977 DME 08/01/09 Proctor Medical Equipment X 0 5409 N Knoxville Avenue Peoria IL 61614 (309) 689-6020 AD 07/01/111671041 DME 01/01/95 04/01/12 Quality Home Health Care Inc. X 0 525 W. Golf Road Arlington IL 3904 (847) 640-3944 C 04/01/12

2232027 DME 03/08/10 Rehab Tech Supply Corp dba Life Tech X 0 650 W. Grand Ave. Elmhurst IL 60126 (888) 800-9445 N 07/01/111621146 DME 01/01/00 07/01/11 Rehabtech Inc. X 0 16W240 83rd Street Burr Ridge IL 60527 (630) 920-0044 CL 08/01/111621146 DME 01/01/00 09/28/11 Rehabtech Inc. X 0 302 Edmund St. Peoria IL 61615 (309) 691-5805 C 11/01/111621146 DME 01/01/00 09/28/11 Rehabtech Inc. X 0 335 Eisenhower Lane Lombard IL 60148 (630) 420-8585 C 11/01/111621146 DME 01/01/00 09/28/11 Rehabtech Inc. X 0

p gAvenue Champaign IL 61820 (217) 366-9287 C 11/01/11

4922046 DME 10/01/98 Reliable Medical Supplies X 0 200 Howard Street Des Plaines IL 60018 (847) 566-0800 AD 09/01/09Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 8 Rev.08-2014

Page 16: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

9970392 DME 01/01/95 Remco Medical X 0 2313 Oak Leaf Street Joliet IL 60435 (815) 744-4600 AD 10/01/091627258 DME 06/01/08 Resurrection Services X 0 5747 W. Dempster Morton Grove IL 60053 (847) 568-8500 A 07/01/084670322 DME 01/01/95 Riverside Health Equipment X 0 1270 N. Kennedy Drive Kankakee IL 60901 (815) 935-75081671321 DME 02/01/01 Service Medical Equipment X 0 2848 Hitchcock Ave. Downers Grove IL 60515 (630) 848-1900 TE 07/01/114570935 DME 01/01/95 Sherman Home Care Partners X 0 1019 E. Chicago Street Elgin IL 60120 (847) 429-62001670178 DME 08/01/00 Simpol Respiratory Equip., Inc. X 0

gRoad Morton Grove IL 60053 (847) 967-6767 A 10/01/00

1619273 DME 01/01/95 Siona Health Care Products X 0 5011 N. Lincoln Ave. Chicago IL 60625 (773) 907-068090000958 DME 05/01/01 Slattery Health Appliance Center X 0 2030 45th Avenue Highland IN 2812 (219) 836-1808 AD&TE 01/01/091635719 DME 03/01/14 Sleep Rx LLC X 0 7536 N St Louis Skokie IL 60076 (847) 676-4138 A 03/01/141630056 DME 07/01/01 Sleepmed Therapy Services, Inc. X 0 2357 W. Hassel Road Hoffman Estates IL 60169 (847) 490-9309 AD 07/01/114532198 DME 10/01/04 07/01/12 Smith Nephew Inc X 0 673 Academy Drive Northbrook IL 60062 (800) 821-5700 C 07/01/122220434 DME 01/01/13 Snyder-Mark Drugs Roselle X 0 A 10/01/132870548 DME 01/01/98 Southern Ill Surgical Appliance X 0 19 W. Frankfort Plaza West Frankfort IL 62896 (618) 932-31571633047 DME 01/01/06 Sterling Medical Services X 0 140 Exchange Blvd. Glendale Hgt IL 60139 (856) 273-9900 A 01/13/06

10132143 DME 01/01/05 06/01/12 Swedish American DME X 0 2550 Charles Street Rockford IL 61108 (815) 391-7550 C 06/01/124926898 DME 03/01/10 Symed, Inc X 0 2502 N Clark Street Chicago IL 60614 (773) 477-8993 A 03/01/10

80001620 DME 07/01/12 Tactile Systems Technology X 0 1331 Tyler St NE Minneapolis MN 55480 (866) 435-3948 A 07/01/122219496 DME 05/01/06 Thera Tech Equipment X 0 108 W. Washington St. Bloomingdale IL 60108 (630) 351-3333 A 12/28/064532691 DME 11/15/08 THH Acquisition LLC X 0 780 S. McLean Blvd. Elgin IL 60123 (847) 931-9300 A 04/01/09

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 9 Rev.08-2014

Page 17: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

HMO Illinois/Blue Advantage HMO Contracting Providers

2234830 DME 09/28/11United Seating & Mobility dba Numotion X 0 335 Eisenhower Ln Lombard IL 60148 (630) 424-0330 N 09/01/13

2234830 DME 09/28/11United Seating & Mobility dba Numotion X 0 302 Edmund Street East Peoria IL 61611 (309) 698-3257 N 09/01/13

1620818 DME 03/01/97 Unlimited Advacare Systems X 0 2939 N. Pulaski Road Chicago IL 5421 (773) 725-8858 N 07/01/111616053 DME 09/01/10 Van Driels Medical Support Wear X 0 Highway Mt Prospect IL 60056 (847) 253-6494 A 09/01/109932878 DME 01/01/09 Walgreen Medical Supply X 0 8402 183rd Street Tinley Park IL 60487 (888) 410-5779 A 05/01/092221749 DME 08/21/98 Walgreens Home Care X 0 655 W. Grand Ave. Elmhurst IL 60126 (630) 530-0579 N 02/01/08

1617011 DME 01/01/95Walgreens Sleep and Respiratory Services X 0 1226 N Michael Dr Wood Dale IL 60191 (630) 741-4700 AD, TE 09/01/12

1617011 DME 09/01/11Walgreens Sleep and Respiratory Services X 0 2425 Bethany Rd Sycamore IL 60178 (800) 738-8233 N 01/01/12

1617011 DME 09/01/11Walgreens Sleep and Respiratory Services X 0 1250 Larry Powell Rd Bourbonnais IL 60914 (800) 979-1250 N 01/01/12

80001622 DME 07/01/12 Zoll LifeCor Corp X 0 121 Gamma Drive Pittsburgh PA 15238 (800) 543-3267 A 07/01/12

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 10 Rev.08-2014

Page 18: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

9932649 DME 12/01/07 Advanced Respiratory X 0 2443 W. 16th Street Chicago IL 60608 (800) 426-42241617625 DME 01/01/98 Advocate Home Care Products X 0 2311 W. 22nd Street Oak Brook IL 60523 (630) 572-59991632168 DME 04/18/02 Alverno Home Medical Equipment X 0 16149 S. Clinton Street Harvey IL 60426 (708) 331-46152220487 DME 01/01/13 Apria Healthcare X 0 1300 W Ogden Ave Naperville IL 60563 (630) 369-65002220487 DME 01/01/13 Apria Healthcare X 0 4711 W 135th ST Crestwood IL 60445 (708) 597-70792220487 DME 01/01/13 Apria Healthcare X 0 1016 NorthPoint Blvd Waukegan IL 60085 (847) 473-07392220487 DME 01/01/13 Apria Healthcare X 0 10910 N 2nd St. Machesney Park Machesney Park IL 61115 (815) 633-7778

90001158 DME 01/01/06 Apria Healthcare X 0 1581 E. 90th Place Merrillville IN 46410 (219) 736-13022220487 DME 01/01/11 Apria Healthcare dba Garrity Home Care X 0 1287 W Galena, Freeport IL 61032 (815) 233-21229971517 DME 08/01/06 Basinger's Pharmacy X 0 2130 W. Jefferson Street Joliet IL 60435 (815) 725-11021629993 DME 04/01/02 Byram Healthcare X 0 3010 Woodcreek Drive Downers Grove IL 60515 (800) 681-13952233029 DME 12/01/06 CNS Home Infusion & Pharmacy X 0 690 E. North Ave. Carol Stream IL 60188 (630) 933-77771627524 DME 08/01/01 DJ O LLC X 0 1308 Lakeview Drive Palatine IL 60067 (877) 406-9676

2234829 DME 11/01/11Dupage Medical Group dba Premier Medical Equipment X 0 428 Pennsylvania Ave Naperville IL

5632003 DME 05/01/10 Edgepark Medical Supplies X 0 1360 Madeline Lane Elgin IL 60124 (800) 307-5930

2232463 DME 01/01/06Elmhurst Memorial Home Health DME dba Action Medical Equipment X 0 X 0 855 N. Church Center Elmhurst IL 60126 (630) 758-7000

82015000 DME 01/01/95 EMPI, Inc X 0 599 Cardigan Road St. Paul MN 55126 (800) 328-25361671535 DME 07/01/08 Gottlieb Prof Building Pharmacy X 0 675 W. North Avenue Melrose Park IL 60160 (708) 450-4941

10170824 DME 01/01/95 Integrated HomeCare Services X 0 5027 Harrison Ave. Rockford IL 61108 (815) 227-0202

Blue Precision HMO Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev.08-2014

Page 19: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Blue Precision HMO Contracting Providers

7221211 DME 10/01/04 KCI USA Inc. X 0 4105 N. Becker Drive Bartonville IL 61607 (309) 633-22812221210 DME 07/01/05 KCI USA Inc. X 0 1193 N Ellsworth Villa Park IL 60181 (800) 275-4524 AD 08/01/149222398 DME 11/01/01 Lincare, dba Pediatric Specialists X 0 2755 B Cirtoss Street Downers Grove IL 60515 (630) 960-9933 2523825 DME 01/01/13 Lincare, Inc. X 0 825 E Golf Rd Arlington Hts IL 60005 (847) 952-1579 2523825 DME 01/01/13 Lincare, Inc. X 0 271 N Industrial Dr. Bradley IL 60915 (815) 932-1392 2523825 DME 01/01/13 Lincare, Inc. X 0 1000 Brown St. Wauconda IL 60084 (847) 526-1357 2523825 DME 01/01/13 Lincare, Inc. X 0 7101 S Adams St. WillowBrook IL 60527 (630) 850-7296 2523825 DME 01/01/13 Lincare, Inc. X 0 2349 W. Grand Chicago IL 60612 (312) 733-7157 2523825 DME 01/01/13 Lincare, Inc. X 0 8910 W. 192nd St. Mokena IL 60448 (708) 478-3941 2523825 DME 01/01/13 Lincare, Inc. X 0 1701 Howard St. Elk Groove IL 60007 (847) 806-80801670691 DME 01/01/95 Little Co. of Mary Home Health Equip. X 0 5610 W. 95th Street Oak Lawn IL 60453 (708) 499-00711633478 DME 10/01/06 Loyola University DME X 0 2160 S. First Ave. Bldg 54 Maywood IL 60153 (708) 216-0435 5632486 DME 10/01/10 Mercy Assisted Care X 0 1819 N Division St Harvard IL 60033 (815) 943-20712225704 DME 02/02/02 Minimed Distribution Corp. X 0 3725 25th Ave Schiller Park IL 60176 (800) 341-3849

80001659 DME 11/01/12 National Biological Corporation X 0 23700 Merchantile Rd Beechwood OH 44122 (216) 831-06001600454 DME 07/09/09 NorthShore University Health System X 0 4901 Searle Parkway Skokie IL 60077 (847) 475-20011621072 DME 08/01/00 Orthofix Inc. X 0 875 N Michigan Ave Chicago IL 60611 (800) 527-04043732061 DME 07/01/13 OSF Home Medical Equipment X 0 125 N Tremont St Kewanee IL 61443 (309) 854-6980

10120714 DME 07/01/13 OSF Home Medical Equipment X 0 5668 E State St Rockford IL 61108 (815) 227-20795332047 DME 07/01/13 OSF Home Medical Equipment X 0 608 N Ladd St Pontiac IL 61764 (815) 844-4906

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev.08-2014

Page 20: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Appendix D

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Blue Precision HMO Contracting Providers

2270918 DME 01/01/95 Premier Medical Products, Inc. X 0 708 W. Fifth Ave. Naperville IL 60563 (630) 420-030880001666 DME 10/29/12 Prentke Romich Company X 0 1022 Heyl Rd Wooster OH 44691 (330) 262-19841627258 DME 06/01/08 Resurrection Services X 0 5747 W. Dempster Morton Grove IL 60053 (847) 568-85004670322 DME 01/01/95 Riverside Health Equipment X 0 1270 N. Kennedy Drive Kankakee IL 60901 (815) 935-7508

80001620 DME 07/01/12 Tactile Systems Technology X 0 1331 Tyler St NE Minneapolis MN 55480 (866) 435-39482234830 DME 09/28/11 United Seating & Mobility dba Numotion X 0 302 Edmund Street East Peoria IL 61611 (309) 698-32572234830 DME 09/28/11 United Seating & Mobility dba Numotion X 0 335 Eisenhower Ln Lombard IL 60148 (630) 424-0330

80001622 DME 07/01/12 Zoll LifeCor Corp X 0 121 Gamma Drive Pittsburgh PA 15238 (800) 543-3267

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev.08-2014

Page 21: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

51686 Home Hlth 01/01/11 24 Seven Health Care Services Inc. X 0.33 5765 N. Lincoln Ave. Chicago IL 60659-3510 (773) 463-3755 AD 12/01/1352144 Home Hlth 10/01/13 A 2 Z Healthcare Services LLC X 0.33 15347 70th Ct. Orland Park IL 60462-5156 (708) 332-9070 A 11/01/1351516 Home Hlth 03/01/10 A and Z Home Health Care Inc. X 0.33 3232 Ridge Road Lansing IL 60438-3127 (708) 418-1608 A 04/01/1051834 Home Hlth 11/01/11 Abcor Home Care, Inc X 0.33 3201 N. Wilke Road Arlington Heights IL 60004-1573 (847) 670-8424 N 03/01/1351856 Home Hlth 02/01/12 Abundant Home Health Care Inc. X 0.33 545 W Taft Dr. South Holland IL 60473-2030 (708) 331-5575 A 04/01/12

52973 Home Hlth 11/01/13ACCESS (Ambulatory Care Center of Excellence in Surgical Serv. X 0.33 26 W Newell Road Danville IL 61834 (217) 446-2400 A 12/01/13

50433 Home Hlth 02/01/06 AdvanCare Healthcare Service, LLC X 0.33 645 East 170th Street South Holland IL 60473 (708) 392-2000 TE 01/01/1051536 Home Hlth 04/01/10 Advance Home Health Inc X 0.33 800 Roosevelt Road Glen Ellyn IL 60137-5847 (630) 545-0179 A 05/01/1050609 Home Hlth 01/01/14 Advantage Home Health Plus Inc X 0.33 30 E Scranton Ave. Lake Bluff IL 60044-2580 (847) 234-9705 A 01/01/14

5024 Home Hlth 01/01/98 Advantage Home HealthCare, Inc. X 0.33 23950 Northern Illinois Dr. Channahon IL 60410 (815) 467-19059665 Home Hlth 01/01/98 Advocate Home Health Care X 0.33 2311 W. 22nd Street Oak Brook IL 60523 (630) 572-1232

51675 Home Hlth 12/01/10 AIM Home Health X 0.33 3033 Ogden Lisle IL 60532 (630) 946-6693 N & TE 03/01/1452025 Home Hlth 02/01/13 Aledli Home Health Care Inc X 0.33 219 W 55th St. Clarendon Hills IL 60514-1598 (630) 323-0128 A 04/01/13

5429 Home Hlth 10/01/00 Alere Women's and Children's Health, LLC X 0.33 9500 West Bryn Mawr Ave Des Plaines IL 60018 (800) 343-6311 N & AD 05/01/099697 Home Hlth 01/01/98 Alexian Brothers Home Health X 0.33 1515 E. Lake Street Hanover Park IL 60133 (847) 437-5500 R

54768 Home Hlth 01/01/14 All Quality Home Health Care, LLC X 0.33 395 E. Dundee Road Wheeling IL 60090 (224) 676-1470 A 04/01/1451908 Home Hlth 06/01/12 All Solutions Healthcare Inc. X 0.33 1550 E Higgins Road Elk Grove Village IL 60007-1687 (847) 378-8189 A 07/01/1252071 Home Hlth 06/01/13 Allied Professionals Health Care, LLC X 0.33 257 N West Ave. Elmhurst IL 60126-2561 (630) 617-5020 A 07/01/1352053 Home Hlth 04/01/13 AlliedCare Home Health of Illinois LLC X 0.33 380 E Northwest Highway Des Plaines IL 60016-2260 (847) 296-9955 A 05/01/13

9866 Home Hlth 01/01/98 Alterna-Care X 0.33 319 E. Madison 3N Springfield IL 62701 (217) 525-373356761 Home Hlth 11/01/13 Alternacare Home Health SC X 0.33 1920 S Highland St. Lombard IL 60148-6145 (630) 629-7700 A 02/01/1450642 Home Hlth 06/01/07 Amedisys Home Health X 0.33 765 Ela Road Lake Zurich IL 60047 (847) 658-2220 AD 03/01/14

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev. 08-2014

Page 22: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51458 Home Hlth 12/01/09 Amedisys Home Health of Belleville X 0.33 624 Pierce Blvd. O'Fallon, IL 62269-2579 (618) 825-0170 AD 08/01/1251475 Home Hlth 12/01/09 02/01/12 Amedisys Home Health of Buffalo Grove X 0.33 1425 McHenry Road Buffalo Grove IL 60089-1332 (847) 821-0439 C 01/01/1250647 Home Hlth 06/01/07 02/01/12 Amedisys Home Health of Chicago X 0.33 3519 N. Lincoln Avenue Chicago IL 60657 (773) 665-2060 C 02/01/1250645 Home Hlth 06/01/07 02/01/12 Amedisys Home Health of Hinsdale X 0.33 15 Spinning Wheel Road Hinsdale IL 60521 (630) 654-1641 C 02/01/1251480 Home Hlth 12/01/09 02/01/12 Amedisys Home Health of Illinois X 0.33 680 North Lake Shore Dr. Chicago IL 60611-8702 (312) 768-5130 C 01/01/1250643 Home Hlth 06/01/07 02/01/12 Amedisys Home Health of Joliet X 0.33 2400 Glenwood Ave Joliet IL 60435 (815) 741-9840 C 01/01/1250644 Home Hlth 06/01/07 Amedisys Home Health of Munster X 0.33 8140 Calumet Avenue Munster IN 46321 (219) 836-4979 N 10/01/0950646 Home Hlth 06/01/07 Amedisys Home Health of Oak Park X 0.33 680 North Lake Shore Drive Chicago IL 60611-4466 (708) 660-6300 AD 11/01/1151474 Home Hlth 12/01/09 02/01/12 Amedisys Home Health of Olney X 0.33 821 S. West St Olney IL 62450-1385 (618) 395-1730 C 01/01/1251476 Home Hlth 12/01/09 02/01/12 Amedisys Home Health of Rockford X 0.33 4920 E. State St. Rockford IL 61108-2262 (815) 229-2605 C 01/01/1251634 Home Hlth 09/01/10 American Choice Home Health Care X 0.33 419 Ridge Road Munster IN 46321-1535 (219) 836-8686 A 11/01/1050187 Home Hlth 01/01/98 American Home Health Corp. X 0.33 1460 N. Farnsworth Ave. Aurora IL 60505 (847) 375-0812 PN 05/01/0353762 Home Hlth 12/01/13 Americhoice Health Care Inc X 0.33 950 Skokie Blvd. Northbrook IL 60062 (847) 714-9787 A 01/01/14

5078 Home Hlth 06/30/99 Anchor Health Systems X 0.33 770 N. Main Street Crown Point IN 46307 (219) 622-3500 N 08/01/999791 Home Hlth 01/01/98 Anderson Home Health X 0.33 6800 State Route 162 Merryville IL 62062 (618) 692-1350

52051 Home Hlth 04/01/13 Angel Health Care LLC X 0.33 2625 Butterfield Road Oak Brook IL 60523 (847) 510-5905 A 05/01/1351526 Home Hlth 04/01/10 12/01/13 Angel Touch Home Healthcare Inc. X 0.33 2716 W. Peterson Ave. Chicago IL 60659 (773) 907-0300 C 01/01/1451748 Home Hlth 07/01/11 Apex Home Health Services Inc X 0.33 6160 N Cicero Ave Chicago IL 60646 (773) 202-1948 A 07/01/1150446 Home Hlth 04/01/06 11/01/13 Apria Healthcare X 0.33 81 Remington Road Schaumburg IL 60173 (847) 252-2100 C 02/01/1450030 Home Hlth 10/01/01 Ardent Home Health X 0.33 6124 W. 63rd St. Chicago IL 60638 (773) 229-8400 A 03/01/1150771 Home Hlth 02/01/12 Assure Home Healthcare Inc. X 0.33 7620 Gross Point Road Skokie IL 60077-2612 (847) 297-4444 A 02/01/1253540 Home Hlth 05/01/14 Assurecare Home Health Inc. X 0.33 2295 Valley Creek Drive Elgin IL 60123-2694 (847) 740-1955 A 08/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev. 08-2014

Page 23: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51996 Home Hlth 12/01/12 Aster Home Health Services, LLC X 0.33 3101 N. California Ave. Chicago IL 60618 (773) 267-5500 A 01/01/1351749 Home Hlth 07/01/11 At Home Health Inc X 0.33 3344 W Peterson Ave. Chicago IL 60659-3533 (773) 279-9244 A 07/01/1151885 Home Hlth 04/01/12 Atrium Homehealth Systems Inc X 0.33 6600 N Lincoln Ave. Lincolnwood IL 60712-3633 (847) 933-9832 A 05/01/12

5015 Home Hlth 01/01/98 Awakened Alternatives, Inc. X 0.33 3235 Vollmer Road Flossmoor IL 60422-2065 (708) 748-1520 AD 02/01/105428 Home Hlth 09/01/00 Baptist Home Health X 0.33 1003 East 5th Street Metropolis IL 62960 (618) 524-3661 A 11/01/00

51945 Home Hlth 08/01/12 Bay Group Health Care LLC X 0.33 4105 Oakton Street Skokie IL 60076- 3243 (773) 282-9610 A 10/01/1251584 Home Hlth 08/01/10 12/01/13 Benevolent Home Health Care, Inc X 0.33 1038 S LaGrange Road LaGrange IL 60525 (708) 579-3630 C 01/01/1451783 Home Hlth 09/01/11 Bestmed Care Services Ltd. X 0.33 15008 S. Woodlwan Ave Dolton IL 60419-2815 (708) 841-2730 A 10/01/1151741 Home Hlth 04/01/11 Better Care Home Health Inc X 0.33 2860 S. River Road Des Plaines IL 60018 (847) 758-1773 AD 06/01/1251232 Home Hlth 06/01/14 BG Home Health Providers LLC X 0.33 321 W. Dundee Road Buffalo Grove IL 60089 (847) 656-5035 06/01/1452097 Home Hlth 07/01/13 BJC Home Care Services X 0.33 3535 College Drive Alton IL 62002-5009 (314) 273-4000 A 10/01/13

5148 Home Hlth 06/01/01 C G H Home Health Center X 0.33 3010 E. Lynn Blvd. Sterling IL 61081 (815) 622-0836 A 08/17/0150599 Home Hlth 07/01/14 Care For Life Home Health X 0.33 2250 Point Boulevard Elgin IL 60123-7882 (847) 214-3633 A 07/01/1451769 Home Hlth 07/01/11 11/30/13 Caring Nurses Home Health Services Inc X 0.33 5122 W Irving Park Road Chicago IL 60641-2624 (773) 853-0623 C 01/01/14

9869 Home Hlth 01/01/98 Carle Home Care X 0.33 206 A. West Anthony Dr. Champaign IL 61822 (217) 383-34889840 Home Hlth 04/01/99 Centegra Home Health Care X 0.33 4201 Medical Center Dr. McHenry IL 60050 (815) 344-6602 D 03/01/00

51980 Home Hlth 11/01/12 Center of Illinois Home Healthcare Inc. X 0.33 855 E. Golf Road Arlington Heights IL 60005 (847) 437-0774 AD 03/01/1352103 Home Hlth 09/01/13 Central Healthcare Inc X 0.33 4751 S Central Ave. Chicago IL 60638 (708) 924-0500 A 10/01/1350113 Home Hlth 12/01/13 Choicecare Home Health Inc X 0.33 6400 W College Drive Palos Heights IL 60463-1798 (708) 489-0123 A 12/01/1351582 Home Hlth 06/01/10 06/04/13 Classic Home Healthcare Inc X 0.33 3531 W. Fullerton Ave. Chicago IL 60647-2417 (773) 252-2800 C 07/01/1351682 Home Hlth 02/01/11 Client Home Healthcare Inc X 0.33 9705 Southwest Highway Oak Lawn IL 60453 (708) 529-2000 A 03/01/11

9610 Home Hlth 01/01/98 CNS Home Health & Hospice X 0.33 690 E. North Avenue Carol Stream IL 60188 (630) 665-7000 N 06/01/12

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev. 08-2014

Page 24: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51565 Home Hlth 06/01/10 Comet Home Healthcare Inc. X 0.33 21141 Governors Hwy. Matteson IL 60443 (708) 748-8100 A 07/01/109706 Home Hlth 01/01/98 01/03/11 Community Memorial Hospital Home Care X 0.33 400 Caldwell Staunton IL 62088 (618) 635-2200 C 10/01/13

50111 Home Hlth 01/01/98 Community Alliance Home Health X 0.33 4050 Healthway Drive Aurora IL 60504 (630) 933-7851 PN 09/19/025029 Home Hlth 01/01/98 Community Home Health X 0.33 9042 Columbia Avenue Munster IN 46321 (219) 836-6737

51737 Home Hlth 05/01/11 Complete Home Health Services X 0.33 16234 Prince Drive South Holland IL 60473 (708) 333-1700 A 06/01/119950 Home Hlth 10/19/98 Coram Specialty Infusion Services X 0.33 1471 Business Center Mt. Prospect IL 60056-6082 (847) 294-6422 N 06/01/125047 Home Hlth 03/01/98 Coram Specialty Infusion Services X 0.33 1290 Arrowhead Ct. Crown Point IN 46307-8222 (219) 661-0272 N 06/01/12

52028 Home Hlth 03/01/13 Corlan Home Health Inc X 0.33 415 W Golf Road Arlington Heights IL 6005-3923 (847) 593-0050 A 04/01/1350512 Home Hlth 07/01/06 Cottage Home Health X 0.33 799 N. Henderson St. Galesburg IL 61401 (309) 343-9031 N & AD 03/01/1351563 Home Hlth 06/01/10 Covenant Healthcare Services & Staffing, Inc X 0.33 840 E. 87th St. Chicago IL 60619 (773) 487-9550 A 07/01/1051721 Home Hlth 02/01/11 Cresecent Home Health Agency X 0.33 10 Emerald Terrace Swansea IL 62226 (618) 277-0939 A 05/01/1150157 Home Hlth 02/01/02 Critical Care System X 0.33 655 W. Grand Ave. Elmhurst IL 60126 (630) 833-3427 R 05/01/0951550 Home Hlth 05/01/10 Crystal Home Health Care, LLC X 0.33 825 Midway Drive Willowbrook IL 60527-5549 (630) 964-7500 AD 07/01/1051773 Home Hlth 08/01/11 D & D Home Healthcare Inc X 0.33 101 Royce Road Bolingbrook IL 60440-1429 (630) 759-3422 A 09/01/1151724 Home Hlth 04/01/11 Daughters Divine Home Health Care Agency X 0.33 2653 N. Harlem Ave. Chicago IL 60707 (773) 385-6670 A 05/01/1151884 Home Hlth 04/01/12 DCARE Inc X 0.33 5040 W 190th St. Contry Club Hills IL 60478-5908 (773) 941-4468 A 05/01/12

9698 Home Hlth 09/01/10 Decatur Memorial Hospital Home Health X 0.33 3122 Brentwood Circle Decatur IL 62526 (217) 876-4600 A 10/01/109702 Home Hlth 01/01/98 Delnor Community Hosp. HHA X 0.33 300 Randall Road Geneva IL 60134-4200 (630) 513-0370

51859 Home Hlth 02/01/12 Deluxe Home Health Care LLC X 0.33 6800 Main St. Downers Grove IL 60516-3495 (630) 963-8696 A 04/01/1251462 Home Hlth 12/01/09 Dinamic Health Care LLC X 0.33 1313 Sibley Blvd Calumet City IL 60409 (708) 832-9908 A 01/01/1051393 Home Hlth 06/01/10 Direct Home Healchcare Inc. X 0.33 4001 W. Devon Ave Chicago IL 60646 (773) 777-9271 A 02/01/1152019 Home Hlth 02/01/13 Divine Intervention Healthcare, Inc. X 0.33 4747 Lincoln Mall Drive Matteson IL 60443 (708) 248-7662 A 03/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4 Rev. 08-2014

Page 25: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51258 Home Hlth 05/01/09 DMJ Home Health Services, Inc. X 0.33 6142 W. Roosevelt Road Oak Park IL 60304 (708) 445-0056 A 06/01/0951643 Home Hlth 09/01/10 Doctors Choice Home Health Agency X 0.33 1133 S. Wabash Ave Chicago IL 60605-2491 (312) 447-0035 A 12/01/1051893 Home Hlth 03/01/12 DR Home Healthcare LLC X 0.33 805 State St. Lemont IL 60439-4691 (630) 243-0527 A 05/01/1251659 Home Hlth 12/01/10 Elite Care at Home X 0.33 568 S Washington St. Naperville IL 60540 (630) 364-7330 A 01/01/1151551 Home Hlth 05/01/10 Elite Healthcare Providers, LLC X 0.33 1000 S. State St. Lockport IL 60441-3956 (815) 836-8100 AD 11/01/12

9875 Home Hlth 01/01/98 Elmhurst Memorial HomeHealth X 0.33 855 N. Church Court Elmhurst IL 60126 (630) 530-120152052 Home Hlth 03/01/13 Encore Home Health Service Inc. X 0.33 2600 W Peterson Ave Chicago IL 60659-4099 (773) 764-2995 A 05/01/1351852 Home Hlth 02/01/12 Epic Home Care Inc. X 0.33 710 E. Ogden Ave. Naperville IL 60563-8633 (630) 470-9668 AD 02/01/1451699 Home Hlth 03/01/11 Essential Preventive Health Care LLC X 0.33 4253 N Milwaukee Ave Chicago IL 60641-1642 (773) 588-0907 AD 03/01/12

5435 Home Hlth 07/18/08 12/01/13 Essex Home Health Services X 0.33 8018 So. Essex Ave Chicago IL 60617 (773) 933-0494 C 01/01/1451854 Home Hlth 02/01/12 12/01/13 Everest Home Healthcare Inc. X 0.33 2644 Dempster St. Park Ridge IL 60068-8431 (847) 699-0804 C 01/01/1451570 Home Hlth 02/01/11 Fairfield Memorial Hospital Home Health X 0.33 303 N W 11th St. Fairfield IL 62837 (618) 842-404951244 Home Hlth 05/01/09 Faith Home Healthcare Inc X 0.33 9919 Roosevelt Road Westchester IL 60154-2772 (708) 681-2853 A 06/01/0951791 Home Hlth 09/01/11 12/01/13 Family Home Care Inc X 0.33 80 Broadway Ave. Mattoon IL 61938-4560 (217) 235-0648 C 01/01/1451427 Home Hlth 10/01/09 Family Home Health Care Professionals Inc. X 0.33 3559 N Cumberland Ave. Chicago IL 60634 (773) 589-0590 A 10/01/0951570 Home Hlth 06/01/10 First Care Healthcare X 0.33 924 Clocktower Springfield IL 62704-6031 (217) 718-4889 A 07/01/1050611 Home Hlth 08/21/09 First Home Health Care Services X 0.33 14730 South Kilbourn Midlothuian IL 60445 (708) 535-8609 A 09/01/0952041 Home Hlth 04/01/13 FMR Home Health Inc X 0.33 10526 W Cermak Westchester IL 60154-5240 (708) 562-0192 A 05/01/1351883 Home Hlth 04/01/12 Forest Home Healthcare Inc. X 0.33 356 Forest Blvd. Park Forest IL 60466-2005 (708) 283-0769 A 05/01/1251357 Home Hlth 08/01/09 Four Seasons Home Healthcare, Inc. X 0.33 6042 Oakton St Morton Grove IL 60053-2702 (847) 966-1616 A 08/01/0951149 Home Hlth 02/01/09 Gateway Regional Home Health X 0.33 2100 Madison Granite City IL 62040 (618) 798-3200 A 05/01/0950210 Home Hlth 06/09/03 04/18/11 Gentiva Health Service (Rockland Island) X 0.33 1600 4th Ave. Street 201 Rock Island IL 61201 (309) 786-3700 C 10/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5 Rev. 08-2014

Page 26: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51750 Home Hlth 07/01/11 Global Home Health I LLC X 0.33 1940 EW 87th St. Chicago IL 60617-2938 (773) 374-9700 A 07/01/11

51890 Home Hlth 04/01/12Goodhope Healthcare and Home Health Services X 0.33 3631 Municipal Drive McHenry IL 60050 (815) 344-9268 TE 12/01/13

9765 Home Hlth 01/01/98 Gottlieb Mem. Hosp. Home Health X 0.33 701 W. North Avenue Melrose Park IL 60160 (708) 450-49499832 Home Hlth 06/01/10 Graham Hospital Home Health X 0.33 210 W Walnut Canton IL 61520-2444 (309) 647-5240 A 06/01/10

51596 Home Hlth 08/01/10 Guaranteed Medical Services Inc X 0.33 6619 Archer St. Chicago IL 60659-4614 (773) 989-7300 AD 02/01/1451638 Home Hlth 11/01/10 Guardian Angel Home Care Inc X 0.33 7366 N Lincoln Ave Lincolnwood IL 60712 (847) 674-2711 A 12/01/1050320 Home Hlth 09/01/12 Guardian Home Health Care LLC X 0.33 181 Waukegan Road Northfield IL 60093-2700 (847) 441-5020 A 09/01/1251518 Home Hlth 08/30/12 Hands on Wellness Inc X 0.33 1062 Sibley Blvd. Calumet City IL 60409 (708) 832-2228 A 09/01/1251698 Home Hlth 02/01/11 Happy Home Health Care X 0.33 5810 N. Lincoln Ave Chicago IL 60659 (773) 878-7222 A 04/01/1151738 Home Hlth 05/01/11 Harrisburg Medical Center Home Health X 0.33 100 Dr. Warren Tuttle Drive Harrisburg IL 62946-0429 (618) 253-7671 AD 09/01/1250155 Home Hlth 07/01/14 Healing Hands Home Care, Inc. X 0.33 6730 W. Higgins Avenue Chicago IL 60656-2106 (773) 793-3333 R 08/01/1451564 Home Hlth 07/01/10 Healing to Heal Home Healthcare Inc. X 0.33 19900 Governors Drive Olympia Fields IL 60461 (773) 253-4750 A 07/01/1051537 Home Hlth 04/01/10 Healing Touch Home Health Services Inc. X 0.33 123 E. Lake St. Bloomingdale IL 60108-1116 (630) 351-9255 A 05/01/10

9627 Home Hlth 01/01/98 Health Care At Home (Hinsdale Hosp) X 0.33 8230 S. Madison St. Burr Ridge IL 60527 (630) 920-83005142 Home Hlth 05/01/01 Healthtrends, Ltd X 0.33 200 E. Howard DesPlaines IL 60018 (847) 803-0774 A 06/01/01

51688 Home Hlth 02/01/11 Healthy Heart Nurse Inc X 0.33 24560 S Kings Road Crete IL 60417-9631 (708) 367-1300 A 03/01/115039 Home Hlth 01/01/98 11/30/13 Heartland Home Care X 0.33 1260 E. Tremont Hillsboro IL 62049 (217) 532-6111 C 01/01/149864 Home Hlth 01/01/98 11/09/11 Heartland Home Health Care, Inc. X 0.33 20646 S. LaGrange Rd. Frankfort IL 60423-3134 (815) 806-1000 C 11/01/11

50276 Home Hlth 05/01/04 11/09/11 Heartland Home Healthcare and Hospice X 0.33 4415 W. Harrison Hillside IL 60162-1955 (708) 531-9339 C 11/01/11

51808 Home Hlth 10/01/11Hillsboro Rehabilitation & Health Care Center X 0.33 1300 E. Tremont St. Hillsboro IL 62019-1913 (217) 532-6191 N

52066 Home Hlth 05/01/13 Holy Mary Home Health Care Inc X 0.33 2200 S. Main St Lombard IL 60148-5364 (708) 867-8405 A 06/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6 Rev. 08-2014

Page 27: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50594 Home Hlth 01/10/07 Home Bound Healthcare Inc. X 0.33 1615 Vollmer Road Flossmoor IL 60422-1992 (708) 798-0800 A 10/16/079754 Home Hlth 09/17/98 Home Care Little Company of Mary Hospital X 0.33 2800 W. 95th Street Evergreen Park IL 60805 (708) 229-4663 N 05/01/10

51635 Home Hlth 10/01/10 Home Health Advantage Inc X 0.33 6120 N Milwaukee Ave Chicago IL 60646 (773) 774-7700 AD 06/01/1251886 Home Hlth 03/01/12 Home Health Connections Inc X 0.33 7348 N Monticello Ave Skokie IL 60076-4025 (847) 676-1244 A 05/01/12

5069 Home Hlth 01/01/14 Home Health Of Illinois X 0.33 5061 N Pulaski Rd Chicago IL 60630 (773) 509-1355 R 05/01/149868 Home Hlth 01/01/98 Home Health Services X 0.33 600 N. College Avenue Geneseo IL 61254 (309) 944-4853

51595 Home Hlth 08/01/10 Home Touch Healthcare X 0.33 2010 US Highway 34 Oswego IL 60543-8641 (630) 585-1457 A 08/01/1051723 Home Hlth 04/01/11 Hope Home Health Inc. X 0.33 18456 Poplar Ave. Homewood IL 60430-3463 (708) 647-2929 A 05/01/1151555 Home Hlth 06/01/10 01/01/13 Hyacinth Home Health Inc. X 0.33 4524 Iris Lane Monee IL 60449 (708) 422-4566 C 01/01/1351618 Home Hlth 10/01/10 09/18/13 I Care Home Health Providers, LLC X 0.33 8707 Skokie Blvd. Skokie IL 60077 (847) 745-8424 C 12/01/1351370 Home Hlth 08/01/09 Immanuel Home Care Services,Inc. X 0.33 712 E. 47th St. Chicago IL 60653 (773) 285-2227 A 09/01/09

9899 Home Hlth 09/01/09 Independence Plus Inc X 0.33 720 Enterprise Drive Oak Brook IL 60523-1908 (708) 366-4500 A 09/01/099712 Home Hlth 01/01/98 Ingalls Home Care X 0.33 One Ingalls Drive Harvey IL 60426 (708) 331-0226

50180 Home Hlth 07/28/07 Interim Healthcare X 0.33 12855 S. Cicero Ave. Alsip IL 60803 (708) 383-7320 AD 08/01/1350180 Home Hlth 07/28/07 Interim Healthcare X 0.33 10735 S. Cicero Avenue Oak Lawn IL 60458 (708) 422-2934 AD 09/01/08

9975 Home Hlth 01/01/98 Iroquois Home Health X 0.33 200 Fairman Avenue Watseka IL 60970 (815) 432-617550712 Home Hlth 02/01/08 JCL Home Healthcare, Inc X 0.33 15300 S. Cicero Oak Forest IL 60452 (708) 535-6800 N 05/01/1351766 Home Hlth 08/01/11 Jessifer Home Health Servicess Inc. X 0.33 4738 N Harlem Ave Harwood Heights IL 60706 (708) 867-8310 A 09/01/11

9874 Home Hlth 01/01/98 11/30/13 Kewanee Hosp. Home Health Care X 0.33 1051 W. South Street Kewanee IL 61443 (309) 853-3361 C 12/01/1351841 Home Hlth 12/01/11 Kindred at Home Chicago Home Health X 0.33 7101 N. Cicero Ave Lincolnwood IL 60712-2112 (847) 972-1590 N 09/01/1351849 Home Hlth 02/01/12 Kingsway Home Health Services X 0.33 7115 N Ridge Blvd. Chicago IL 60645-3503 (773) 761-8342 TE 05/01/1352073 Home Hlth 01/01/13 Kishhealth System Home Care X 0.33 2727 Sycamore Road DeKalb IL 60115 (815) 748-8916 A 08/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 7 Rev. 08-2014

Page 28: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

9713 Home Hlth 03/01/00 Lake Forest Hospital Home Health X 0.33 660 N. Westmoreland Rd. Lake Forest IL 60045 (847) 535-8788 A 05/12/0051533 Home Hlth 04/01/10 Legen Home Health X 0.33 3405 W. Fullerton Ave Chicago IL 60647-2415 (773) 278-0100 A 05/01/1051626 Home Hlth 10/01/10 Lifeline Home Care LLC X 0.33 15 E. Park Blvd. Villa Park IL 60181-2984 (847) 680-3880 AD 10/01/1351784 Home Hlth 09/01/11 Livingspring Home Health Care Inc. X 0.33 18350 Kedzie Ave. Homewood IL 60430-2759 (708) 960-4767 A 10/01/1152082 Home Hlth 07/01/13 LKB Health Care Ltd X 0.33 355 W Dundee Road Buffalo Grove IL 60089 (847) 947-8900 A 08/01/1351814 Home Hlth 12/01/11 Loving Care Agency Inc X 0.33 2400 E. Devon Avenue Des Plaines IL 60018-4627 (847) 298-0859 A 12/01/11

9729 Home Hlth 01/01/98Loyola University Ct. for Home Care & Hospice X 0.33 2160 S. First Avenue Maywood IL 60153 (708) 531-3642

51099 Home Hlth 12/01/08 MARI Home Healthcare Services, LLC X 0.33 21141 Governors Hwy. Matteson IL 60443 (708) 283-5940 AD 12/01/139831 Home Hlth 06/01/10 Mason District Hospital HHA X 0.33 615 N Promenade St. Havana IL 62644 (309) 543-6137 A 07/01/10

51714 Home Hlth 03/01/11 Maxicare Home Health Services X 0.33 5200 Main St. Skokie IL 60077-2100 (847) 675-6007 A 04/01/1150233 Home Hlth 03/01/08 Maxim Healthcare Services X 0.33 1049 Lake Street Oak Park IL 60301-6708 (866) 286-8773 A 03/10/0850136 Home Hlth 10/01/02 Maximum Home Health Care, Inc. X 0.33 2959 W. 95th Street Evergreen Park IL 60805 (708) 952-1900 A 03/07/0350727 Home Hlth 02/26/08 03/01/13 MCC Healthcare Services Inc X 0.33 9143 S. Kedzie Avenue Evergreen Park IL 60805 (708) 581-7700 C 03/01/13

9657 Home Hlth 06/01/10 McHenry County Department of Health X 0.33 2200 N Seminary Ave. Woodstock IL 60098-2637 (815) 334-4510 A 06/01/1050668 Home Hlth 01/01/08 MDH Home Health Care X 0.33 525 E. Grant Street Macomb IL 61455-3313 (309) 833-4101 A 02/01/0852050 Home Hlth 04/01/13 Medcore Home Health Care Inc X 0.33 1011 E. Touhy Ave Des Plaines IL 60018 (847) 768-6080 A 05/01/1351742 Home Hlth 05/01/11 Medex Home Healthcare Inc. X 0.33 8124 S. Cottage Grove Ave Chicago IL 60619 (773) 488-1400 A 07/01/1151955 Home Hlth 09/01/12 Medi Link Health Services LLC X 0.33 1701 E Woodfield Road Schaumburg IL 60173-5129 (847) 995-9900 A 04/01/1350398 Home Hlth 08/01/05 Medi Plex Professionals X 0.33 10700 Lincoln Trail Fairview Hts IL 62208-2037 (618) 293-6776 A 01/13/06

9651 Home Hlth 04/01/13Medical Professional for Home Health Care Inc. X 0.33 7928 SML King Drive Chicago IL 60617 (773) 487-2400 A 04/01/13

52621 Home Hlth 10/01/13 MedPro Health Providers X 0.33 16335 S Harlem Ave Tinley Park IL 60477-1618 (708) 240-8088 A 01/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 8 Rev. 08-2014

Page 29: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51858 Home Hlth 02/01/12 Medtec Home Health Agency Inc. X 0.33 Medtec Home Health Agency Inc Westchester IL 60154-2563 (708) 681-2009 A 04/01/129688 Home Hlth 04/01/98 Memorial Home Services NFP X 0.33 720 North Bond Street Springfield IL 62702 (217) 523-4113 N 03/01/109980 Home Hlth 01/01/98 Mendota Community Home Health X 0.33 909 Main St. Mendota IL 61342 (815) 539-1421 AD 03/01/129930 Home Hlth 01/01/98 Methodist Med. Ctr. Home Health X 0.33 221 N.E. Glen Oak Peoria IL 61636 (309) 671-8247

50759 Home Hlth 07/30/08 02/29/12 Metrosouth Home Care X 0.33 12935 S. Gregory Blue Island IL 60406 (708) 371-7777 CP 05/01/1251879 Home Hlth 03/01/12 Metrosouth Home Health X 0.33 12935 S Gregory Blue Island IL 60406-2428 (708) 371-7777 P 05/01/1251810 Home Hlth 11/01/11 Midwest Home Health Care of Frankfort LLC X 0.33 8936 Charrington Drive Frankfort IL 60423-9447 (815) 277-2631 A 07/01/12

9715 Home Hlth 01/01/98 03/01/13Mt. Sinai Hospital & Med. Ctr. Home Health Care X 0.33 15th at California Chicago IL 60605 (773) 542-2000 C 03/01/13

52009 Home Hlth 12/01/12 New Beginnings Home Health Care X 0.33 13011 S 104th Ave. Palos Park IL 60464-1512 (708) 671-1700 A 02/01/1352043 Home Hlth 04/01/13 Newage Home Health X 0.33 205 W Grand Ave. Bensenville IL 60106 (847) 679-0541 A 05/01/1351706 Home Hlth 01/01/11 Newsome Home Health Care Agency X 0.33 920 Essington Road Joliet IL 60435-2859 (815) 744-4770 A 04/01/1151502 Home Hlth 02/01/10 Next Level Healthcare Outreach, Inc. X 0.33 2259 E 73rd St Chicago IL 60649-3233 (773) 445-9040 A 03/01/10

50987 Home Hlth 10/01/08Northshore University Health System Home & Hospice Services X 0.33 4901 Searle Parkwy Skokie IL 60077-2919 (847) 475-2001 PN 11/01/08

9714 Home Hlth 01/01/98 Northwest Comm. Hosp. Home Care X 0.33 3060 Salt Creek Lane Arlington Hgts IL 60005 (847) 618-1000 N9662 Home Hlth 02/26/14 Nurses Plus Home HealthCare X 0.33 350 Victory Dr Park Forest IL 60466 (708) 748-1118 A 04/01/14

52072 Home Hlth 06/01/13 Nurture Care Home Health, Inc. X 0.33 125 E. Lake Street Bloomingdale IL 60108 (847) 285-1802 A 07/01/1350511 Home Hlth 06/01/14 O & P Home Health Care X 0.33 4950 Main Street Skokie IL 60089 (847) 329-7050 A 07/01/1451719 Home Hlth 04/01/11 Oasis Medical Services X 0.33 396 S. Kennedy Drive Kankakee IL 60915 (815) 935-4663 N 06/01/12

5028 Home Hlth 01/01/98 Option Health LTD X 0.33 985 Avenue of the Cities Silvis IL 61282-7001 (309) 762-7979 AD 03/01/129958 Home Hlth 01/01/98 Orsini Nursing Agency, Inc. X 0.33 1111 Nicholas Blvd. Elk Grove IL 60007 (847) 734-7373 AD 04/01/099661 Home Hlth 05/01/99 Ottawa Regional Home Health X 0.33 1601Mercury Circle Ottawa IL 61350 (815) 433-6091 N 07/01/11

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 9 Rev. 08-2014

Page 30: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

9861 Home Hlth 07/01/98 Palos Community Hosp. Home Health X 0.33 15295 E. 127th Street Lemont IL 60439 (630) 257-1111 A 09/01/989923 Home Hlth 01/01/98 Pediatric Serv. of America,Inc. X 0.33 2755-B Curtiss Street Downers Grove IL 60515 (630) 725-13689717 Home Hlth 09/01/10 Pekin Hospital Home Health X 0.33 600 S 13th St. Pekin IL 61554-4936 (309) 347-1151 A 10/01/10

50351 Home Hlth 05/01/05 Phoenix Home Care, LLC X 0.33 200 S. Frontage Road Burr Ridge IL 60527 (630) 321-9400 A 06/07/0551846 Home Hlth 01/01/12 Preferred Home Health Care X 0.33 150 W. South St. Kewanee IL 61441-3749 (918) 252-2000 A 02/01/1251247 Home Hlth 05/01/09 Premier Point Home Health NFP X 0.33 1212 W. Thorndale Ave. Chicago IL 60660-3398 (773) 275-8390 A 06/01/09

5081 Home Hlth 07/03/99 Presence Home Care Services X 0.33 2380 W. Dempster Des Plaines IL 60016 (847) 568-8500 N & AD 10/01/1350150 Home Hlth 01/01/00 Presence Home Care (Elgin) X 0.33 799 South McLean Blvd. Elgin IL 60123 (847) 622-2055 N 10/01/1350160 Home Hlth 01/01/00 Presence Home Care - Joliet X 0.33 1060 Essington Road Joliet IL 60435-8200 (815) 741-7371 N 10/01/1357792 Home Hlth 12/01/13 Presence Home Care - Urbana X 0.33 1501 Interstate Pkwy. Champaign IL 61821-2405 (217) 355-4120 P 05/01/1450162 Home Hlth 01/01/00 Presence Home Care - Urbana X 0.33 1501 Interstate Pkwy. Champaign IL 61821-2405 (217) 355-4120 CP 01/01/1450161 Home Hlth 01/01/00 Presence Home Care Kankakee X 0.33 179 E. Bethel Bourbonnais IL 60914-1456 (815) 937-2475 N 10/01/13

9639 Home Hlth 07/01/14 Private Home Care Unlimited X 0.33 5517 N. Cumberland Chicago IL 60656 (773) 467-6000 A 07/01/1450458 Home Hlth 06/01/06 Proctor Home Care X 0.33 5409 N. Knoxville Ave. Peoria IL 61614 (309) 691-1075 A 12/28/0651785 Home Hlth 09/01/11 Proficient Health Care Services Inc. X 0.33 20316 S. Torrence Ave Lynwood IL 60411-7629 (708) 895-5560 A 10/01/1150163 Home Hlth 01/01/00 Provena Home Health Waukegan X 0.33 222 S. Greenleaf Ave. Waukegan IL 60031 (847) 360-7660 N 06/01/0450070 Home Hlth 01/01/11 Providence at Home HealthCare X 0.33 16300 S Louis Ave. South Holland IL 60473 (708) 331-0400 R 01/01/1151200 Home Hlth 03/01/09 Provider A Care LLC X 0.33 500 E. Higgins Road Elk Grove IL 60007 (773) 326-6860 A 05/01/0951213 Home Hlth 04/01/09 PSA Healthcare X 0.33 16655 Oak Park Ave Tinley Park IL 60477-2313 (708) 429-5551 A 05/01/0951732 Home Hlth 03/01/11 Quality Assured Home Health Inc. X 0.33 3900 W. 95th St. Evergreen Park IL 60805-1901 (708) 529-3823 A 05/01/1151887 Home Hlth 03/01/12 12/01/13 Quality Home Health LLC X 0.33 18525 Torrence Ave. Lansing IL 60438-2891 (708) 983-5137 C 01/01/1454152 Home Hlth 09/01/13 Recover at Home Inc X 0.33 7040 Centennial Drive Tinley Park IL 60477-1649 (708) 444-4170 A 01/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 10 Rev. 08-2014

Page 31: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51096 Home Hlth 01/01/09 Red Bud Regional Home Care X 0.33 1010 Locust St. Red Bud IL 62278 (618) 282-3338 AD 03/01/1251836 Home Hlth 12/01/11 12/01/13 Regal Home Healcare Inc X 0.33 8930 Grosspoint Road Skokie IL 60077-1864 (647) 965-8146 C 01/01/1451329 Home Hlth 06/01/09 Regency Home Health Care PC X 0.33 10448 S. Pulaski Road Oak Lawn IL 60453-4895 (708) 398-4022 A 08/01/0954307 Home Hlth 10/01/13 12/13/13 Regional Home Care X 0.33 517 N Main St Anna IL 62906-1668 (618) 833-2033 C 05/01/1451133 Home Hlth 01/01/09 Regional Home Care Crossroads X 0.33 1009 S 42nd Street Mt Vernon IL 62864 (618) 244-9028 A 05/01/0951711 Home Hlth 02/01/11 Reliable Home Care Providers Inc. X 0.33 430 N Milwaukee Lincolnshire IL 60069 (847) 883-8555 A 04/01/1151073 Home Hlth 10/01/08 Reliance Home Health Care, Inc. X 0.33 1111 Plaza Drive Schaumburg IL 60173 ( 63) 052-9693 A 01/01/09

5016 Home Hlth 01/01/98Residential Home Health (was Edward Home Care) X 0.33 801 S. Washington St. Naperville IL 60540 (630) 527-6840 N 11/01/09

51407 Home Hlth 11/01/09 Residential Home Health IL LLC X 0.33 40 Shuman Blvd. Naperville IL 60563 (630) 527-6830 A 12/01/0950482 Home Hlth 01/01/05 RMC Home Health Care X 0.33 1905 W. Court Street Kankakee IL 60901-3163 (815) 935-3272 PN 03/30/0751597 Home Hlth 08/01/10 Royal Home Health Services Inc X 0.33 14810 S Cicero Ave. Oak Forest IL 60452-1400 (708) 535-0277 A 09/01/1052037 Home Hlth 03/01/13 Sacred Heart Home Health Inc X 0.33 9850 S Cicero Ave Oak Lawn IL 60453-3161 (708) 422-2956 A 05/01/13

9798 Home Hlth 09/01/10 Saint Francis Home Health X 0.33 2265 W. Altorfer Drive Peoria IL 61615 (309) 683-7700 A 12/01/1050350 Home Hlth 02/01/05 Sarah Bush Lincoln Health Center X 0.33 1000 Health Center Dr. Mattoon IL 61938 (217) 258-2525 A 06/07/0551461 Home Hlth 12/01/09 Select Home Care, Inc. X 0.33 2622 W. Peterson Ave. Chicago IL 60659 (773) 338-2230 A 12/01/09

9758 Home Hlth 05/01/14 Shay Healthcare Services, Inc. X 0.33 5730 W. 159th Street Oak Forest IL 60452 (708) 535-4300 A 05/01/149981 Home Hlth 01/01/98 Shelby Memorial Home Health X 0.33 200 S. Cedar Shelbyville IL 62565 (217) 774-4499 TE 10/01/13

4570935 Home Hlth 01/01/98 Sherman Home Care Partners X 0.33 1019 E. Chicago Street Elgin IL 60120 (847) 429-62009770 Home Hlth 01/01/98 06/01/13 Sherman Home Care Partners X 0.33 901 Center Street Elgin IL 60120 (224) 783-6200 C 10/01/139836 Home Hlth 01/01/98 Silver Cross Home Health X 0.33 1200 Maple Road Joliet IL 60432 (815) 740-7124

51762 Home Hlth 06/01/11 Simply Home Health LLC X 0.33 2908 N. Lincoln Chicago IL 60657 (847) 562-0800 AD 02/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 11 Rev. 08-2014

Page 32: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51988 Home Hlth 11/01/12 Someone Who Cares Home Health Care, Inc. X 0.33 1405 S. Harlem Ave. Berwyn IL 60402 (708) 484-8275 A 12/01/1251912 Home Hlth 07/01/12 Soul Care Services Inc X 0.33 2200 E Devon Ave Des Plaines IL 60018-4505 (847) 260-5140 A 08/01/12

9689 Home Hlth 01/01/00 Southwestern Illinois VNA X 0.33 #7 Executive Woods Swansea IL 62226 (618) 236-5800 A 03/01/0051646 Home Hlth 10/01/10 11/30/13 Spectrum Nurses Inc. X 0.33 481 W. Boughton Road Bolingbrook IL 60440-2475 (630) 771-9069 C 01/01/1451366 Home Hlth 08/01/09 12/01/13 Spring Meadows Home Health Care, LLC X 0.33 1835 Broadway Street. Melrose Park IL 60160-2040 (708) 223-8960 C 01/01/14

50671 Home Hlth 01/01/08SSM Health Care at St. Mary's Good Samaritan X 0.33 605 N. 12th Street Mt. Vernon IL 62864-2857 (618) 241-1621

50981 Home Hlth 01/01/08 11/01/13 SSM Home Care of St. Louis X 0.33 20 Junction Dr. Glen Carbon IL 62034 (618) 288-8020 C 12/01/139925 Home Hlth 01/01/98 St. Anthony Ctr. for Home Care X 0.33 5501 E State St. Rockford IL 61108 (815) 921-8700 AD 03/01/149721 Home Hlth 09/01/10 St. Anthonys Hospital Home Health Care X 0.33 915 E 5th St. Alton IL 62002-6434 (618) 463-5683 A 11/01/105144 Home Hlth 05/01/01 St. Anthony's Memorial Home Health X 0.33 503 North Maple Street Effingham IL 62401 (217) 342-2121 A 06/01/019889 Home Hlth 01/01/98 St. Elizabeth Hosp. Home Health X 0.33 211 S. Third Street Belleville IL 62220 (618) 277-93609728 Home Hlth 01/01/98 St. James Home Health X 0.33 1400 Otto Blvd. Chicago Hgts IL 60411 (708) 709-20309862 Home Hlth 09/01/10 St. James Home Health X 0.33 608 N Ladd St. Pontiac IL 61764 (815) 844-6982 C 03/01/139673 Home Hlth 09/01/99 St. John's Home Health Care X 0.33 800 E. Carpenter St. Springfield IL 62702 (217) 525-5641 A 12/01/999850 Home Hlth 01/01/98 St. Margaret Mercy Healthcare X 0.33 5454 Hohman Avenue Hammond IN 46320 (219) 932-23009919 Home Hlth 01/01/98 St. Mary Home Health X 0.33 3205 N. Seminary Street Galesburg IL 61401 (309) 344-3161 AD 12/01/10

52024 Home Hlth 02/01/13 Star Home Health of Waukegan X 0.33 2645 Washington St. Waukegan IL 60085 (847) 360-2220 A 04/01/1351479 Home Hlth 12/01/09 Sunny Hill Home Health Care Inc. X 0.33 10522 S. Cicero Ave. Oak Lawn IL 60453-5200 (708) 424-7025 A 01/01/1051652 Home Hlth 11/01/10 Supportive Home Health X 0.33 1261 Humbracht Circle Bartlett IL 60103-1647 (630) 830-8000 A 01/01/1151722 Home Hlth 04/01/11 Supreme Home Health Care LLC X 0.33 3525 W. Peterson Ave. Chicago IL 60659-5513 (773) 564-9225 A 05/01/1150309 Home Hlth 01/01/05 Swedish American Home Health X 0.33 2550 Charles Street Rockford IL 61110 (815) 391-7500 P 03/08/05

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 12 Rev. 08-2014

Page 33: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

9638 Home Hlth 01/01/98 Swedish Covenant Hospital HH X 0.33 2965 W. Peterson Ave. Chicago IL 60659 (773) 275-970051097 Home Hlth 12/01/08 Synergy Home Healthcare, inc. X 0.33 2644 Dempster Park Ridge IL 60068-8431 (847) 430-6771 A 02/01/0951690 Home Hlth 02/01/11 Total Health Home Care Services Inc. X 0.33 19150 S Kedzie Flossmoor IL 60422 (708) 799-6022 A 03/01/1152046 Home Hlth 04/01/13 Total Home Healthcare Inc X 0.33 4001 West Devon Chicago IL 60646-4540 (773) 853-2641 A 05/01/1351995 Home Hlth 11/01/12 Transitions Home Care LLC X 0.33 310 7th St. - Valkommen Plaza Rockford IL 61104-1233 (773) 354-4133 A 03/01/13

9691 Home Hlth 01/01/98 Trinity Visinting Nurse Homecare X 0.33 106 19 Avenue Moline IL 61265 (309) 779-7600 W 12/01/0851525 Home Hlth 04/01/10 Tru Care Home Health Inc. X 0.33 4433 W. Touhy Ave Lincolnwood IL 60712-1833 (847) 329-0066 A 04/01/1052049 Home Hlth 04/01/13 Ultra Care Home Health Inc. X 0.33 2400 E Devon Ave. Des Plaines IL 60018 (847) 827-3500 A 05/01/13

9946 Home Hlth 01/01/98 01/03/14 Ultra Care, LLC X 0.33 2100 N. Menheim Rd. Northlake IL 60164 (708) 273-4100 C 03/01/1453815 Home Hlth 03/01/14 UNI Care Home Health Services, Inc. X 0.33 6006 W, 159th Street Oak Forest IL 60452 (708) 444-8445 A 05/01/14

5124 Home Hlth 01/01/07 06/05/13 Union County Hosp. Home Health X 0.33 517 N. Main Street Anna IL 62906-1668 (618) 833-2033 C 09/01/1351745 Home Hlth 07/01/11 United Caregivers Inc. X 0.33 7420 South County Line Road Burr Ridge IL 60527 (630) 655-3204 A 07/01/1151829 Home Hlth 12/01/11 United Medical Care X 0.33 5301 Dempster St Skokie IL 60077 (847) 966-9911 A 01/01/12

5102 Home Hlth 02/22/00 Vanguard Home Care X 0.33 2315 Enterprise Drive Westchester IL 60154-5809 (708) 447-3555 N & AD 12/01/1359539 Home Hlth 10/01/13 Vanguard Health and Wellness X 0.33 1585 Ellinwood Ave DesPlaines IL 60016-4510 (847) 512-7126 A 01/01/1451439 Home Hlth 10/01/09 VCP Home Healthcare Inc. X 0.33 330 N. Madision St. Joliet IL 60435 (815) 725-7391 A 12/01/0951163 Home Hlth 03/01/09 Vintage Healthcare Services, Inc. X 0.33 7 Blanchard Circle Wheaton IL 60187 (630) 517-0191 A 04/01/0951693 Home Hlth 03/01/11 Virgos Home Health Care Inc. X 0.33 8930 Gross Point Road Skokie IL 60077-1854 (847) 965-8914 A 04/01/1152034 Home Hlth 03/01/13 Vision Home Health Care Inc X 0.33 500 W Central Road Mount Prospect IL 60056 (847) 483-9722 A 04/01/1351746 Home Hlth 05/01/11 Vitacare Health Services Inc. X 0.33 4736 Main St. Lisle IL 60532-1986 (630) 324-6592 A 07/01/11

9953 Home Hlth 12/01/13 Vital Home Health Care X 0.33 8051 W 186th St Tinley Park IL 60477 (708) 342-7076 A 12/01/139682 Home Hlth 01/01/98 VNA of Fox Valley X 0.33 400 N. Highland Avenue Aurora IL 60504 (630) 978-2532

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 13 Rev. 08-2014

Page 34: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

5051 Home Hlth 06/01/98 VNA of Porter County X 0.33 2401 Valley Drive Valparaiso IN 46383 (219) 462-51959687 Home Hlth 01/01/98 VNA of Rockford X 0.33 4223 East State Street Rockford IL 61108 (815) 229-1100

50275 Home Hlth 04/01/04 Walgreens Infusion and Respiratory X 0.33 1226 Michael Dr. Wood Dale IL 60191 (800) 551-9355 N & AD 03/01/1251633 Home Hlth 06/14/10 Walgreens Specialty Infusion X 0.33 2050 S. Finley Road Lombard IL 60148 (630) 495-2777 TE 02/01/1451734 Home Hlth 05/01/14 Wellness Healthcare Partners X 0.33 2338 W. Morse Avenue Chicago IL 60645 (773) 654-1690 A 05/01/1451198 Home Hlth 04/01/09 Wellspring Healthcare Services, Inc. X 0.33 494 W. Boughton Road Bolingbrook IL 60440 (630) 759-7808 A 05/01/0951685 Home Hlth 02/01/11 Whitestar Home Health Agency X 0.33 1495 W King St. Decatur IL 62522-1444 (217) 462-0355 A 03/01/1151747 Home Hlth 06/01/11 Willow Home Care LTD X 0.33 13246 S Route 59 Plainfield IL 60585-9801 (815) 230-3910 A 08/01/1151826 Home Hlth 12/01/11 Wound and Rehab Home Health Care Inc. X 0.33 700 Busse Highway Park Ridge IL 60068-2402 (847) 692-6000 A 12/01/11

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 14 Rev. 08-2014

Page 35: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

2219836 Home HIT 01/01/98 Accredo Health Inc. X 0.33 650 W. Grand Avenue Elmhurst IL 60126 (630) 993-8830 N 03/07/032221697 Home HIT 01/01/98 Advocate Home Care Products X 0.33 1441 Branding Lane Downers Grove IL 60515 (630) 963-32002232303 Home HIT 07/01/03 Alexian Brothers Home Health X 0.33 1515 Lake Street Hanover Park IL 60133 (847) 956-5464 A 01/13/061630269 Home HIT 03/21/05 Alverno Home Infusion Services X 0.33 1400 Otto Blvd. Chicago Heights IL 60411 (800) 709-2165 A 01/13/062219340 Home HIT 01/01/98 05/01/12 Apria Health Care X 0.33 81 Remmington Road Schaumburg IL 60173 (847) 252-2100 C 05/01/129927598 Home HIT 06/29/01 Care Tech Omnicare Infusion X 0.33 2289 S. Mt. Prospect Rd. Des Plaines IL 60018 (888) 833-1116 PN 08/01/012215464 Home HIT 01/01/98 Caremark Inc. X 0.33 800 Biermann Ct Mt. Prospect IL 60056 (847) 634-74002233041 Home HIT 12/01/06 CNS Home Infusion & Pharmacy X 0.33 690 E. North Avenue Carol Stream IL 60188 (630) 665-7000 A 10/16/07

90000728 Home HIT 01/01/98 Coram Health Care Corp. of IN X 0.33 1290 Arrowhead Ct. Crown Point IN 46307 (219) 661-02721619976 Home HIT 01/01/98 Coram Specialty Infusion Services X 0.33 2022 Glen Park Drive Champaign IL 61821 (217) 356-7900 AL 05/01/121619976 Home HIT 01/01/98 Coram Specialty Infusion Services X 0.33 1471 E. Business Center Dr. Mt. Prospect IL 60056 (847) 294-6422 N 05/01/121629909 Home HIT 03/01/01 Critical Care System, Inc. X 0.33 655 W. Grand Ave. Elmhurst IL 60126 (630) 833-3427 AD & TE 05/01/091670523 Home HIT 01/01/98 02/01/12 Dyna Care IV Supplies X 0.33 18454 Creek Drive Tinley Park IL 60477 (708) 560-7900 C 02/12/122221411 Home HIT 10/01/97 Elmhurst Mem Hosp Home Infusion X 0.33 200 Berteau Avenue Elmhurst IL 60126 (630) 993-5165 A 01/13/061633718 Home HIT 01/01/06 ENH VNA Home Services X 0.33 1603 Orrington Ave. Evanston IL 60201 (847) 475-2001 A 01/13/065871311 Home HIT 03/01/01 Enloes Drug Inc. X 0.33 2106 W. Townline Rd. Peoria IL 61615 (800) 354-0677 A 03/01/01

90001058 Home HIT 03/01/02 Fairmeadows Pharmacy, Inc. X 0.33 800 Macathur Blvd Munster IN 46321 (219) 836-8700 A 07/09/021634500 Home HIT 01/01/13 Health Delivery Mgmt dba Home Infusion X 0.33 610 So Maple Ave Oak Park IL 60304 (708) 660-6200 AL 05/01/13

1634500 Home HIT 01/01/05Health Delivery Mgmt dba Professional Office X 0.33 1725 W. Harrison Chicago IL 60612 (312) 563-2093 A 03/08/05

4970984 Home HIT 01/01/98 Health Options X 0.33 110 S. Market Street Sparta IL 62286 (618) 443-1155 N & TE 11/01/101620277 Home HIT 01/01/98 Heartland Home Hlth Care Hospice X 0.33 2235 Enterprise Drive Westchester IL 60154 (708) 531-99392271395 Home HIT 01/01/98 Heartland Home Infusions X 0.33 500 E. Ogden Avenue Hinsdale IL 60521 (630) 986-43901620054 Home HIT 01/01/98 Home Care Solutions X 0.33 6456 W. Archer Ave. Chicago IL 60638 (773) 229-93001622112 Home HIT 12/01/03 Ingalls Home Care Infusion X 0.33 1 Ingalls Drive Harvey IL 60426 (708) 331-0226 P 12/08/038223260 Home HIT 08/01/01 IV Care LLC X 0.33 65 S. 65th Street Belleville IL 62223 (618) 398-2720 A 10/05/01

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev. 08-2014

Page 36: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

4930043 Home HIT 06/01/01 IV Solutions LLC X 0.33 420 Lake Cook Road Deerfield IL 60015 (847) 945-4444 A 08/17/011671580 Home HIT 01/01/98 Loyola Univ Med Ctr Home Care X 0.33 2160 S. First Avenue Maywood IL 60153 (708) 216-4983 N 02/01/991620168 Home HIT 05/05/03 MacNeal Infusion Therapy X 0.33 3249 S. Oak Park Ave. Berwyn IL 60402 (708) 447-3555 A 01/13/068470416 Home HIT 04/01/98 Memorial Home Care X 0.33 644 N. Second Street Springfield IL 62702 (217) 788-46631634065 Home HIT 01/01/06 Metro Infectious Disease Consultants X 0.33 500 E. Ogden Ave. Hinsdale IL 60521 (630) 654-4201 A 01/13/06

4930161 Home HIT 07/24/01Option Care Enterprises dba Walgreens Infusion Services X 0.33 1226 Michael Drive Wood Dale IL 60191 (800) 551-9355 N/AD 01/01/12

4930161 Home HIT 11/01/10 12/05/13Option Care Enterprises dba Walgreens Infusion Services X 0.33 1221 Arrowhead Cour Crown Point IN 46307 (800) 883-3394 C 04/01/14

3715472 Home HIT 01/15/13Option Health dba Bioscript Infusion Services X 0.33 321 W. Lake St Elmhurst IL 60126 (630) 617-0034 AL 02/01/13

90000733 Home HIT 01/01/98 10/31/10 OptionCare Inc, Indiana X 0.33 9111 Broadway Merrillville IN 46410 (219) 736-1928 C 11/01/103715472 Home HIT 01/01/98 OptionCare Inc, Moline X 0.33 5111 22nd Avenue Moline IL 61265 (309) 762-79792233468 Home HIT 02/04/08 Orsini Pharmaceutical Services X 0.33 2450 Delta Lane Elk Grove Village IL 60007 (847) 879-9550 A 05/01/087215176 Home HIT 07/01/13 OSF Home Infusion Pharmacy X 0.33 2265 W Altorfer Dr Peoria IL 61615 (309) 683-7700 A 08/01/137215176 Home HIT 07/01/13 OSF Home Infusion Pharmacy X 0.33 9951 Rock Cut Crossing Loves Park IL 61111 (309) 692-4731 AL 08/01/131618719 Home HIT 01/01/10 Pri-Med Infusion Services X 0.33 5517 N Cumberland Ave. Chicago IL 60656 (773) 467-6000 A 02/01/104630122 Home HIT 08/01/01 Riverside Home Infusion X 0.33 350 N. Wall Street Kankakee IL 60901 (815) 935-7505 A 11/29/014523585 Home HIT 10/01/02 Sherman Home Care Partners X 0.33 1019 E. Chicago Street Elgin IL 60120 (847) 429-6200 A 01/13/068422219 Home HIT 06/01/01 St. Johns Home Infusion X 0.33 800 E. Carpenter Street Springfield IL 62702 (217) 525-5641 A 08/01/01

10132144 Home HIT 01/12/05 Swedish American Infusion Serv. X 0.33 2550 Charles Street Rockford IL 61108 (815) 391-7575 P 03/08/051670830 Home HIT 01/01/98 10/31/13 Ultra Care X 0.33 2001 Janice Avenue Melrose Park IL 60160 (708) 273-4100 C 05/01/142222890 Home HIT 09/01/00 01/01/11 Valley Infusion Care LLC X 0.33 1815 W. Diehl Road Naperville IL 60563 (630) 355-5630 C 01/01/124520900 Home HIT 01/01/98 VNA of Fox Valley X 0.33 1245 Corporate Blvd Aurora IL 60505 (630) 978-98352234465 Home HIT 05/01/10 Walgreens Specialty Pharmacy X 0.33 2050 S. Finley Road Lombard IL 60148 (630) 495-2777 A 07/01/10

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev. 08-2014

Page 37: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

50417 Hospice 01/31/06 09/11/13 A Touch of Grace Hospice X * 8250 S. Cicero Ave. Burbank IL 60459-1510 (312) 733-2317 C 10/01/139519 Hospice 01/01/98 Advocate Hospice X * 1441 Branding Avenue Downers Grove IL 60515 (630) 963-6800

51558 Hospice 05/01/10 Alexian Brothers Hospice X * 1515 E Lake St. Hanover Park IL 60133-7152 (630) 233-5100 A 06/01/1052042 Hospice 03/01/13 Angels Grace Hospice LLC X * 440 Quadrangle Drive Bolingbrook IL 60440 (888) 444-8341 TE 06/01/1352036 Hospice 04/01/13 APEX Hospice and Palliative Care Inc. X * 2607 W 22nd St Oak Brook IL 60523-4634 (630) 601-1280 N 11/01/1353974 Hospice 11/01/13 BJC Home Care Services X * 1 Professional Dr. Alton IL 62002 (314) 747-8600 A 03/01/1458572 Hospice 11/01/13 Blessing Hospice and Palliative X * 936 Broadway Quincy IL 62301 (217) 223-8400 A 02/01/1450240 Hospice 11/01/03 Blue Skies Hospice X * 2712 169th Street Hammond IN 46323-1433 (219) 554-0688 TE 04/01/1450010 Hospice 07/01/01 BroMenn Hospice X * 1322 S. Main Normal IL 61761-3442 (309) 888-0930 A 10/05/019517 Hospice 01/01/98 Carle Hospice X * 206A West Anthony Dr. Champaign IL 61822-1218 (217) 383-31519571 Hospice 11/01/98 Cass-Schuyler Area Hospice X * 331 S. Main Virginia Il 62691 (217) 452-3057 A 02/01/99

51255 Hospice 05/01/09 CNS Home Health and Hospice X * 690 East North Avenue Carol Stream IL 60188-2172 (630) 665-7000 A 06/01/099525 Hospice 01/01/98 Community Nursing Serv.of DuPage County X * 690 E. North Avenue Carol Stream IL 60188 (630) 665-70009545 Hospice 01/01/98 Decatur Mem. Hosp. Hospice X * 2300 N. Edward St. Decatur IL 62526 (217) 876-6770

51151 Hospice 03/01/09 Family Centered Hospice X * 2171 Executive Drive Addison IL 60101 (630) 317-3300 A 03/01/099544 Hospice 01/01/98 Family Hospice of Belleville Area X * 5110 W. Main Street Belleville IL 62226 (618) 277-1800

50364 Hospice 05/01/05 Fayette County Health Dept X * 416 West Edwards St. Vandalia IL 62471-2707 (618) 283-1044 A 08/03/0551627 Hospice 09/01/10 03/01/13 Franciscan Hospice of Central Illinois X * 608 N Ladd St. Pontiac IL 61764-6982 (815) 844-6982 C 03/01/139546 Hospice 01/01/98 Freeport Memorial Hospice X * 1045 W. Stephenson Freeport IL 61032 (815) 233-6100

51150 Hospice 02/01/09 Gateway Regional Hospice Granite City X * 2100 Madison Granite City IL 62040 (618) 798-3399 PN 05/01/0950223 Hospice 07/01/03 10/01/13 Generations Healthcare, LLC X * 2 Westbrook Corp. Ct Westchester IL 60154 (708) 409-3040 C 10/01/1350209 Hospice 03/01/03 Gentiva Hospice X * 9415 S. Western Ave. Chicago IL 60620 (773) 445-7528 N 05/01/1451569 Hospice 05/01/10 Gentiva Hospice X * 4 Westbrook Corp Ct Westchester IL 60154-5721 (708) 409-3040 N 05/01/1450654 Hospice 08/01/07 Good Heart Hospice, Inc. X * 1550 N. Northwest Hwy. Park Ridge Il 60068 (847) 803-0400 A 02/01/089559 Hospice 09/01/13 Gottlieb Hospice X * 701 W. North Ave Melrose Park IL 60160 (708) 450-5072 R 09/01/13

51451 Hospice 10/01/09 Guardian Healthcare and Hospice X * 1775 Winnetka Road Northfield IL 60093 (847) 446-0000 A 12/01/09

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 38: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

9562 Hospice 01/01/98 Harbor Light Hospice X * 800 Roosevelt Road Glen Ellyn IL 60137 (800) 419-0542 N50409 Hospice 10/01/05 Heartland Home Health Care X * 333 Salem Plaza Fairview Heights IL 62208 (618) 632-0364 N 08/03/069547 Hospice 01/01/98 09/30/11 Heartland Home Health Care and Hospice X * 333 Salem Plaza Fairview Heights IL 62208 (618) 632-0304 C 11/01/11

51571 Hospice 06/01/10 Heartland Home Healthcare & Hospice X * 220 N Smith St. Palatine IL 60067-2477 (847) 272-7338 TE 02/01/1451572 Hospice 06/01/10 Heartland Home Healthcare & Hospice X * 20646 Abbey Wood Ct. Frankfort IL 60423-3166 (815) 806-1000 A 07/01/1050336 Hospice 06/01/06 Heartland Hospice Service X * 363 Financial Court Rockford IL 61107 (815) 227-4917 AD 09/01/1350409 Hospice 10/01/05 Heartland Hospice Services X * 4415 W. Harrison Hillside IL 60162 (708) 234-2800 N 07/01/1051574 Hospice 06/10/10 Heartland Hospice Services X * 1426 10th Ave. . Fulton IL 61252 (815) 589-9900 AD 03/01/1151599 Hospice 08/01/10 Henderson County Health Department Hospice X * 208 W Elm St. Gladstone IL 61437-0220 (309) 627-2812 A 09/01/109512 Hospice 01/01/98 Horizon Hospice X * 833 W. Chicago Avenue Chicago IL 60642 (312) 733-2233 AD 11/01/12

50370 Hospice 05/01/05 Hospice Care of America X * 3815 N. Mulford Rd Rockford IL 61114 (815) 316-2700 AD 05/01/109573 Hospice 02/01/99 Hospice COMPASSUS X * 1640 N. Henderson St. Galesburg IL 61401 (309) 342-3007 N 05/01/129524 Hospice 01/01/98 Hospice of Kankakee Valley X * 482 Main Street N.W. Bourbonnais IL 60914 (815) 393-41419542 Hospice 01/01/98 Hospice of Rock River Valley X * 264 IL Rt. 2 Dixon IL 61021 (815) 288-36739522 Hospice 01/01/98 Hospice of Southeastern IL X * 800 East Locust Olney IL 62450 (618) 395-21319510 Hospice 01/01/98 Hospice of Southern X * 305 S. Illinois Belleville IL 62220 (618) 235-17039537 Hospice 01/01/98 Hospice of the Calumet Area X * 600 Superior Avenue Munster IL 46321 (219) 922-27329536 Hospice 01/01/98 Hospice of the Calumet Area X * 3224 Ridge Road Lansing IL 60438 (708) 895-83329564 Hospice 01/01/98 Hospice of the Wabash Valley X * 600 South First St. Terre Haute IN 47807 (812) 232-7611 N 10/01/009558 Hospice 01/01/98 Illinois Valley Hospice X * 1701 Fourth Street Peru IL 61354 (815) 224-13079530 Hospice 01/01/98 Ingalls Home Hospice X * One Ingalls Drive Harvey IL 60426 (708) 331-0226

53921 Hospice 11/01/13 Integrated Palliative Hospice LLC X * 900 Technology Way Libertyville IL 60048 (847) 549-0588 A 01/01/1450344 Hospice 03/01/05 Iroquois Memorial Hospice X * 200 Fairman Avenue Watseka IL 60970-1644 (815) 432-0185 A 06/07/059518 Hospice 01/01/98 Joliet Area Community Hospice X * 250 Waterstone Circle Joliet IL 60431 (815) 740-41049511 Hospice 01/01/98 Journeycare Inc. X * 405 Lake Zurich Road Barrington IL 60010 (847) 381-5599 N 10/01/139580 Hospice 05/01/01 KishHealth System Hospice X * 2727 Sycamore Road DeKalb IL 60115 (815) 758-8673 N 04/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev. 08-2014

Page 39: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50453 Hospice 08/01/06 Lexington Hospice Services, LLC X * 665 W. North Ave. Lombard IL 60148 (630) 652-7900 AD 06/01/129576 Hospice 08/10/99 Lincolnland Hospice of Sarah Bush X * 700 E. Broadway Mattoon IL 61938 (217) 235-4063 N 12/01/99

51489 Hospice 12/01/09 Loving Hands Hospice Inc. X * 6535 N. Olmsted Ave Chicago IL 60631-1414 (773) 775-1536 A 02/01/109538 Hospice 01/01/98 Loyola University Center for HC X * 2160 S. 1st Avenue Maywood IL 60153 (708) 216-4983

50502 Hospice 10/01/06 Maximum Hospice Palliative Care X * 2959 W. 95th Street Evergreen Park IL 60805-2409 (708) 952-1900 A 03/30/079575 Hospice 12/20/09 Memorial Home Services NFP X * 720 N. Bond Street Springfield IL 62702 (217) 523-4113 N 03/01/109539 Hospice 01/01/98 Memorial Hospice X * 855 N. Church Court Elmhurst IL 60126 (630) 530-1201

50758 Hospice 07/30/08 02/29/12 MetroSouth Hospice X * 12935 Gregory Street Blue Island IL 60406 (708) 385-0372 CP 05/01/1251881 Hospice 03/01/12 Metrosouth Hospice X * 12945 Gregory St Blue Island IL 60406 (708) 385-0372 P 05/01/129516 Hospice 11/01/06 Midwest Palliative & Hopice Care Center X * 2050 Clarie Court Glenview IL 60025 (847) 467-7423 N 08/15/07

50365 Hospice 05/01/05 Monarch Hospice & Palliative Care X * 33 W Higgins Road South Barrington IL 60010 (847) 885-1818 AD 04/01/149579 Hospice 04/01/00 Northern Illinois Hospice Assoc. X * 6930 W. Touhy Ave. Niles IL 60714 (815) 398-0500 A 05/12/00

51141 Hospice 12/27/08 Northshore University Health Systen Home and Hospice X * 4901 Searle Parkway Skokie IL 60077-1041 (847) 581-1717 AD 12/01/099521 Hospice 01/01/98 09/25/13 Northwestern Hospital Hospice X * 303 E. Superior Chicago IL 60611 (312) 908-7476 C 12/01/13

51631 Hospice 09/01/10 OSF Hospice X * 3405 N Seminary Galesburg IL 61401-1216 (309) 344-3161 A 12/01/1051630 Hospice 09/01/10 OSF Hospice X * 2265 W Altorfer Drive Peoria IL 61615-1807 (309) 683-7703 A 12/01/1051628 Hospice 09/01/10 OSF Hospice X * 9951 Rock Cut Crossing Loves Park IL 61111-1999 (815) 921-8700 A 12/01/1051629 Hospice 09/01/10 OSF Hospice Eastern Region X * 211 N Landmark Normal IL 61704 (309) 451-5925 AD 05/01/139554 Hospice 01/01/98 Ottawa Regional Hospice X * 1601 Mercury Circle Ottawa IL 61350 (815) 433-6096 N, AD 10/01/09

51212 Hospice 03/01/09 Passages Hospice LLC X * 134 N. McLean Blvd. Elgin IL 60123 (847) 742-8822 A 05/01/0959455 Hospice 11/01/13 Preferred Home Health Care X * 150 W South St Kewanee IL 61443-3749 (309) 853-8000 A 02/01/149565 Hospice 01/01/98 Premier Hospice, Inc. X * 432 N. Halleck DeMotte IN 64310 (219) 324-77339565 Hospice 01/01/98 Premier Hospice, Inc. X * 1600 W. 167th Street Calumet City IL 60409 (708) 868-69609565 Hospice 01/01/98 Premier Hospice, Inc. X * 1205 W. 81st Merrillville IN 46410 (219) 756-76409565 Hospice 01/01/98 Premier Hospice, Inc. X * 1319 Lake Street LaPorte IN 46350 (219) 324-7733

50216 Hospice 01/01/98 Presence Hospice - Elgin X * 799 S. McLean Blvd. Elgin IL 60123 (847) 695-3200 N & AD 10/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3

Rev. 08-2014

Page 40: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

6 Hospice 01/01/98 Presence Saint Mary and Elizabeth Medical Center X * 2233 W. Division Street Chicago IL 60622-3086 (312) 770-2000 PN 10/01/1150607 Hospice 08/01/06 Presense Hospice - Urbana X * 1501 Interstate Pkwy. Champaign IL 61821 (217) 337-2273 N & AD 10/01/1351648 Hospice 09/01/10 Providence Hospice X * 16300 Louis Ave. South Holland IL 60473 (708) 331-0400 A 01/01/1151889 Hospice 03/01/12 Quad County Hospice X * 1 Huber St. Pana IL 62557-1721 (217) 562-6380 A 05/01/129523 Hospice 01/01/98 Rainbow Hospice and Palliative Care X * 444 N. Northwest Hwy. Park Ridge IL 60068 (847) 699-2000 N 12/01/099570 Hospice 08/01/98 Seasons Hospice X * 6400 Shafter Ct Rosemont IL 60018-4989 (847) 759-9449 AD 12/01/09

50047 Hospice 12/01/01 Serenity Hospice and Home X * 1658 So. Route 2 Oregon IL 61061-0462 (815) 732-2499 N & AD 03/01/1250920 Hospice 07/01/08 Southern Illinois Homecare and Hospice X * 129 North 8th Street East St. Louis IL 62201 (618) 482-71479526 Hospice 01/01/98 Spoon River Hospice X * 210 W. Walnut Canton IL 61520 (309) 647-5240

50671 Hospice 01/01/08 SSM Home Care of Illinois X * 605 N. 12th Street Mt. Vernon IL 62864-2857 (618) 241-1612 N 03/01/1150700 Hospice 01/01/08 SSM Hospice of the Good Samaritan X * 605 N. 12th Street Mt. Vernon IL 62864-2857 (618) 241-1621 A 03/10/0850557 Hospice 02/01/10 St. Anthony Hospice X * 203 Franciscan Drive Crown Point IN 46307 (219) 661-5306 A 01/01/139577 Hospice 11/14/99 St. John's Hospital X * 800 E. Carpenter Springfield IL 62769 (217) 544-6464 A 12/01/999513 Hospice 01/01/98 St. Thomas Hospice X * 8230 S. Madison Street Burr Ridge IL 60521 (630) 856-6990 TE 05/01/10

50711 Hospice 05/01/08 The MDH Hospice X * 525 E. Grant Street Macomb IL 61455 (309) 833-4107 A 05/01/0851332 Hospice 08/01/09 Transitions Hospice LLC X * 5100 E State St. Rockford IL 61108 (815) 637-2200 A 08/01/099555 Hospice 01/01/98 05/21/12 Unity Hospice X * 439 East 31st Street Chicago IL 60616 (312) 949-1188 C 06/01/12

50444 Hospice 04/01/06 Unity Hospice of Chicagoland X * 439 E. 31st Street Chicago IL 60616 (312) 949-1188 A 08/03/0650445 Hospice 04/01/06 Unity Hospice of Greater St. Louis X * 907 N. Bluff Road Collinsville IL 62234 (618) 346-1111 A 08/03/0650443 Hospice 04/01/06 Unity Hospice of Northwest IN X * 7863 Broadway Merrillville IN 46410-5554 (219) 769-8648 A 08/03/0650442 Hospice 04/01/06 Unity Hospice of Western IL X * 1201 S. 7th Street Rochelle IL 61068 (815) 561-8866 A 08/03/069550 Hospice 01/01/98 Unity Point Hospice X * 106 19th Ave Moline IL 61265-3700 (309) 779-7600 AD, N 02/01/119578 Hospice 02/01/00 VHS of Illinois Inc. X * 7222 W. Cermak North Riverside IL 60546 (708) 447-3555 PN 05/01/00

51860 Hospice 02/01/12 Vitas Healthcare Corp Midwest X * 8 Executive Dr. Fairview Heights IL 62208-1348 (618) 622-9073 A 04/01/1251250 Hospice 05/01/09 Vitas Healthcare Corp of Illinois X * 8525 W. 183rd St. Tinley Park IL 60487 (708) 781-4400 N & AD 03/01/1250158 Hospice 09/01/04 Vitas Healthcare of Illinois X * 580 Waters Edge Lombard IL 60148 (800) 938-4827 N 08/03/05

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4

Rev. 08-2014

Page 41: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51248 Hospice 05/01/09 Vitas Innovative Hospice Care - Chicago X * 1340 S Damen Ave. Chicago IL 60608-1170 (312) 997-7200 A 06/01/0951249 Hospice 05/01/09 Vitas Innovative Hospice Care - LaSalle X * 105 Marquette St. LaSalle IL 61301-2474 (815) 220-0021 A 06/01/099569 Hospice 06/01/98 VNA Hospice Homcare X * 2401 Valley Drive Valparaiso IN 46383 (219) 462-5195 N & AD 04/01/109532 Hospice 01/01/98 VNA Hospice of Rockford X * 4223 East State St. Rockford IL 61108 (815) 229-11009533 Hospice 01/01/98 VNA of Fox Valley Hospice X * 1245 Corporate Blvd Aurora IL 60505 (630) 978-2532

50217 Hospice 10/01/13 VNA Tip Hospice X * 217 E. Center Drive Alton IL 62002-5946 (618) 467-2080 A 12/01/1350456 Hospice 07/01/06 Waukegan Hospice Corp. X * 2645 Washington St. Waukegan IL 60085 (847) 360-2220 N 03/01/11

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association*Hospice day charge depends on the type of utilization

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5

Rev. 08-2014

Page 42: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date90 IP Metro 01/01/96 Adventist Glen Oaks Hospital I 1 701 Wintrop Ave. Glendale Heights IL 60139-1405 (630) 545-8000 N 05/08/0620 IP Metro 01/01/96 Adventist Hinsdale Hospital I 1 120 North Oak Hinsdale IL 60521-3829 (630) 856-9000 N 05/08/06

50667 IP Metro 01/07/08 Adventist Hospital Bolingbrook I 1 500 Remington Blvd Bolingbrook IL 60440-4906 (630) 312-5000 A 02/01/08399 IP Metro 02/01/99 Adventist LaGrange Memorial Hospital I 1 5101 S. Willow Spring Rd. LaGrange IL 60525-2600 (708) 352-1200 N 05/08/06

16 IP Metro 01/01/95 06/30/10 Advocate Bethany Hospital I 1 3435 W. Van Buren Chicago IL 60624-3359 (773) 878-9700 CP 08/01/1051046 IP Metro 12/01/08 Advocate Condell Medical Center I 1 801 S. Milwaukee Avenue Libertyville IL 60048-3204 (847) 362-2900 A 01/01/0951914 IP Metro 07/01/12 Advocate Hope Children's Hospital I 1 4440 West 95th Street Oak Lawn IL 60453-2600 (708) 684-8000 A 09/01/12

410 IP Metro 11/04/00 Advocate Illinois Masonic Medical Center I 1 836 Wellington Ave. Chicago IL 60657-5147 (773) 975-1600 PN 12/01/0051915 IP Metro 07/01/12 Advocate Lutheran General Childrens I 1 1775 Dempster Street Park Ridge IL 60068-1143 (847) 723-2210 A 09/01/12

63 IP Metro 01/01/96 Advocate Sherman Hospital I 1 1425 N Randall Road Elgin IL 60120-2125 (847) 742-9800 N 07/01/13402 IP Metro 02/01/99 Alexian Brothers Behavioral Health Hospital I 1 1650 Moonlake Blvd. Hoffman Estates IL 60194-1010 (847) 882-1600 N 05/01/99368 IP Metro 01/01/96 Alexian Brothers Medical Center I 1 800 West Biesterfield Road Elk Grove Village IL 60007-3311 (847) 437-5500

50033 IP Metro 10/18/01 Aurora Chicago Lakeshore Hospital I 1 4840 North Marine Drive Chicago IL 60640-4220 (773) 878-9700 PN 01/23/02319 IP Metro 01/01/96 Centega Hospital McHenry I 1 4201 Medical Center Dr. McHenry IL 60050-8409 (815) 344-5000 N 01/01/09

79 IP Metro 01/01/96 Centegra Hospital Woodstock I 1 3701 Doty Road Woodstock IL 60098-3756 (815) 338-2500 N 01/01/09363 IP Metro 01/01/96 Central DuPage Hospital I 1 25 North Winfield Road Winfield IL 60190 (630) 682-1600339 IP Metro 01/01/96 Christ Hosp. & Med. Ctr. - Advocate I 1 4440 West 95th Street Oak Lawn IL 60453-2600 (708) 684-8000

10 IP Metro 01/01/96 Copley Memorial Hospital, Inc. I 1 2000 Ogden Ave. Aurora IL 60504-7222 (630) 978-6200 N 03/01/139 IP Metro 01/01/96 Delnor Community Hospital I 1 300 Randall Road Geneva IL 60134-4200 (630) 208-3000

312 IP Metro 01/01/96 Edward Hospital I 1 801 South Washington Street Naperville IL 60540-7430 (630) 355-045012 IP Metro 01/01/96 Elmhurst Memorial Hospital I 1 200 Berteau Avenue Elmhurst IL 60126-2966 (630) 833-140077 IP Metro 01/01/96 Good Samaritan Hospital - Advocate I 1 3815 Highland Avenue Downers Grove IL 60515-1500 (630) 275-5900

109 IP Metro 01/01/96 Good Shepherd Hospital - Advocate I 1 450 West Highway 22 Barrington IL 60010 (847) 381-9600341 IP Metro 01/01/96 Gottlieb Memorial Hospital I 1 701 West North Ave. Melrose Park IL 60160-1612 (708) 681-3200352 IP Metro 04/16/99 Hartgrove Hospital I 1 5730 West Roosevelt Road Chicago IL 60644 (773) 413-1700 AD 05/01/08

21 IP Metro 01/01/96 Holy Cross Hospital I 1 2701 West 68th Street Chicago IL 60629-1813 (773) 471-800025 IP Metro 01/01/96 Ingalls Memorial Hospital I 1 One Ingalls Drive Harvey IL 60426-3558 (708) 333-230026 IP Metro 01/01/96 Jackson Park Hospital I 1 7531 Stony Island Avenue Chicago IL 60649-3913 (773) 947-7500

Appendix D HMO Illinois, Blue Advantage and Blue Precision MO Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel - prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 43: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage and Blue Precision MO Contracting Providers

1 IP Metro 11/01/97 John H. Stroger Jr Hospital Cook County I 1 1835 W. Harrison Street Chicago IL 60612 (312) 633-6000 N 08/31/05160 IP Metro 01/01/96 LaRabida Children's Hospital I 1 6501 Promontory Drive Chicago IL 60649-1326 (773) 363-6700497 IP Metro 01/01/96 Linden Oaks Hospital I 1 852 West Street Naperville IL 60540-6400 (630) 305-5500

30 IP Metro 01/01/96 Little Company of Mary Hospital I 1 2800 West 95th Street Evergreen Park IL 60805-2701 (708) 422-620031 IP Metro 01/01/96 Loretto Hospital I 1 645 South Centeral Chicago IL 600644-5059 (773) 626-4300

50073 IP Metro 01/01/96 Louis A. Weiss Memorial Hospital I 1 4646 North Marine Drive Chicago IL 60640-5700 (773) 878-8700 P 07/09/02500 IP Metro 01/01/96 Loyola University Med. Ctr. I 1 2160 South First Ave. Maywood IL 60153-3304 (708) 216-9000333 IP Metro 01/01/96 Lutheran General Hospital I 1 1775 Dempster Street Park Ridge IL 60068-1143 (847) 723-2210405 IP Metro 02/01/00 MacNeal Memorial Hospital I 1 3249 S. Oak Park Ave. Berwyn IL 60402-3429 (708) 783-9100 P 05/01/00

7 IP Metro 04/12/99 Marianjoy Rehab. Hospital I 1 26 West 171 Roosevelt Rd. Wheaton IL 60187-0795 ( 63) 909-8000 TE 09/01/1235 IP Metro 01/01/96 Mercy Hospital & Medical Center I 1 2525 S. Michigan Ave. Chicago IL 60616 (312) 567-200085 IP Metro 01/01/03 Methodist Hospital of Chicago I 1 5025 N. Paulina St. Chicago IL 60640-2772 (773) 271-9040 A 05/01/03

50874 IP Metro 07/30/08 02/29/12 Metrosouth Medical Center I 1 12935 S Gregory St. Blue Island IL 60406 (708) 597-2000 CP 05/01/1251880 IP Metro 03/01/12 Metrosouth Medical Center I 1 12935 S Gregory St. Blue Island IL 60406-2428 (708) 597-2000 P 05/01/12

38 IP Metro 01/01/96 Mount Sinai Hospital Medical Center I 1 California Avenue at 15th St. Chicago IL 60608-1797 (773) 542-200050135 IP Metro 01/01/03 Neurological and Orthopedic Institute I 1 4501 North Winchester Ave. Chicago IL 60640-5205 (773) 878-4300 AD 05/01/12

15 IP Metro 01/01/96 NorthShore University Healty System I 1 2650 Ridge Avenue Evanston IL 60201-1718 (847) 570-2000 N 10/01/08334 IP Metro 01/01/96 Northwest Community Health Care I 1 800 W. Central Rd. Arlington Hgts IL 60005-2349 (847) 618-1000

87 IP Metro 01/01/96 Northwestern Memorial Hospital I 1 Superior Street at Fairbanks Chicago IL 60611-2914 (312) 908-200039 IP Metro 01/01/96 Norwegian American I 1 1044 North Francisco Ave. Chicago IL 60622-2743 (773) 278-880048 IP Metro 11/01/97 Oak Forest Hospital of Cook County I 1 15900 S. Cicero Ave. Oak Forest IL 60452 (847) 928-4200 A 07/01/9952 IP Metro 01/01/96 Palos Community Hospital I 1 12251 South 80th Ave. Palos Heights IL 60463-1256 (708) 923-4000 TE 11/01/1256 IP Metro 01/01/96 Presence St. Joseph Med. Center I 1 333 North Madison St. Joliet IL 60435 (815) 725-7133 N 10/01/13

200 IP Metro 05/01/02 Presence Convant Medical Center I 1 1400 W. Park Street Urbana IL 61801-2334 (217) 337-2000 N 10/01/1357 IP Metro 01/01/96 Presence Mercy Medical Center I 1 1325 North Highland Ave. Aurora IL 60506-1449 (630) 859-2222 N 12/01/13

316 IP Metro 01/01/96 Presence Our Lady of the Resurrection Med. Ct. I 1 5645 W. Addison Street Chicago IL 60634-4403 (773) 282-7000 N 10/01/1355 IP Metro 01/01/96 Presence Provena St. Joseph Hospital I 1 77 North Airlite Street Elgin IL 60123-4912 (847) 695-3200 N 10/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel - prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev. 08-2014

Page 44: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage and Blue Precision MO Contracting Providers

269 IP Metro 01/01/96 Presence Resurrection Medical Center I 1 7435 West Talcott St. Chicago IL 60631-3702 (773) 774-8000 N 10/01/13

6 IP Metro 01/01/96Presence Saint Mary and Elizabeth Medical Center I 1 2233 W. Division Street Chicago IL 60622-3043 (312) 770-2000 PN 10/01/11

6 IP Metro 11/01/09Presence Saint Mary and Elizabeth Medical Center I 1 1431 N. Claremont Ave. Chicago IL 60622-1702 (773) 278-2000 PN 10/01/13

51 IP Metro 01/01/96 Presence St. Francis Hospital (Evanston) I 1 355 Ridge Avenue Evanston IL 60202-3328 (847) 492-4000 N 10/01/13415 IP Metro 06/30/01 Presence St. Joseph Hospital I 1 2900 North Lake Shore Dr. Chicago IL 60657-5640 (773) 665-3000 N 10/01/13

60 IP Metro 05/01/02 Presence St. Mary's Hospital I 1 500 W. Court S. Kankakee IL 60901-3661 (815) 937-2490 N 10/01/1393 IP Metro 11/01/97 Provident Hospital of Cook County I 1 500 East 51st Street Chicago IL 60615 (312) 572-2000 A 07/01/99

354 IP Metro 01/01/96 Rehab. Institute of Chicago I 1 345 East Superior St. Chicago IL 60611-3015 (312) 908-6000406 IP Metro 03/01/00 Riveredge Hospital I 1 8311 West Roosevelt Rd. Forest Park IL 60130-2529 (708) 771-7000 PN 05/01/00

45 IP Metro 10/12/05 Roseland Community Hospital I 1 45 West 111th Street Chicago IL 60628 (773) 995-3000 R 01/13/0640 IP Metro 01/01/96 Rush Oak Park Hospital I 1 520 South Maple Ave. Oak Park IL 60304-1022 (708) 383-9300

50462 IP Metro 10/01/06 Rush-University Medical Center I 1 1653 West Congress Parkway Chicago IL 60612-3809 (312) 942-5000 P 08/15/0792 IP Metro 10/01/97 07/19/13 Sacred Heart Hospital I 1 3240 W. Franklin Blvd. Chicago IL 60624 (773) 772-3020 C 12/01/13

353 IP Metro 01/01/96 Schwab Rehabilitation Hospital I 1 1401 S. California Ave. Chicago IL 60608-1612 (773) 522-201051994 IP Metro 01/01/13 Shriners Hospitals for Children I 1 2211 North Oak Park Ave Chicago IL 60707-3351 (773) 622-5400 A 01/01/13

64 IP Metro 01/01/96 Silver Cross Hospital I 1 1900 Silver Cross Blvd. New Lenox IL 60451-9509 (815) 300-1100 TE 08/01/1251076 IP Metro 01/01/09 Skokie Hospital I 1 9600 Gross Point Road Skokie IL 60076-1214 (847) 677-9600 PN 03/01/09

66 IP Metro 01/01/96 South Shore Hospital I 1 8012 S. Crandon Chicago IL 60617-1151 (773) 768-0810259 IP Metro 01/01/96 South Suburban Hospital - Advocate I 1 17800 S. Kedzie Ave. Hazel Crest IL 60429-2029 (708) 799-8000398 IP Metro 02/01/99 St. Alexius Med. Center I 1 1555 N. Barrington Rd. Hoffman Estates IL 60194-1018 (847) 843-2000 A 04/01/99210 IP Metro 01/01/96 St. Anthony Hospital I 1 2875 W. 19th Street Chicago IL 60623-3501 (773) 521-1710

47 IP Metro 01/01/96 St. Bernard Hospital I 1 326 West 64th Street Chicago IL 60621-3119 (773) 962-390050 IP Metro 01/01/96 St. Francis Hospital (Blue Island) I 1 12935 S. Gregory Blue Island IL 60406-2428 (708) 597-2000 PN 09/01/08

404 IP Metro 01/08/00 06/30/11 St. James Hosp.& Health Ctrs-Olympia Fields I 1 20201 S. Crawford Olympia Field IL 60461-0100 (708) 747-4000 CP 08/01/1153 IP Metro 01/01/96 St. James Hospital I 1 1423 Chicago Road Chicago Hgts IL 60411-3400 (708) 756-1000

50061 IP Metro 03/01/14 Streamwood Hospital I 1 1400 E. Irving Park Road Streamwood IL 60107 (630) 837-9000 A 05/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel - prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3

Rev. 08-2014

Page 45: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage and Blue Precision MO Contracting Providers

67 IP Metro 01/01/96 Swedish Covenant Hospital I 1 5145 N. California Ave. Chicago IL 60625-3642 (773) 878-820080 IP Metro 01/01/96 The Ann and Robert H. Lurie Children's Hospital I 1 225 E Chicago Ave. Chicago IL 60611-2605 (312) 227-4000 N 08/01/12

2 IP Metro 01/01/96 Thorek Memorial Hospital I 1 850 West Irving Park Rd. Chicago IL 60613-3011 (773) 525-678065 IP Metro 01/01/96 Trinity Hospital - Advocate I 1 2320 East 93rd Street Chicago IL 60617-3909 (773) 978-2000

401 IP Metro 01/01/96 University of Chgo. Med. Center I 1 5841 Maryland Ave. Chicago IL 60637-1463 (773) 702-1000 TI 10/05/98112 IP Metro 01/01/96 University of Illinois Hospital I 1 1740 West Taylor Street Chicago IL 60612-7232 (312) 996-3892394 IP Metro 01/01/99 Valley West Community Hospital I 1 11 E. Pleasant Sandwich IL 60548 (815) 786-8484 R 02/01/00

51587 IP Metro 08/01/10 VHS West Suburban Medical Center I 1 3 Erie Court Oak Park IL 60302-2510 (708) 383-6200 PN 08/01/1051588 IP Metro 08/01/10 VHS Westlake Hospital Inc I 1 1225 West Lake Street Melrose Park IL 60160-4021 (708) 671-3000 PN 08/01/1050448 IP Metro 07/01/06 Vista Medical Center East I 1 1324 North Sheridan Rd. Waukegan IL 60085-2161 (847) 360-3000 PN 12/28/0650449 IP Metro 07/01/06 Vista Medical Center West I 1 2615 Washington Street Waukegan IL 60085-4916 (847) 249-3900 PN 12/28/06

73 IP Metro 01/01/96 West Suburban Hospital I 1 3 Erie Court Oak Park IL 60302-2510 (708) 383-620074 IP Metro 01/01/96 Westlake Community Hospital I 1 1225 West Lake Street Melrose Park IL 60160-4021 (708) 671-3000

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel - prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4

Rev. 08-2014

Page 46: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date272 IP - State Market 01/01/96 Abraham Lincoln Mem. Hosp. I 1 315 Eighth Street Lincoln IL 62656 (217) 732-2161233 IP - State Market 01/01/96 Alton Memorial I 1 One Memorial Drive Alton IL 62002-6722 (618) 463-739078 IP - State Market 09/01/96 Anderson Hospital I 1 RT 162 & Old Edwardsville Maryville IL 62062 (618) 288-5711

257 IP - State Market 01/01/00 Carlinville Area Hospital I 1 1001 E. Morgan Street Carlinville IL 62626-1448 (217) 854-3141 A 09/01/00822 IP - State Market 04/01/99 Children Hospital of Wisconsin I 1 9000 W. Wisconsin Ave. Milwaukee WI 53226-3518 (414) 266-2000 TI 01/01/01895 IP - State Market 05/01/96 Community Mem. Hospital I 1 W180 N8085 Town Hall Road Menomonee Falls WI 53052 (414) 251-1000131 IP - State Market 01/01/96 Crossroads Comm. Hospital I 1 #8 Doctor's Park Mount Vernon IL 62864-6224 (618) 244-5500810 IP - State Market 01/01/96 Deaconess Hospital I 1 600 Mary Street Evansville IN 47747-0001 (812) 426-3000

52070 IP - State Market 07/01/13 Franciscan Healthcare Munster I 1 701 Superior Ave Munster IN 46321-4037 (219) 922-4200 PN 08/01/1350708 IP - State Market 04/01/08 06/30/13 Franciscan Physicians Hospital LLC I 1 701 Superior Ave Munster IN 46321-4037 (219) 922-4200 CP 08/01/13

838 IP - State Market 01/01/98 Franciscan St. Anthony Health - Crown Point I 1 1201 S. Main Street Crown Point IN 46307 (219) 663-8120 A 01/01/01804 IP - State Market 01/01/96 Franciscan St. Margaret Health - Hammond I 1 5454 Hohman Ave. Hammond IN 46320-1931 (219) 932-2300 N 05/01/11801 IP - State Market 01/01/96 Franciscan St. Margaret Mercy Hospital I 1 U.S. Highway 30 Dyer IN 46311 (219) 865-2141 N 05/01/11

50078 IP - State Market 07/27/07 Franklin Hospital I 1 201 Bailey Lane Benton IL 62812-1969 (618) 439-3161 P 02/01/0814 IP - State Market 01/01/96 Good Samaritan Reg. Health Ctr. I 1 1 Good Samaritan Way Mount Vernon IL 62864-2857 (618) 242-4600 AD 10/01/13

298 IP - State Market 01/01/96 Heartland Regional Medical Center I 1 917 West Main Street Marion IL 62959-1836 (618) 997-5341 N 03/07/03140 IP - State Market 01/01/96 Herrin Hospital I 1 201 S. 14th Street Herrin IL 62948-2857 (618) 942-2171275 IP - State Market 07/01/97 Jersey Community Hospital I 1 400 Maple Summit Road Jerseyville IL 62052-2028 (618) 498-640259 IP - State Market 07/01/96 Kishwaukee Community Hosp. I 1 626 Bethany Road DeKalb IL 60115 (815) 756-1521

212 IP - State Market 08/01/96 06/30/11 Lawrence County Mem. Hospital I 1 2200 West State Lawrenceville IL 62439 (618) 943-1000 C 10/01/1350878 IP - State Market 02/27/09 Lincoln Prairie Behavioral Health Center I 1 5230 S. Sixth St. Springfield, IL 62707 (217) 585-1180 A 04/01/09

237 IP - State Market 01/01/96 Memorial Hosp. of Carbondale I 1 405 West Jackson Street Carbondale IL 62901-2904 (618) 549-0721347 IP - State Market 01/01/96 Memorial Hospital I 1 1900 State Street Chester IL 62233-1116 (618) 826-4581327 IP - State Market 07/01/97 Memorial Hospital Belleville I 1 4500 Memorial Drive Belleville IL 62226-5399 (618) 233-7750175 IP - State Market 01/01/00 Memorial Medical Center I 1 701 N. 1st Street Springfield IL 62702-3757 (217) 788-3000 A 09/01/00196 IP - State Market 01/01/96 Mercy Harvard Hospital I 1 901 Grant Street Harvard IL 60033 (815) 943-5431 N 02/01/08

HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers Appendix D

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel-prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 47: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers Appendix D

880 IP - State Market 04/01/06 Mercy Hospital of Janesville I 1 1000 Mineral Point Avenue Janesville IL 53548-2940 (608) 756-6625 A 12/28/06802 IP - State Market 01/01/96 Methodist Hospital I 1 600 Grant Street Gary IN 46402-6001 (219) 886-4000828 IP - State Market 01/01/96 Methodist Hospital Southlake I 1 8701 Broadway Merrillville IN 46410-7035 (219) 738-5500116 IP - State Market 01/01/03 Methodist Medical Center of Illinois I 1 221 NE Glen Oak Ave. Peoria IL 61636-0001 (309) 672-5522 A 03/07/03230 IP - State Market 01/01/00 Passavant Memorial. Area Hosp. I 1 1600 W. Walnut Jacksonville IL 62650-1136 (217) 245-9551 A 09/01/00240 IP - State Market 01/01/96 Presence United Samaritan Medical Center I 1 812 North Logan Danville IL 61832-3716 (217) 443-5000 N 10/01/13117 IP - State Market 01/01/96 Proctor Community Hospital I 1 5409 North Knoxville Ave. Peoria IL 61614-5016 (309) 691-4702 N 02/01/08

50021 IP - State Market 03/01/02 Red Bud Regional Hospital I 1 325 Spring Street Red Bud IL 62278 (618) 282-3831 A 06/01/04360 IP - State Market 01/01/96 Riverside Medical Development I 1 350 North Wall Street Kankakee IL 60901-2901 (815) 933-1671859 IP - State Market 01/01/96 SSM Rehabilitation Institute I 1 6420 Clayton Road St. Louis MO 63117-1811 (314) 768-5200170 IP - State Market 05/01/13 St Marys Hospital I 1 1800 E. Lake Shore Drive Decatur IL 62521-3810 (217) 464-2966 A 06/01/13371 IP - State Market 04/01/13 St. Anthony Med. Center I 1 5666 East State Street Rockford IL 61108-2425 (815) 226-2000 R 05/01/13806 IP - State Market 01/01/96 St. Catherine Hospital I 1 4321 Fir Street East Chicago IN 46312-3049 (219) 392-1700248 IP - State Market 01/01/96 St. Elizabeth's Hospital I 1 211 S. Third Street Belleville IL 62222 (618) 234-2120174 IP - State Market 05/01/98 St. John's Hospital I 1 800 East Carpenter St. Springfield IL 62769 (217) 544-6464 A 07/01/98204 IP - State Market 08/05/01 St. Joseph Memorial Hosp. I 1 Two South Hospital Drive Murphysboro IL 62966-3337 (618) 684-3156 P 02/27/02181 IP - State Market 10/01/97 St. Joseph’s Hospital I 1 9515 Holy Cross Lane Breese IL 62230-0099 (618) 526-4511251 IP - State Market 07/01/97 St. Joseph's Hospital I 1 12866 Troxler Avenue Highland IL 62249-1698 (618) 654-7421 AD 10/01/13867 IP - State Market 01/01/96 St. Louis Children's Hospital I 1 One Children's Place St. Louis MO 63110-1077 (314) 454-6000870 IP - State Market 01/01/96 St. Mary's Health Center I 1 6420 Clayton Road St. Louis MO 63117-1811 (314) 768-8000803 IP - State Market 01/01/96 St. Mary's Medical Center I 1 1500 South Lake Park Hobart IN 46342 (219) 942-0551

50862 IP - State Market 07/01/08 04/21/11 Surgical Hospital of Munster I 1 7847 Calumet Ave Munster IN 46321-1213 (219) 836-5102 C 10/01/13370 IP - State Market 01/01/96 Swedish American I 1 1400 Charles Street Rockford IL 61104-2224 (815) 968-4400173 IP - State Market 01/01/97 Taylorville Memorial Hospital I 1 201 E. Pleasant Street Taylorville IL 62568 (217) 824-3331 N 10/16/07829 IP - State Market 01/01/96 The Community Hospital I 1 901 MacArthur Blvd. Munster IN 46321-2901 (219) 836-1600

50055 IP - State Market 11/01/06 VanMatre Health South Rehabiliation Hosp I 1 950 S. Mulford Road Rockford IL 61108-4274 (815) 381-8500 A 03/10/08

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel-prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev. 08-2014

Page 48: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers Appendix D

59999 IP - State Market 03/01/12 Des Peres Hospital III 3 2345 Dougherty Ferry Road St Louis MO 63122-3313 (314) 966-9100 A 04/01/12

59998 IP - State Market 03/01/12 St. Louis University Hospital III 3 3635 Vista St Louis MO 61110-2539 (314) 577-8000 A 04/01/12

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel-prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3

Rev. 08-2014

Page 49: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

195 Long Term Acute Care 01/01/96 Kindred Chicago Central Hospital I 0.5 4058 W. Melrose Street Chicago IL 60641 (773) 736-7000106 Long Term Acute Care 01/01/96 Kindred Hospital Chicago North I 0.5 2544 W Montrose Chicago IL 60618 (708) 345-8100 AL 09/01/11106 Long Term Acute Care 01/01/96 Kindred Hospital Chicago Northlake I 0.5 365 East North Avenue Northlake IL 60164 (708) 345-8100

51967 Long Term Acute Care 04/01/12 Kindred Hospital Peoria I 0.5 500 W Romeo B Garrett Ave Peoria IL 61605 (309) 680-1500 A 10/01/1251968 Long Term Acute Care 04/01/12 Kindred Hospital Springfield I 0.5 701 North Walnut St. Springfield IL 62702-4931 (217) 528-1217 CP 01/01/14

28 Long Term Acute Care 01/01/96 Kindred Hospital Sycamore I 0.5 225 Edward Street Sycamore IL 60178-2137 (815) 895-2144195 Long Term Acute Care 01/01/96 Kindred Lakeshore I 0.5 6130 No Sheridan Rd Chicago IL 60610 (773) 736-7000 AL 09/01/11340 Long Term Acute Care 01/01/96 Presence Holy Family Medical Center I 0.5 100 North River Road Des Plaines IL 60016-1209 (847) 813-3100 N 10/01/13305 Long Term Acute Care 06/01/97 R M L Specialty Hospital I 0.5 5601 South County Line Rd. Hinsdale IL 60521 (630) 268-4223

51576 Long Term Acute Care 07/01/10 RML Chicago I 0.5 3435 W. Van Buren Chicago IL 60624-3312 (630) 286-400057961 Long Term Acute Care 09/01/13 Vibra Hospital of Springfield LLC I 0.5 701 North Walnut St. Springfield IL 62702-4931 (217) 528-1217 PN 01/01/14

Appendix D

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAD: AddressAL: Additional LocationCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 50: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

51763 Mental Health IOP/PHP 08/01/11 Compass Health Center LLC X 0.25 60 Revere Drive Northbrook IL 60062 (224) 306-1879 A 12/01/1251518 Mental Health IOP/PHP 03/01/11 Insight Psychological Centers LLC X 0.25 333 N. Michigan Ave Chicago IL 60601 (312) 540-9955 A 12/01/1251717 Mental Health IOP/PHP 03/01/11 07/01/13 Insight Psychological Centers LLCV X 0.25 1609 Sherman Avenue Evanston IL 60201-3753 (312) 540-9955 C 07/01/1351715 Mental Health IOP/PHP 03/01/11 04/13/13 Inspire Behavioral Health Centers X 0.25 333 N. Michigan Chicago IL 60601-3901 (312) 540-9955 C 10/01/1351716 Mental Health IOP/PHP 03/01/11 06/04/13 Inspire Behavioral Health Centers X 0.25 1609 Sherman Ave Evanston IL 60201-3753 (312) 540-9955 C 10/01/131813 Mental Health IOP/PHP 12/01/12 Meier Clinics of Illinois P C X 0.25 2100 Manchester Road Wheaton IL 60187-4561 (630) 653-1717 A 12/01/12

51919 Mental Health IOP/PHP 07/01/12 Tazwood Mental Health Center X 0.25 124 S. Chicago St Lincoln IL 62656-2719 (309) 347-5522 A 12/01/1251918 Mental Health IOP/PHP 07/01/12 Tazwood Mental Health Center X 0.25 111 W Washington St East Peoria IL 61611-256- (309) 347-5522 A 12/01/1251928 Mental Health IOP/PHP 07/01/12 Tazwood Mental Health Center X 0.25 3248 Vandever Ave Pekin IL 61554-6257 (309) 347-5522 A 12/01/12

Appendix D

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAD: AddressAL: Additional LocationCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 51: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

2234142 Orthotic & Prosthetic 07/15/09 A Women's Place (mastectomy products) X 0 2222 Maple Avenue Downers Grove IL 60515 (630) 548-9346 AD 05/01/131633525 Orthotic & Prosthetic 01/01/06 Accelerated Prosthetics & Orthotics X 0 2604 Dempster Street Park Ridge IL 60068 (847) 296-7755 A 01/13/061680001 Orthotic & Prosthetic 09/01/01 Acme Orthotic & Prosthetic Lab X 0 6450 College Drive Palos Hts IL 60463 (708) 389-75201680001 Orthotic & Prosthetic 09/01/01 Acme Orthotic & Prosthetic Lab X 0 1836 40 E. 71st Street Chicago IL 60649 (708) 363-0400 A 10/05/011680001 Orthotic & Prosthetic 09/01/01 Acme Orthotic & Prosthetic Lab X 0 3700 W. 203rd Street Olympia Fields IL 60461 (708) 481-11001632158 Orthotic & Prosthetic 06/01/03 American Limb & Orthotic Center X 0 5800 W. Higgins Ave. Chicago IL 60630 (773) 685-4998 A 07/10/034519535 Orthotic & Prosthetic Aurora Orthopedic Laboratories X 0 110 John Street North Aurora IL 60542 (630) 897-63631670063 Orthotic & Prosthetic Ballert Orthopedic X 0 233 E. Erie Street Chicago IL 60611 (312) 787-44001670063 Orthotic & Prosthetic Ballert Orthopedic X 0 139 141 Front Street Wood Dale IL 60191 (630) 694-93051670063 Orthotic & Prosthetic Ballert Orthopedic X 0 125 E. Lake Cook Road Buffalo Grove IL 60089 (847) 459-40061670063 Orthotic & Prosthetic Ballert Orthopedic X 0 5959 S. Cottage Grove Chicago IL 60637 (773) 493-24451670063 Orthotic & Prosthetic Ballert Orthopedic X 0 1725 W. Harrison Chicago IL 60612 (312) 563-27951670063 Orthotic & Prosthetic Ballert Orthopedic of Chicago X 0 1250 N. Mill Street Naperville IL 60563 (630) 637-95401670063 Orthotic & Prosthetic Ballert Orthopedic of Chicago X 0 2445 W. Peterson Ave. Chicago IL 60659 (773) 878-24451618347 Orthotic & Prosthetic Bardach Schoene Company X 0 7318 W. North Ave. Elmwood Park IL 60707 (708) 456-8780

4933426 Orthotic & Prosthetic 11/15/10Barrington Rehab & Sports Physical Therapy (for custom hand orthotics only) X 0 27401 W IL Route 22 Barrington IL 60010 (847) 381-8812 A 02/01/12

5632100 Orthotic & Prosthetic 02/15/06 Benchmark Atlantic Healthcare X 0 5419 Bull Valley Road McHenry IL 60050 (815) 578-0304 A 02/01/081671413 Orthotic & Prosthetic 09/01/06 Best Fit Surgical (Mastectomy products) X 0 11350 S. Cicero Ave. Alsip IL 60803 (800) 585-4580 A 10/16/07

4933008 Orthotic & Prosthetic 11/01/12Betty Schwartz’s Intimate Boutique (Mastectomy products) X 0 1833 Second St Highland Park IL 60035 (847) 432-0220 A 12/01/12

1671478 Orthotic & Prosthetic Bioconcept, Inc. X 0 100 Tower Drive Burr Ridge IL 60527 (630) 986-000780000145 Orthotic & Prosthetic Calumet Orthopedic & Prosthetics Co. X 0 7554 Grand Blvd. Hobart IN 46342 (219) 942-2148

2232921 Orthotic & Prosthetic 02/15/06Castle Orthopeadics & Sports Medicine (for custom hand orthotics only) X 0 2111 Ogden Ave Aurora IL 60504 (630) 978-3800 A 02/01/12

2215274 Orthotic & Prosthetic Central DuPage Orthotics X 0 399 S. Schmale Road Carol Stream IL 60188 (630) 462-7997 N 02/01/08

4933031 Orthotic & Prosthetic 01/01/10Chrysalis Anaplastology & Ocularistry (Ocularist) X 0 23605 N High Ridge Dr Lake Zurich IL 60047 (847) 719-2984 N 11/01/11

7232129 Orthotic & Prosthetic 07/01/06 CPO Services X 0 416 St. Marks Court Peoria IL 61603 (309) 676-2276 A 02/01/082222181 Orthotic & Prosthetic 10/01/06 Cranial Technologies X 0 3633 W. Lake Ave. Glenview IL 60026 (847) 832-9131 A 10/16/07

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev.08-2014

Page 52: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

2222181 Orthotic & Prosthetic 10/01/06 Cranial Technologies X 0 17W662 Bufferfield Rd. Oakbrook IL 60181 (630) 627-5383 A 10/16/071670232 Orthotic & Prosthetic Dean Prosthetic & Orthotic Service X 0 2530 Crawford Ave. Evanston IL 60201 (847) 475-02415720228 Orthotic & Prosthetic 05/01/08 DJ Peters Orthopedics X 0 908 N. Hershey Bloomington IL 61704 (309) 664-6930 A 07/01/081670158 Orthotic & Prosthetic 07/01/00 Dreher Orthotics and Prosthetics X 0 7350 W. 119th Street Palos Heights IL 60463 (708) 448-6909 A 09/01/001670372 Orthotic & Prosthetic 07/01/00 Dreher Orthotics and Prosthetics X 0 214 Chicago Ave. Oak Park IL 60302 (708) 848-4646 A 09/01/00

4532767 Orthotic & Prosthetic 07/01/09Dreyer Medical Group (Custom Hand Orthotics only) X 0 1221 N Highland Ave Aurora IL 60506 (630) 264-8787 A 03/01/12

2271316 Orthotic & Prosthetic 05/15/12 DuPage Prosthetic-Orthotic Serv. X 0 1100 Sherman Ave Naperville IL 60563 (630) 261-9317 AL 05/01/122271316 Orthotic & Prosthetic DuPage Prosthetic-Orthotic Serv. X 0 121 E. Roosevelt Road Lombard IL 60148 (630) 261-93175621740 Orthotic & Prosthetic 01/01/06 Gullbrandson Orthotics X 0 2615 Three Oak Road Cary IL 60013 (847) 639-4140 A 01/13/06

10021921 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics X 0 7 Bronze Pointe South Belleville IL 62226 (618) 222-703210021921 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics X 0 217 W. Clay Street Troy IL 6224 (618) 667-411410021921 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics (Herrin, IL) X 0 404 Rushing Drive Herrin IL 62948 (618) 997-1451 N 05/12/00

1621056 Orthotic & ProstheticHanger Prosthetics & Orthotics (Orland Park, IL X 0 10719 W. 160th Street Orland Park IL 60467 (708) 364-1570 N 05/12/00

7221371 Orthotic & Prosthetic Hanger Prosthetics & Orthotics (Peoria) X 0 719 N. Kumpf Blvd. Peoria IL 61605 (309) 637-6581 N 05/12/00123424 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics (Quincy) X 0 325 S. Eighth Ave. Quincy IL 62301 (217) 222-3680 N 05/12/00

8423425 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics (Springfield) X 0 1101 No 9th Street Springfield IL 62702 (217) 523-9679 N 05/12/00

90001308 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics & Orthotics (St. John IN) X 0 8626 Wicker Ave. St. John IN 46373 (219) 365-1424 P 02/01/08

1621054 Orthotic & Prosthetic Hanger Prosthetics and Orthotics X 0 1123 Emerson Street Evanston IL 60201 (847) 864-7711 A 02/01/08

4521744 Orthotic & Prosthetic 04/01/98 Hanger Prosthetics and Orthotics X 0 75 Market Place Elgin IL 60123 (847) 695-6955 N 02/01/08

5815197 Orthotic & Prosthetic Hanger Prosthetics and Orthotics X 0 415 N. Main Street Decatur IL 62523 (217) 429-6656

1621374 Orthotic & Prosthetic 01/01/07 Hanger Prosthetics and Orthotics X 0 11231 W Cermak Rd Westchester IL 60154 (708) 447-9860 AL 02/01/13

21622993 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics and Orthotics X 0 4525 W. Lincoln Highway Matteson IL 60443-2318 (708) 755-2200 AD 02/01/11

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev.08-2014

Page 53: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

4622994 Orthotic & Prosthetic 03/01/00 Hanger Prosthetics and Orthotics X 0 215 N. Convent Street Bourbonnais IL 60914 (815) 937-0241 AD 02/01/12

4521052 Orthotic & Prosthetic Hanger Prosthetics and Orthotics (Aurora) X 0 4255 Westbrook Dr. Aurora IL 60504 (630) 820-5673 N 05/12/00

1621164 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics (Crestwood.) X 0 13443 S. Cicero Crestwood IL 60455 (708) 371-9999 N 05/12/00

4921372 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics and Orthotics (Gurnee) X 0 35 Tower Court Street Gurnee IL 60031 (847) 623-6080 N 05/12/00

90001305 Orthotic & Prosthetic 01/01/06Hanger Prosthetics and Orthotics (Hammond) X 0 7324 Indianapolis Blvd Hammond IN 46324 (219) 844-2021 A 02/01/08

1622995 Orthotic & ProstheticHanger Prosthetics and Orthotics (Hazel Crest) X 0 17530 S. Kedzie Avenue Hazel Crest IL 60429-2004 (708) 957-0240 N 05/12/00

9921375 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics and Orthotics (Joliet) X 0 330 N. Madison Street Joliet IL 60435 (815) 744-9944 N 05/12/00

24941542 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics (Libertyville) X 0 624 E. Park Ave. Libertyville IL 60048 (847) 367-6572 N 05/12/00

5621373 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics (McHenry, IL) X 0 620 S. Route 31 McHenry IL 60050 (815) 344-3070 N 05/12/00

90001309 Orthotic & Prosthetic 01/01/06Hanger Prosthetics and Orthotics (Merrillville, IN) X 0 8691 Connecticut Merrillville IN 46410 (219) 793-1900 A 02/01/08

40021311 Orthotic & Prosthetic 01/01/00 Hanger Prosthetics and Orthotics (Morris) X 0 1051 W. US Route 6 Morris IL 60450 (708) 957-0240 N 05/12/00

2221055 Orthotic & ProstheticHanger Prosthetics and Orthotics (OakBrook, IL) X 0 1S224 Summit Ave. Oak Brook Terrace IL 60181 (630) 620-5333 N 05/12/00

40021341 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics (Portage, IN.) X 0 6375 U S Highway 6 Portage IN 46368-5111 (219) 887-5101 N 05/12/00

4122195 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics(Mt. Vernon, IL) X 0 301 Main Street Mt Vernon IL 62864 (618) 244-9456 N 05/12/00

1621374 Orthotic & Prosthetic 01/01/00Hanger Prosthetics and Orthotics(North Riverside) X 0 7222 W. Cermak Road North Riverside IL 60546 (708) 447-9860 N 05/12/00

1621376 Orthotic & Prosthetic 01/01/06Hanger Prosthetics and OrthoticsPeterson Ave. (Chg) X 0 4801 W. Peterson Ave. Chicago IL 60646 (773) 777-9494 A 02/01/08

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3

Rev.08-2014

Page 54: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

1606621 Orthotic & Prosthetic 10/01/13Illinois Bone and Joint Institute (Custom Hand Orthotics only) X 0 900 Rand Road Des Plaines IL 60016 (847) 324-3060 A 11/01/13

1618522 Orthotic & Prosthetic 09/01/10 June RR Nichols, Ocularist X 0 1767 E Oakton Street Des Plaines IL 60018 (847) 803-5050 A 09/01/101680007 Orthotic & Prosthetic 10/01/09 Keller Orthotics X 0 2451 N Lincoln Avenue Chicago IL 60614 (773) 929-4700 A 10/01/091618546 Orthotic & Prosthetic Kinetic Orthotics X 0 3958 Rose Ave Western Springs IL 50558 (708) 246-9249 AD 12/01/121618546 Orthotic & Prosthetic Kinetic Orthotics X 0 1815 So Wolf Rd Hillside IL 60162 (708) 246-9249 AL 12/01/121680020 Orthotic & Prosthetic 02/15/06 Koebers Prosthetic and Orthotic Lab X 0 3834 W. Irving Park Road Chicago IL 60618 (773) 539-7333 A 02/01/088932008 Orthotic & Prosthetic 04/01/08 Lavendar N Lace X 0 733 W.. Galena Avenue Freeport IL 61032 (815) 235-1551 A 07/01/081617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 8400 Brookfield Avenue Bellwood IL 60513 (888) 635-2271 AD 08/01/081617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 825 E. Golf Road Arlington Hts IL 60005 (708) 547-9871 11/01/001617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 227 N. Hammes Joliet IL 60435 (815) 741-3722 C 03/01/13

90001246 Orthotic & Prosthetic 01/01/06 M.D. Orthotic & Prosthetic Labs, PC X 0 9111 Broadway Merrillville IN 46410 (219) 736-8896 A 02/01/081617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 10408 So Western Chicago IL 60643 (708) 547-9871 AD 04/01/131617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 4801 W. Petterson Ave. Chicago IL 60646 (708) 547-9871 11/01/001617511 Orthotic & Prosthetic 12/01/00 M.D. Orthotic & Prosthetic Labs, PC X 0 1259 Rickert Drive Naperville IL 60540 (708) 547-9871 11/01/004932217 Orthotic & Prosthetic 09/15/09 Mc Kinney Prosthetics X 0 6475 Washington Street Gurnee IL 60031 (847) 855-0030 A 10/01/095632221 Orthotic & Prosthetic 12/01/06 Mercy Health System Corp X 0 2000 Lake Avenue Woodstock IL 60098 (815) 337-1584 A 10/16/071633178 Orthotic & Prosthetic 01/01/06 Merrick Hopkins Co. X 0 6655 W. Archer Avenue Chicago IL 60638 (773) 586-2222 A 02/01/08

90001304 Orthotic & Prosthetic 03/01/07 Midwest Ocular Prosthetics X 0 450 St. John Road Michigan City IN 46360 (219) 874-7236 A 10/16/071603148 Orthotic & Prosthetic 02/01/13 Midwest Orthotic & Technology Center X 0 5521 N. Cumberland Ave Chicago IL 60656 (773) 930-3770 A 02/01/131671645 Orthotic & Prosthetic 05/01/08 Naturally Yours X 0 7219 Kingery Highway Willowbrook IL 60527 (630) 570-5004 A 05/01/08

10180001 Orthotic & Prosthetic 01/01/98 Northern Prosthetic & Orthotics X 0 2629 Charles Street Rockford IL 61108 (815) 226-0444 A 07/01/991617673 Orthotic & Prosthetic Occupational & Hand Therapy Ltd. X 0 14620 John Humphrey Dr. Orland Park IL 60462 (708) 403-0010

35040141 Orthotic & Prosthetic 03/01/06 Optech Orthotics and Prosthetics X 0 301 E. Hickory Streator IL 61364 (815) 932-8640 A 02/01/084622011 Orthotic & Prosthetic 03/01/06 06/01/12 Optech Orthotics and Prosthetics X 0 138 N. Schuyler Ave. Kankakee IL 60901 (815) 932-8564 CP 07/01/12

39941357 Orthotic & Prosthetic 03/01/06 Optech Orthotics and Prosthetics X 0 121 Springfield Avenue Joliet IL 60435 (815) 741-9700 A 02/01/0891640519 Orthotic & Prosthetic 03/01/06 Optech Orthotics and Prosthetics X 0 18210 S. LaGrange Road Tinley Park IL 60477 (708) 364-9700 A 02/01/08

4632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 119 E Court St Kankakee IL 60901 (815) 932-8564 P 07/01/124632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 111 W Jackson Morris IL 60450 (815) 942-4000 AL 07/01/124632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 200 N Laird Lane Watseka, IL 60970 (815) 932-8564 AL 07/01/12

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4

Rev.08-2014

Page 55: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

4632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 4900 W 95th St Evergreen Park IL 60805 (866) 990-7832 AL 07/01/124632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 18016 S Wolf Rd Orland Park IL 60467 (708) 364-9700 AL 07/01/124632221 Orthotic & Prosthetic 06/01/12 Optech Orthotics and Prosthetics Services X 0 121 Springfield Ave Joliet IL 60435 (815) 741-9700 AL 07/01/12

8432043 Orthotic & Prosthetic 01/01/06Orthotic & Prosthetic Associates of Central IL X 0 355 W. Carpenter Street Springfield IL 62702 (217) 789-1450 A 01/13/06

90001222 Orthotic & Prosthetic 01/01/06 Orthotic & Prosthetic Specialists, Inc. X 0 625 Ridge Road Munster IN 46321 (219) 836-8668 A 01/13/061670211 Orthotic & Prosthetic 09/01/01 Patrick G. Adkins Ocularist, LTD X 0 2434 E. Dempster Des Plaines IL 60016 (847) 827-0666 A 07/09/027280003 Orthotic & Prosthetic 03/01/07 Plattner Orthopedic Company X 0 311 W. Romeo B Garrett Ave. Peoria IL 61605 (309) 682-1382 A 02/01/087232049 Orthotic & Prosthetic 03/01/07 Plattner Pedorthic Services X 0 311 W. Romeo B. Garrett Ave. Peoria IL 61605 (309) 682-1382 A 02/01/088232326 Orthotic & Prosthetic 12/01/12 Prosthetic and Orthotic Care, Inc X 0 13 Executive Drive Fairview Heights, IL 62208 (618) 212-0006 A 12/01/129933360 Orthotic & Prosthetic 03/25/13 Rinella Orthotics X 0 1890 Silver Cross Blvd New Lenox IL 60451 (815) 717-8970 A 04/01/131670147 Orthotic & Prosthetic 01/01/06 Robert B. Scott Ocularists X 0 111 N. Wabash Avenue Chicago IL 60602 (312) 782-3558 A 01/13/066020694 Orthotic & Prosthetic Roberta Lovely Ladies Boutique X 0 603 W. Delmar Avenue Alton IL 62002 (618) 467-0640

10180002 Orthotic & Prosthetic Rockford Orthopedic Appliance X 0 422 East State Street Rockford IL 61104 (815) 965-775990000081 Orthotic & Prosthetic Saint Giles Orthopedic Lab. X 0 8035 Euclid Avenue Munster IN 46321 (219) 836-2251 R 02/01/08

1680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 1725 W. Harrison Street Chicago IL 60612 (312) 942-20111680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 1551 Bond Street Naperville IL 60563 (630) 637-46381680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 6629 W. Lincoln Hwy. Schereville IN 46375 (219) 864-95021680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 2101 Waukegan Road Bannockburn IL 60015 (847) 444-06901680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 2530 Crawford Ave. Evanston IL 60201 (847) 475-7080 AL 09/01/111680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 401 Harrison Street Oak Park IL 60304 (708) 383-22571680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 8641 W. 95th Street Hickory Hills IL 60457 (708) 599-83361680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 1740 W. Taylor Street Chicago IL 60612 (312) 996-64501680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 1S376 Summit Ave. Oakbrook Terrace IL 60181 (630) 464-03921680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 617 E. Golf Road Arlington Heights IL 60005 (847) 437-39291680014 Orthotic & Prosthetic Scheck & Siress Prosthetics, Inc. X 0 2552 N. Clark Street Chicago IL 60614 (773) 472-36631670563 Orthotic & Prosthetic Schwartz’s Intimate Apparel X 0 161 Skokie Valley Rd Highland Park IL 60035 (847) 251-1118 AD 03/01/121629675 Orthotic & Prosthetic 03/01/12 Second Act (Mastectomy products) X 0 3020 N Lincoln Ave Chicago IL 60657 (773) 525-2228 A 04/01/12

8432146 Orthotic & Prosthetic 03/01/06SIU Physicians & Surgeons (for custom hand orthotics only) X 0 747 N Rutledge St Springfield IL 62702 (217) 545-0885 A 02/01/12

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5

Rev.08-2014

Page 56: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois/Blue Advantage HMO Contracting Providers

1604224 Orthotic & Prosthetic 02/01/14 Smithotics, LLC X 0 2353 Hassell Road Hoffman Estates IL 60169 (224) 653-8411 A 01/01/149932112 Orthotic & Prosthetic 04/01/03 Stellar Orthotics Prothetics, Ltd. X 0 9631 Gross Point Road Skokie IL 60076 (847) 410-2751 A 07/10/039932112 Orthotic & Prosthetic 04/01/03 Stellar Orthotics Prothetics, Ltd. X 0 815 N. Larkin Avenue Joliet IL 60435 (815) 207-4200 A 07/10/031616246 Orthotic & Prosthetic Suburban Orthotics & Prosthetics, Inc. X 0 450 Lee Street DesPlaines IL 60016 (847) 298-7107

10132122 Orthotic & Prosthetic 10/01/10 The Inspiration (Mastectomy products) X 0 2591 N Mulford Rd. Rockford IL 61114 (815) 639-9251 A 11/01/101617119 Orthotic & Prosthetic 09/01/99 Woodfield Ortho Services X 0 37W002 S. Mooseheart Rd. Batavia/Mooseheart IL 60539 (630) 844-9969 A 09/01/991617119 Orthotic & Prosthetic 09/01/99 Woodfield Ortho Services X 0 2155 Stonington Ave. Hoffman Estates IL 60195 (847) 885-6100 A 09/01/99

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6

Rev.08-2014

Page 57: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

4933426 Orthotic & Prosthetic 11/15/10Barrington Rehab & Sports Physical Therapy (for custom hand orthotics only) X 0 27401 W IL Route 22 Barrington IL 60010 (847) 381-8812

2232921 Orthotic & ProstheticCastle Orthopeadics & Sports Medicine (for custom hand orthotics only) X 0 2111 Ogden Ave Aurora IL 60504 (630) 978-3800

4933031 Orthotic & Prosthetic 01/01/10 Chrysalis Anaplastology & Ocularistry (Ocularist) X 0 23605 N High Ridge Dr Lake Zurich IL 60047 (847) 719-29844532767 Orthotic & Prosthetic 07/01/09 Dreyer Medical Group (Custom Hand Orthotics only) X 0 1221 N Highland Ave Aurora IL 60506 (630) 264-87874521744 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Elgin X 0 75 Market Place Elgin IL 60123 (847) 695-6955

90001305 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Hammond X 0 7324 Indianapolis Blvd Hammond IN 46324 (219) 844-2021 1621374 Orthotic & Prosthetic 01/01/07 Hanger Prosthetics and Orthotics - Westchester X 0 11231 W Cermak Rd Westchester IL 60154 (708) 447-98604521052 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Aurora X 0 4255 Westbrook Dr. Aurora IL 60504 (630) 820-5673 4622994 Orthotic & Prosthetic 03/01/00 Hanger Prosthetics and Orthotics - Bourbonnais X 0 215 N. Convent Street Bourbonnais IL 60914 (815) 937-0241 1621164 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Creastwood X 0 13443 S. Cicero Crestwood IL 60455 (708) 371-9999 1621054 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Evanston X 0 1123 Emerson Street Evanston IL 60201 (847) 864-77114921372 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Gurnee X 0 35 Tower Court Street Gurnee IL 60031 (847) 623-6080 1622995 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Hazel Crest X 0 17530 S. Kedzie Avenue Hazel Crest IL 60429 (708) 957-0240 9921375 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Joliet X 0 330 N. Madison Street Joliet IL 60435 (815) 744-9944

24941542 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Libertyville X 0 624 E. Park Ave. Libertyville IL 60048 (847) 367-6572 40031364 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Lincolnshire X 0 300 Village Green Dr, Lincolnshire IL 60069 847-478-815421622993 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Matteson X 0 4525 W. Lincoln Highway Matteson IL 60443 (708) 755-2200

7221371 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - McHenry X 0 620 S Route 31, McHenry IL 60050 815-344-307090001309 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Merrillville, IN X 0 8691 Connecticut Merrillville IN 46410 (219) 793-1900

1621374 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - North Riverside X 0 7222 W. Cermak Road North Riverside IL 60546 (708) 447-9860 2221055 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Oak Brook X 0 1S224 Summit Ave. Oak Brook Terrace IL 60181 (630) 620-5333 1621056 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Orland Pk X 0 10719 W. 160th Street Orland Park IL 60467 (708) 364-1570

40021341 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - Portage, IN X 0 6375 U S Highway 6 Portage IN 46368 (219) 887-5101 90001308 Orthotic & Prosthetic Hanger Prosthetics and Orthotics - St John IN X 0 8626 Wicker Ave. St. John IN 46373 (219) 365-1424

1621376 Orthotic & Prosthetic 01/01/06Hanger Prosthetics and Orthotics Peterson Ave.- Chicago X 0 4801 W. Peterson Ave. Chicago IL 60646 (773) 777-9494

Appendix D Blue Precision HMO Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev.08-2014

Page 58: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D Blue Precision HMO Contracting Providers

1606621 Orthotic & Prosthetic 10/01/13Illinois Bone & Joint Institute CHT (Custom Hand Orthotics only) X 0 900 Rand Rd, Des Plaines IL 60016 847-324-3060

1618522 Orthotic & Prosthetic 09/01/10 June RR Nichols, Ocularist X 0 1767 E Oakton Street Des Plaines IL 60018 (847) 803-505090001304 Orthotic & Prosthetic Midwest Ocular Prosthetics X 0 450 St. John Road Michigan City IN 46360 (219) 874-723610180001 Orthotic & Prosthetic 01/01/98 Northern Prosthetic & Orthotics X 0 2629 Charles Street Rockford IL 61108 (815) 226-0444

1670211 Orthotic & Prosthetic 09/01/01 Patrick G. Adkins Ocularist, LTD X 0 2434 E. Dempster Des Plaines IL 60016 (847) 827-06661670147 Orthotic & Prosthetic Robert B. Scott Ocularists X 0 111 N. Wabash Avenue Chicago IL 60602 (312) 782-3558

10180002 Orthotic & Prosthetic Rockford Orthopedic Appliance X 0 422 East State Street Rockford IL 61104 (815) 965-775910132122 Orthotic & Prosthetic 10/01/10 The Inspiration (Mastectomy products) X 0 2591 N Mulford Rd. Rockford IL 61114 (815) 639-9251

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressAL: Additional LocationPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev.08-2014

Page 59: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

272 OP Surgery 01/01/96 Abraham Lincoln Mem. Hosp. I 1 315 Eighth Street Lincoln IL 62656 (217) 732-216190 OP Surgery 01/01/98 Adventist Glen Oaks Hospital I 1 701 Wintrop Ave. Glendale Heights IL 60139-1405 (630) 545-8000 N 05/08/0620 OP Surgery 01/01/98 Adventist Hinsdale Hospital I 1 120 North Oak Hinsdale IL 60521-3829 (630) 856-9000 N 05/08/06

50667 OP Surgery 01/07/08 Adventist Hospital Bolingbrook I 1 500 Remington Blvd Bolingbrook IL 60440-4906 (630) 312-5000 A 02/01/08399 OP Surgery 02/01/99 Adventist LaGrange Memorial Hospital I 1 5101 S. Williow Spring Rd. LaGrange IL 60525-2600 (708) 352-1200 N 05/08/06

16 OP Surgery 01/01/95 06/30/10 Advocate Bethany Hospital I 1 3435 W. Van Buren Chicago IL 60624-3359 (773) 265-7700 CP 08/01/1051046 OP Surgery 12/01/08 Advocate Condell Medical Center I 1 801 S. Milwaukee Avenue Libertyville IL 60048-3204 (847) 362-2900 A 01/01/0951914 OP Surgery 07/01/12 Advocate Hope Children's Hospital I 1 4440 West 95th Street Oak Lawn IL 60453-2600 (708) 684-8000 A 09/01/12

410 OP Surgery 11/04/00 Advocate Illinois Masonic Medical Center I 1 836 Wellington Ave. Chicago IL 60657-5147 (773) 975-1600 PN 12/01/0051915 OP Surgery 07/01/12 Advocate Lutheran General Childrens I 1 1775 Dempster Street Park Ridge IL 60068-1143 (847) 723-2210 A 09/01/12

63 OP Surgery 01/01/98 Advocate Sherman Hospital I 1 1425 N Randall Road Elgin IL 60123 (847) 742-9800 N 07/01/13402 OP Surgery 02/01/99 Alexian Brothers Behavioral Health Hospital I 1 1650 Moonlake Blvd. Hoffman Estates IL 60194-1010 (847) 882-1600 N 05/01/99368 OP Surgery 01/01/98 Alexian Brothers Medical Center I 1 800 West Biesterfield Road Elk Grove IL 60007-3311 (847) 437-5500

78 OP Surgery 09/01/96 Anderson Hospital I 1 RT 162 & Old Edwardsville Maryville IL 62062 (618) 288-5711257 OP Surgery 01/01/00 Carlinville Area Hospital I 1 1001 E. Morgan Street Carlinville IL 62626-1448 (217) 854-3141 A 09/01/00319 OP Surgery 05/01/99 Centegra Hospital McHenry I 1 4201 Medical Center Dr. McHenry IL 60050-8409 (815) 344-5000 N 01/09/09

79 OP Surgery 05/01/99 Centegra Hospital Woodstock I 1 3701 Doty Road Woodstock IL 60098-3756 (815) 338-2500 N 01/01/09363 OP Surgery 01/01/98 Central DuPage Hospital I 1 25 North Winfield Road Winfield IL 60190 (630) 682-1600822 OP Surgery 04/01/99 Children's Hosp. of Wisconsin I 1 9000 W. Wisconsin Ave. Milwaukee WI 53226-3518 (414) 266-2000 01/01/01339 OP Surgery 01/01/98 Christ Hospital I 1 4440 West 95th Street Oak Lawn IL 60453-2600 (708) 684-8000895 OP Surgery 05/01/96 Community Mem. Hospital I 1 W180 N8085 Town Hall Road Menomonee Falls WI 53052 (414) 251-1000

10 OP Surgery 01/01/98 Copley Memorial Hospital, Inc. I 1 2000 Ogden Ave. Aurora IL 60504-7222 (630) 978-6200 N 03/01/139 OP Surgery 01/01/98 Delnor Community Hospital I 1 300 Randall Road Geneva IL 60134-4200 (630) 208-3000

312 OP Surgery 01/01/98 Edward Hospital I 1 801 South Washington Street Naperville IL 60540-7430 (630) 833-140012 OP Surgery 01/01/98 Elmhurst Memorial Hospital I 1 200 Berteau Avenue Elmhurst IL 60126-2966 (331) 221-1000 TE 03/01/13

52070 OP Surgery 07/01/13 Franciscan Healthcare Munster I 1 701 Superior Ave Munster IN 46321-4037 (219) 922-4200 PN 08/01/1350708 OP Surgery 04/01/08 06/30/13 Franciscan Physicians Hospital LLC I 1 701 Superior Ave Munster IN 46321-4037 (219) 922-4200 CP 08/01/13

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev. 08-2014

Page 60: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

804 OP Surgery 04/01/00 Franciscan St. Margaret Health - Hammond I 1 5454 Hohman Ave. Hammond IN 46320-1931 (219) 932-2300 N 05/01/11801 OP Surgery 04/01/00 Franciscan St. Margaret Mercy Hospital I 1 U.S. Highway 30 Dyer IN 46311 (219) 865-2141 N 05/01/11

77 OP Surgery 01/01/98 Good Samaritan Hospital - Advocate I 1 3815 Highland Avenue Downers Grove IL 60515-1500 (630) 275-5900109 OP Surgery 01/01/98 Good Shepherd Hospital - Advocate I 1 450 West Highway 22 Barrington IL 60010 (847) 381-9600341 OP Surgery 01/01/98 Gottleib Memorial I 1 701 West North Ave. Melrose Park IL 60160-1612 (708) 681-3200352 OP Surgery 04/16/99 Hartgrove Hospital I 1 5730 West Roosevelt Road Chicago IL 60644 (773) 413-1700 AD 05/01/08

21 OP Surgery 01/01/98 Holy Cross Hospital I 1 2701 West 68th Street Chicago IL 60629-1813 (773) 471-800025 OP Surgery 01/01/98 Ingalls Memorial Hospital I 1 One Ingalls Drive Harvey IL 60426-3558 (708) 333-2300

275 OP Surgery 07/01/97 Jersey Community Hospital I 1 400 Maple Summit Road Jerseyville IL 62052-2028 (618) 498-64021 OP Surgery 11/01/97 John H. Stroger Jr Hospital Cook County I 1 1835 W. Harrison Street Chicago IL 60612 (312) 633-6000 N 08/31/05

59 OP Surgery 01/01/98 Kishwaukee Community Hosp. I 1 626 Bethany Road DeKalb IL 60115 (815) 756-1521 A 07/01/98212 OP Surgery 08/01/96 06/30/11 Lawrence County Mem. Hospital I 1 2200 West State Lawrenceville IL 62439 (618) 943-1000 C 10/01/13497 OP Surgery 01/01/96 Linden Oaks Hospital I 1 852 West Street Naperville IL 60540-6400 (630) 305-5500

30 OP Surgery 01/01/98 Little Company of Mary Hospital I 1 2800 West 95th Street Evergreen Park IL 60805-2701 (708) 422-620050073 OP Surgery 01/01/98 Louis A. Weiss Memorial Hospital I 1 4646 North Marine Drive Chicago IL 60640-5700 (708) 216-9000 P 07/09/02

333 OP Surgery 01/01/98 Lutheran General Hospital I 1 1775 Dempster Street Park Ridge IL 60068-1143 (847) 723-2210405 OP Surgery 02/01/00 MacNeal Hospital I 1 3249 S. Oak Park Ave. Berwyn IL 60402-3429 (708) 783-9100 P 05/01/00327 OP Surgery 07/01/97 Memorial Hospital Belleville I 1 4500 Memorial Drive Belleville IL 62226-5399 (618) 233-7750

35 OP Surgery 01/01/98 Mercy Hospital & Med. Ctr. I 1 2525 S. Michigan Ave. Chicago IL 60616 (312) 567-2000880 OP Surgery 04/01/06 Mercy Hospital of Janesville I 1 1000 Mineral Point Avenue Janesville IL 53548-2940 (608) 756-6625 A 12/28/06

85 OP Surgery 01/01/03 Methodist Hospital of Chicago I 1 5025 N. Paulina St. Chicago IL 60640-2772 (773) 271-9040 A 05/01/03116 OP Surgery 01/01/03 Methodist Medical Center (Peoria) I 1 221 NE Glen Oak Ave. Peoria IL 61636-0001 (309) 672-5522 A 03/07/03

50874 OP Surgery 07/30/08 02/29/12 Metrosouth Medical Center I 1 12935 S Gregory St. Blue Island IL 60406 (708) 597-2000 CP 05/01/1251880 OP Surgery 03/01/12 Metrosouth Medical Center I 1 12935 S Gregory St. Blue Island IL 60406 (708) 597-2000 P 05/01/12

38 OP Surgery 01/01/00 Mount Sinai Hospital I 1 California Avenue at 15th Street Chicago IL 60608-1797 (773) 542-2000 TI 12/01/9950135 OP Surgery 01/01/03 05/22/13 Neurological and Orthopedic Institute I 1 4550 North Winchester Ave. Chicago IL 60640-5205 (773) 878-4300 C 12/01/13

15 OP Surgery 01/01/98 NorthShore University Healty System I 1 2650 Ridge Avenue Evanston IL 60201-1718 (847) 570-2000 N 10/01/08

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev. 08-2014

Page 61: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

334 OP Surgery 11/10/08 Northwest Community Hospital I 1 800 W. Centtral Rd. Arlington Hgts IL 60005-2349 (847) 618-1000 TI 11/01/0887 OP Surgery 01/01/98 Northwestern Memorial Hospital I 1 Superior Street at Fairbanks Chicago IL 60611-2914 (312) 908-200039 OP Surgery 01/01/98 Norwegian American I 1 1044 North Francisco Ave. Chicago IL 60622-2743 (773) 278-880052 OP Surgery 01/01/98 Palos Community I 1 12251 South 80th Ave. Palos Hgts IL 60463-1256 (708) 923-4000 TE 11/01/12

230 OP Surgery 01/01/00 Passavant Memorial. Area Hosp. I 1 1600 W. Walnut Jacksonville IL 62650-1136 (217) 245-9551 A 09/01/00200 OP Surgery 05/01/02 Presence Covenant Medical Center I 1 1400 W. Park Street Urbana IL 60506-1449 (217) 337-2000 A 03/07/03340 OP Surgery 01/01/98 Presence Holy Family Medical Center I 1 100 North River Road Des Plaines IL 60016-1209 (847) 813-3100 N 10/01/13

57 OP Surgery 01/01/98 Presence Mercy Medical Center I 1 1325 North Highland Ave. Elgin IL 60123-4912 (815) 725-7133 N 12/01/13316 OP Surgery 01/01/98 Presence Our Lady of the Resurrection I 1 5645 W. Addison Street Chicago IL 60634-4403 (773) 282-7000 N 10/01/13269 OP Surgery 01/01/98 Presence Resurrection Medical Center I 1 7435 West Talcott St. Chicago IL 60631-3702 (773) 774-8000 N 10/01/13

6 OP Surgery 01/01/98 Presence Saint Mary and Elizabeth Medical Center I 1 2233 W. Division Street Chicago IL 60622-3043 (312) 770-2000 PN 10/01/116 OP Surgery 01/01/98 Presence Saint Mary and Elizabeth Medical Center I 1 1431 N. Claremont Ave. Chicago IL 60622-1702 (773) 278-2000 PN 10/01/13

51 OP Surgery 01/01/98 Presence St. Francis Hospital (Evanston) I 1 355 Ridge Avenue Evanston IL 60202-3328 (847) 492-4000 N 10/01/1355 OP Surgery 01/01/98 Presence St. Joseph (Elgin) I 1 77 North Airlite Street Elgin IL 60123-4912 (847) 695-3200 N 10/01/13

415 OP Surgery 06/30/01 Presence St. Joseph Hospital I 1 2900 North Lake Shore Dr. Chicago IL 60657-5640 (773) 665-3000 N 10/01/1356 OP Surgery 01/01/98 Presence St. Joseph Med. Center(Joliet) I 1 333 North Madison St. Joliet IL 60435 (815) 725-7133 N 10/01/1360 OP Surgery 05/01/02 Presence St. Mary's Hospital I 1 500 W. Court S. Chicago IL 60901-3661 (815) 937-2490 N 10/01/13

240 OP Surgery 01/01/98 Presence United Samaritan Medical Center I 1 812 North Logan Danville IL 61832-3716 (217) 443-5000 N 03/07/0393 OP Surgery 11/01/97 Provident Hospital of Cook County I 1 500 East 51st Street Chicago IL 60615 (312) 572-2000 A 07/01/99

305 OP Surgery 06/01/97 R M L Specialty Hospital I 1 5601 South County Line Rd. Hinsdale IL 60521 (630) 268-4223 R 03/07/0350021 OP Surgery 03/01/02 Red Bud Regional Hospital I 1 325 Spring Street Red Bud IL 62278 (618) 282-3831 A 06/01/04

406 OP Surgery 03/01/00 Riveredge Hospital I 1 8311 West Roosevelt Rd. Forest Park IL 60130-2529 (708) 771-7000 PN 05/01/00360 OP Surgery 04/01/98 Riverside Medical Center I 1 350 North Wall Street Kankakee IL 60901 (815) 933-1671 TI 07/01/98

51576 OP Surgery 07/01/10 RML Chicago I 1 3435 W. Van Buren Chicago IL 60624-3312 (630) 286-4000 PN 08/01/1045 OP Surgery 10/12/05 Roseland Community Hospital I 1 45 West 111th Street Chicago IL 60628 (773) 995-3000 R 01/13/0640 OP Surgery 01/01/98 Rush Oak Park Hospital I 1 520 South Maple Ave. Oak Park IL 60304-1022 (708) 383-9300

50462 OP Surgery 10/01/06 Rush-Presbyterian St. Lukes I 1 1653 West Congress Parkway Chicago IL 60612-3809 (312) 942-5000 P 08/15/07

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev. 08-2014

Page 62: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

92 OP Surgery 10/01/97 07/19/13 Sacred Heart Hospital I 1 3240 W. Franklin Blvd. Chicago IL 60624 (773) 772-3020 C 12/01/1351994 OP Surgery 01/01/13 Shriners Hospitals for Children I 1 2211 North Oak Park Ave Chicago IL 60707-3351 (773) 622-5400 A 01/01/13

64 OP Surgery 01/01/98 Silver Cross Hospital I 1 1900 Silver Cross Blvd. New Lenox IL 60451-9509 (815) 300-1100 TE 08/01/1251076 OP Surgery 01/01/09 Skokie Hospital I 1 9600 Gross Point Road Skokie IL 60076-1214 (847) 677-9600 PN 03/01/09

259 OP Surgery 01/01/98 South Suburban Hospital - Advocate I 1 17800 S. Kedzie Ave. Hazel Crest IL 60429-2029 (708) 799-8000170 OP Surgery 05/01/13 St Marys Hospital I 1 1800 E. Lake Shore Drive Decatur IL 62521-3810 (217) 464-2966 A 06/01/13398 OP Surgery 02/01/99 St. Alexius Med. Center I 1 1555 N. Barrington Rd. Hoffman Estates IL 60194-1018 (847) 843-2000 A 04/01/00210 OP Surgery 01/01/98 St. Anthony (Chicago) I 1 2875 W. 19th Street Chicago IL 60623-3501 (773) 521-1710371 OP Surgery 04/01/13 St. Anthony Med. Center I 1 5666 East State Street Rockford IL 61108-2425 (815) 226-2000 R 05/01/13838 OP Surgery 03/01/99 St. Anthony Medical Center of Crown Point I 1 1201 S. Main Street Crown Point IN 46307 (219) 663-8120 N 07/01/99

47 OP Surgery 01/01/98 St. Bernard Hospital I 1 326 West 64th Street Chicago IL 60621-3119 (773) 962-3900248 OP Surgery 01/01/96 St. Elizabeth's Hospital I 1 211 S. Third Street Belleville IL 62222 (618) 234-2120

50 OP Surgery 01/01/98 St. Francis Hospital (Blue Island) I 1 12935 S. Gregory Blue Island IL 60406-2428 (708) 597-2000 PN 09/01/08404 OP Surgery 01/08/00 06/30/11 St. James Hosp.& Health Ctrs-Olympia Fields I 1 20201 S. Crawford Olympia Field IL 60461-0100 (708) 747-4000 CP 08/01/11

53 OP Surgery 01/01/98 St. James Hospital I 1 1423 Chicago Road Chicago Hgts IL 60411-3400 (708) 756-1000174 OP Surgery 05/01/98 St. John's Hospital I 1 800 East Carpenter St. Springfield IL 62769 (217) 544-6464 A 07/01/98204 OP Surgery 08/05/01 St. Joseph Memorial Hosp. I 1 Two South Hospital Drive Murphysboro IL 62966-3337 (618) 684-3156 P 02/27/02181 OP Surgery 10/01/97 St. Joseph’s Hospital I 1 9515 Holy Cross Lane Breese IL 62230-0099 (618) 526-4511251 OP Surgery 07/01/97 St. Joseph's Hospital I 1 12866 Troxler Ave. Highland IL 62249-1698 (618) 654-7421 AD 10/01/13

50862 OP Surgery 07/01/08 04/21/11 Surgical Hospital of Munster I 1 7847 Calumet Ave Munster IN 46321-1213 (219) 836-5102 C 10/01/1367 OP Surgery 01/01/98 Swedish Covenant I 1 5145 N. California Ave. Chicago IL 60625-3642 (773) 878-8200

173 OP Surgery 01/01/97 Taylorville Memorial Hospital I 1 201 E. Pleasant Street Taylorville IL 62568 (217) 824-3331 N 10/16/0780 OP Surgery 01/01/98 The Ann and Robert H. Lurie Children's Hospital I 1 225 E Chicago Ave. Chicago IL 60611-2605 (312) 227-4000 N 08/01/12

829 OP Surgery 01/01/05 The Community Hospital I 1 901 MacArthur Blvd. Munster IN 46321-2901 (219) 836-1600 TI 01/10/052 OP Surgery 01/01/98 Thorek Memorial Hospital I 1 850 West Irving Park Rd. Chicago IL 60613-3011 (773) 525-6780

65 OP Surgery 01/01/98 Trinity Hospital - Advocate I 1 2320 East 93rd Street Chicago IL 60617-3909 (773) 978-2000401 OP Surgery 09/01/08 University of Chgo. Med. Center I 1 5841 Maryland Ave. Chicago IL 60637-1463 (773) 702-1000 TI 09/01/08

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4 Rev. 08-2014

Page 63: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

112 OP Surgery 04/01/13 University of Illinois I 1 1740 West Taylor Street Chicago IL 60612-7232 (312) 996-3892 TI 03/01/13394 OP Surgery 01/01/99 Valley West Community Hospital I 1 11 E. Pleasant Sandwich IL 60548 (815) 786-8484 R 02/01/00

50055 OP Surgery 11/01/06 VanMatre Health South Rehabiliation Hosp I 1 950 S. Mulford Road Rockford IL 61108-4274 (815) 381-8500 A 03/10/0851587 OP Surgery 08/01/10 VHS West Suburban Medical Center I 1 3 Erie Court Oak Park IL 60302-2510 (708) 383-6200 PN 08/01/1051588 OP Surgery 08/01/10 VHS Westlake Hospital Inc I 1 1225 West Lake Street Melrose Park IL 60160-4021 (847) 681-3000 PN 08/01/1050448 OP Surgery 07/01/06 Vista Medical Center East I 1 1324 North Sheridan Rd. Waukegan IL 60085-2161 (847) 360-3000 PN 12/28/0650449 OP Surgery 07/01/06 Vista Medical Center West I 1 2615 Washington Street Waukegan IL 60085-4916 (847) 249-3900 PN 12/28/06

73 OP Surgery 06/01/02 West Suburban Hospital I 1 3 Erie Court Oak Park IL 60302-2510 (708) 383-620074 OP Surgery 01/01/98 Westlake Community Hospital I 1 1225 West Lake Street Melrose Park IL 60160-4021 (847) 681-3000

233 OP Surgery 02/01/09 Alton Memorial II 2 One Momorial Drive Alton IL 62002-6722 (618) 463-7390 TI 02/05/0950033 OP Surgery 02/01/09 Aurora Chicago Lakeshore Hospital II 2 4840 North Marine Drive Chicago IL 60640-4220 (773) 878-9700 TI 02/05/09

131 OP Surgery 02/01/09 Crossroads - Mt. Vernon II 2 #8 Doctor's Park Mount Vernon IL 62864-6224 (618) 244-5500 TI 02/05/09810 OP Surgery 02/01/09 Deaconess Hospital (IN) II 2 600 Mary Street Evansville IL 62864-6224 (618) 244-5500 TI 02/05/09

50078 OP Surgery 02/01/09 Franklin Hospital II 2 201 Bailey Lane Benton IL 62812-1969 (618) 439-3161 TI 02/05/0914 OP Surgery 02/01/09 Good Samaritan - Mt. Vernon II 2 1 Good Samaritan Way Mount Vernon IL 62864-2857 (618) 242-4600 AD 10/01/13

298 OP Surgery 02/01/09 Heartland Regional Medical Center II 2 917 West Main Street Marlon IL 62959-1836 (618) 997-5341 TI 02/05/09140 OP Surgery 02/01/09 Herrin Hospital II 2 201 S. 14th Street Herrin IL 62948-2857 (618) 942-2171 TI 02/05/09

26 OP Surgery 02/01/09 Jackson Park Hospital II 2 7531 Stony Island Avenue Chicago IL 60649-3913 (773) 947-7500 TI 02/05/09195 OP Surgery 02/01/09 Kindred Chicago Central Hospital II 2 4058 W. Melrose Street Chicago IL 60641 (773) 736-7000 TI 02/05/09106 OP Surgery 02/01/09 Kindred Hospital Chicago Northlake II 2 365 East North Avenue Northlake IL 60164 (708) 345-8100 TI 02/05/09

28 OP Surgery 02/01/09 Kindred Hospital Sycamore II 2 225 Edward Street Sycamore IL 60178 (815) 895-2144 TI 02/05/09160 OP Surgery 02/01/09 LaRabida Children's Hospital II 2 6501 Promontory Drive Chicago IL 60649-1326 (773) 363-6700 TI 02/05/09

31 OP Surgery 02/01/09 Loretto Hospital II 2 645 South Centeral Chicago IL 600644-5059 (773) 626-4300 TI 02/05/09500 OP Surgery 01/01/98 Loyola University Med. Ctr. II 2 2160 South First Ave. Maywood IL 60153-3304 (708) 216-9000

7 OP Surgery 02/01/09 Marianjoy Rehab. Hospital II 2 26 West 171 Roosevelt Rd. Wheaton IL 60187-0795 (630) 909-8000 TE 09/01/12237 OP Surgery 02/01/09 Memorial Hospital (Carbondale) II 2 405 West Jackson Street Carbondale IL 62901-2904 (618) 549-0721 TI 02/05/09347 OP Surgery 02/01/09 Memorial Hospital (Chester) II 2 1900 State Street Chester IL 62233-1116 (618) 826-4581 TI 02/05/09

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5 Rev. 08-2014

Page 64: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

175 OP Surgery 02/01/09 Memorial Medical Center II 2 701 N. 1st Street Springfield IL 62702-3757 (217) 788-3000 TI 02/05/09196 OP Surgery 01/01/98 Mercy Harvard Hospital (WI) II 2 901 Grant Street Harvard IL 62959-1836 (618) 997-5341 N 02/01/08802 OP Surgery 02/01/09 Methodist (Northlake IN) II 2 600 Grant Street Gary IN 46402-6000 (219) 886-4000 TI 02/05/09828 OP Surgery 02/01/09 Methodist (Southlake IN) II 2 8701 Broadway Merrillville IN 46410-7035 (219) 886-4000 TI 02/05/09117 OP Surgery 02/01/09 Proctor Community II 2 5409 North Knoxville Ave. Peoria IL 61614-5016 (309) 691-4702 TI 02/05/09354 OP Surgery 02/01/09 Rehab. Inst. of Chicago II 2 345 East Superior St. Chicago IL 60611-3015 (312) 908-6000 TI 02/05/09353 OP Surgery 02/01/09 Schwab Rehabilitation Hospital II 2 1401 S. California Ave. Chicago IL 60608-1612 (773) 522-2010 TI 02/05/09

66 OP Surgery 02/01/09 South Shore Hospital II 2 8012 S. Crandon Chicago IL 60617-1151 (773) 768-0810 TI 02/05/09859 OP Surgery 02/01/09 SSM Rehabilitation Institute II 2 6420 Clayton Road St. Louis MO 63117-1811 (314) 768-5200 TI 02/05/09806 OP Surgery 01/01/98 St. Catherine Hospital (IN) II 2 4321 Fir Street East Chicago IN 46312-3049 (219) 392-1700867 OP Surgery 02/01/09 St. Louis Children's II 2 One Children's Place St. Louis MO 63110-1077 (314) 454-6000 TI 02/05/09803 OP Surgery 01/01/98 St. Mary's (Gary and Hobart, IN) II 2 1500 South Lake Park Hobart IN 46342 (219) 942-0551870 OP Surgery 02/01/09 St. Mary's Health Center II 2 6420 Clayton Road St. Louis MO 63117 (314) 768-8000 TI 02/05/09370 OP Surgery 02/01/09 Swedish American II 2 1400 Charles Street Rockford IL 61104-2224 (815) 968-4400 TI 02/05/09112 OP Surgery 03/01/02 03/31/13 University of Illinois II 2 1740 West Taylor Street Chicago IL 60612-7232 (312) 996-3892 TO 03/01/13

59999 OP Surgery 03/01/12 Des Peres Hospital III 3 2345 Dougherty Ferry Road St Louis MO 63122-3313 (314) 966-9100 A 09/01/1259998 OP Surgery 03/01/12 St. Louis University Hospital III 3 3635 Vista St Louis MO 61110-2539 (314) 577-8000 A 09/01/12

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changePN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6 Rev. 08-2014

Page 65: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

51649 Renal Dialysis 10/01/10 Adams County Dialysis I 0 436 N. 10th Street Quincy IL 62301 (217) 223-7913 A 01/01/1163 Renal Dialysis 01/01/05 Advocate Sherman Hospital I 0 1425 N Randall Road Elign IL 60120 (847) 742-9800 AD 12/01/09

50490 Renal Dialysis 09/01/06 Affiliated Dialysis I 0 715 Lake Street Oak Park IL 60301 (630) 690-464252128 Renal Dialysis 07/01/13 Affiliated Dialysis Of Glen Ellyn I 0 800 Roosevelt Glen Ellyn IL 60137 (309) 698-1800 A 11/01/1351041 Renal Dialysis 01/01/09 Affiliated Home Dialysis I 0 2500 N. Main Street East Peoria IL 61611 (309) 698-1800 A 04/01/1050357 Renal Dialysis 01/01/05 Aledo Kidney Center, LLC I 0 409 N.W. Ninth Avenue Aledo IL 61231 (309) 762-557050592 Renal Dialysis 01/01/05 Alton Dialysis I 0 3511 College Street Alton IL 62002 (618) 465-4745

664 Renal Dialysis 01/01/05 Aurora Dialysis Center I 0 455 Mercy Lane Aurora IL 60506 (630) 892-744550355 Renal Dialysis 01/01/05 Austin Community Kidney Center I 0 4800 W. Chicago Avenue Chicago IL 60651 (773) 287-068051989 Renal Dialysis 11/01/12 Barrington Creek Dialysis I 0 28160 W. Northwest Hwy Lake Barrington IL 60010 (847) 381-1325 A 12/01/1250565 Renal Dialysis 01/01/05 Benton Dialysis I 0 1151 Route 14 West Benton IL 62812 (618) 435-485050560 Renal Dialysis 01/01/05 Beverly Dialysis I 0 8109 South Western Avenue Chicago IL 60620 (773) 238-5200 AD 02/11/1051687 Renal Dialysis 02/01/11 Big Oaks Dialysis I 0 5623 W. Touhy Avenue Niles IL 60714 (847) 647-3140 A 04/01/11

2139 Renal Dialysis 01/01/05 08/31/13 Bma Belmont I 0 4943 West Belmont Avenue Chicago IL 60641 (773) 685-7500 CP 12/01/13660 Renal Dialysis 01/01/05 Bma Of Carbondale I 0 725 S. Lewis Lane Carbondale IL 62901 (618) 529-2112659 Renal Dialysis 01/01/05 Bma Of Niles I 0 7332 Milwaukee Avenue Niles IL 60714 (847) 647-8505

2137 Renal Dialysis 01/01/05 Bolingbrook Dialysis Center I 0 329 Remington Blvd Boilingbrook IL 60440 (630) 972-8662 AD 09/01/1350400 Renal Dialysis 01/01/05 Center For Renal Replacement LLC I 0 7301 N. Lincoln Lincolnwood IL 60712 (847) 675-555550567 Renal Dialysis 01/01/05 Centralia Dialysis I 0 1231 State Route 161 East Centralia IL 62801 (618) 533-2535 AD 04/01/1450206 Renal Dialysis 01/01/05 Chicago Heights Dialysis I 0 177 B West Joe Orr Road Chicgo Heights IL 60411 (708) 755-9000 A 07/01/09

652 Renal Dialysis 01/01/05 Chicagoland Dialysis Center I 0 820 W. Jackson Blvd Chicago IL 60607 (312) 930-936550268 Renal Dialysis 01/01/05 Churchview Dialysis I 0 5970 Churchview Drive Rockford IL 61107 (815) 971-8252

687 Renal Dialysis 01/01/05 Circle Medical Management I 0 1426 W. Washington Blvd Chicago IL 60607 (312) 829-142451707 Renal Dialysis 03/01/11 Cobblestone Dialysis I 0 836 Dundee Avenue Elgin IL 60120 (847) 888-9386 AD 08/01/1251214 Renal Dialysis 01/01/09 Community Dialysis Of Harvey I 0 16641 S Halsted Street Harvey IL 60426 6100 (708) 210-9500 A 04/01/1050586 Renal Dialysis 01/01/05 Comprehensive Renal Care - East Chicago I 0 4320 Fir Street East Chicago IN 46312 (219) 397-119950588 Renal Dialysis 01/01/05 Comprehensive Renal Care - Gary I 0 4802 Broadway Gary IN 46408 (219) 887-119950589 Renal Dialysis 01/01/05 Comprehensive Renal Care - Hammond I 0 222 Douglas St Hammond IN 46320 (219) 932-119950602 Renal Dialysis 01/01/05 Comprehensive Renal Care Michigan City I 0 120 Dunes Plaza Michigan City IN 46360 (219) 878-198950603 Renal Dialysis 01/01/05 Comprehensive Renal Care Valparaiso I 0 606 E. Lincolnway Valparaiso IN 46383 (219) 531-1299

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev. 08-2014

Page 66: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50591 Renal Dialysis 01/01/05 CRC - Munster I 0 8317 Calumet Avenue Munster IN 46321 (219) 836-1299 N 10/15/1152101 Renal Dialysis 05/01/13 Crimson Ridge Home Training I 0 2540 Hauser Ross Drive Sycamore IL 60178 (815) 748-3508 A 10/01/1352101 Renal Dialysis 05/01/13 Crimson Ridge Home Training I 0 2540 Hauser Ross Drive Sycamore IL 60178-3171 (815) 748-3508 A 11/01/1351453 Renal Dialysis 11/01/09 Crystal Lake Dialysis Llc I 0 6298 Northwest Hwy Crystal Lake IL 60014 (815) 477-8025 A 02/01/1051986 Renal Dialysis 09/01/12 Crystal Springs Dialysis I 0 720 Cog Circle Crystal Lake IL 60014-7301 (815) 459-4945 A 12/01/1251708 Renal Dialysis 03/01/11 08/31/12 Crystal Springs Dialysis I 0 4900 South IL Rt 31 Crystal Lake IL 60012 (224) 783-5815 C 03/01/1351819 Renal Dialysis 10/01/11 Danville Dialysis Services I 0 910 W. Clay Street Danville Illinois 61832 (217) 446-1111 A 12/01/1151990 Renal Dialysis 11/01/12 Danville Home Training I 0 3 Poland Road Danville IL 61834 (217) 443-3350 A 12/01/1257836 Renal Dialysis 09/01/13 Davita A/k/a Shiloh Dialysis I 0 1095 N. Green Mount Road Belleville IL 62221 (618) 628-1108 A 04/01/1450247 Renal Dialysis 01/01/05 Davita Granite City I 0 9 American Village Shopping Ctr Granite City IL 62040 (618) 452-5858 P50568 Renal Dialysis 01/01/05 Decatur Eastwood Dialysis I 0 794 East Wood Street Decatur IL 62573 (217) 425-6403

632 Renal Dialysis 01/01/05 Dialysis Center Of America I 0 4861-73 Cal Sag Rd Crestwood IL 60445 (708) 385-1400640 Renal Dialysis 01/01/05 Dialysis Center Of America D/b/a Rcg Garfield I 0 5401 S. Wentworth Chicago IL 60609 (773) 548-5714635 Renal Dialysis 01/01/05 Dialysis Center Of America D/b/a Rcg Orland Pk I 0 9160 W. 159th St Orland Park IL 60462 (708) 403-2790634 Renal Dialysis 01/01/05 Dialysis Center Of America D/b/a Rcg Prairie I 0 1712 S. Prairie Chicago IL 60616 (312) 913-0000637 Renal Dialysis 01/01/05 Dialysis Center Of America D/b/a Rcg Rogers Pk I 0 2277 W. Howard St Chicago IL 60645 (773) 262-7147

51850 Renal Dialysis 11/01/11 Dialysis Newco I 0 4651 West 79th Street Chicago IL 60652 (773) 582-8911 A 03/01/1250352 Renal Dialysis 01/01/05 Direct Dialysis I 0 14255 S. Cicero Avenue Crestwood IL 60445 (708) 824-920050306 Renal Dialysis 01/01/05 Dixon Dialysis Center, LLC I 0 101 W. 2nd Street Dixon IL 61021 (309) 762-557050338 Renal Dialysis 01/01/05 Dixon Kidney Center I 0 1131 N. Galena Avenue Dixon IL 61021 (815) 284-0595

650 Renal Dialysis 01/01/05 Downers Grove Dialysis Center I 0 3825 Highland Ave Downers Grove IL 60515 (630) 964-260552065 Renal Dialysis 03/01/13 Driftwood I 0 1808 S. West Avenue Freeport IL 61032 (818) 232-0295 A 07/01/1350624 Renal Dialysis 01/01/05 DSI Buffalo Grove I 0 1291 W. Dundee Road Buffalo Grove IL 60089 (247) 253-5400 PN 11/01/0850631 Renal Dialysis 08/01/07 DSI Renal Arlington Heights I 0 17 W Golf Road Arlington Heights il 60006 (847) 437-2188 A 11/01/0850626 Renal Dialysis 01/01/05 DSI Renal Markham I 0 3053 3065 W. 159th Street Markham IL 60426 (708) 333-3516 PN 11/01/0850622 Renal Dialysis 01/01/05 DSI Renal Schaumburg I 0 1156 S. Roselle Road SCHAUMBURG IL 60193 (847) 524-4310 PN 11/01/0850629 Renal Dialysis 01/01/05 DSI Renal Waukegan I 0 1616 Grand Avenue C Waukegan IL 60085 (847) 662-5111 PN 11/01/0851583 Renal Dialysis 08/01/10 DSI Schaumburg Home Renal Center I 0 17 W. Golf Road Arlington Heights IL 60005 (847) 437-2188 A 08/01/1050628 Renal Dialysis 01/01/05 10/31/11 DSL Scottsdale I 0 7929 S. Cicero Avenue Chicago IL 60652 (773) 582-8911 C 10/01/1351583 Renal Dialysis 08/01/10 DSI Waukegan Home Renal Center I 0 1616 Grand Avenue Waukegan IL 60085 (874) 360-9621 A 08/01/10

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev. 08-2014

Page 67: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

2151 Renal Dialysis 01/01/05 Dupage Peritoneal Dialysis Service I 0 183 N. Addison Elmhurst IL 60126 (630) 858-802552003 Renal Dialysis 12/01/12 East Chicago Dialysis Center I 0 1207 E. Chicago Avenue East Chicago IN 46312 (219) 397-7751 P 02/01/13

2107 Renal Dialysis 01/01/05 11/30/12 East Chicago Dialysis Center I 0 1207-19 Chicago Avenue East Chicago IN 46312 (219) 397-7751 CP 02/01/1351647 Renal Dialysis 10/01/10 Edwardsville Dialysis I 0 235 S. Buchanan Street Edwardsville IL 62025 (618) 692-9217 A 01/01/1150569 Renal Dialysis 01/01/05 Effingham Dialysis I 0 904 Medical Park Drive Effingham IL 62401 (217) 342-9558

654 Renal Dialysis 01/01/05 Elk Grove Dialysis Ctr I 0 901 Biesterfield Rd Elk Grove Village IL 60007 (847) 737-08242112 Renal Dialysis 01/01/05 Elk Grove Home Dialysis Center I 0 901 Biesterfield Rd Elk Grove IL 60007 (847) 952-9890

50060 Renal Dialysis 01/01/05 Emerald Kindney Center I 0 710 West 43rd Street Chicago IL 60609 (773) 947-077050630 Renal Dialysis 01/01/05 Evanston Renal Center I 0 1922 Dempster Street Evanston IL 60202 (847) 869-5336 AD 01/01/1450328 Renal Dialysis 01/01/05 FMC – Ottawa I 0 1000 E. Norris Drive Ottawa IL 61350 (815) 434-2125

648 Renal Dialysis 01/01/05 FMC Blue Island I 0 12200 S. Western Blue Island IL 60406 (708) 597-993350658 Renal Dialysis 01/01/05 FMC Chicago West Side Dialysis I 0 1340 S. Damen Chicago IL 60608 (312) 738-258750200 Renal Dialysis 01/01/05 FMC Dialysis Service Of Alsip I 0 12250 S. Cicero Avenue Alsip IL 60803 (708) 389-095550201 Renal Dialysis 01/01/05 FMC Dialysis Service Of Congress Parkway I 0 3410 W. Vanburen Street Chicago IL 60624 (773) 722-4245

669 Renal Dialysis 01/01/05 FMC Dialysis Service Of Westchester I 0 2400 Wolf Road Westlake IL 60154 (708) 409-778050202 Renal Dialysis 01/01/05 FMC Dialysis Service Of Willowbrook I 0 6300 Kingery Highway Willowbrook IL 60527 (630) 325-030950733 Renal Dialysis 01/01/05 FMC Dupage Home Dialysis I 0 242 N. York Road Elmhurst IL 60126 (630) 832-5276

2109 Renal Dialysis 01/01/05FMC Lagrange Home Dialysis Center Service Of Westchester I 0 2400 Wolf Rd Westchester IL 60154 (708) 562-8220

50423 Renal Dialysis 01/01/05 FMC Lake Bluff I 0 101 Wakegan Road Lake Bluff IL 60044 (847) 735-087051528 Renal Dialysis 02/01/10 FMC Lombard Home Therapies I 0 1960 Springer Drive Lombard IL 60148 (630) 693-0394 A 04/01/1050436 Renal Dialysis 01/01/05 FMC Mchenry I 0 4312 W. Elm Street McHenry IL 60050 (815) 363-725450125 Renal Dialysis 01/01/05 FMC Of Williamson City I 0 900 Skyline Drive, #200 Marion IL 62959 (618) 993-162550300 Renal Dialysis 01/01/05 08/31/13 FMCNA Burbank I 0 4811 W. 77th Street Burbank IL 60459 (708) 229-0584 CP 12/01/13

644 Renal Dialysis 01/01/05 Fox Valley Dialysis I 0 1300 Waterford Dr Aurora IL 60504 (630) 851-481250265 Renal Dialysis 01/01/05 Freeport Dialysis I 0 1028 Konkle Blvd. Freeport IL 61032 (815) 232-2477

655 Renal Dialysis 01/01/05 Fresenius Dupage West Dialysis I 0 450 E. Roosevelt West Chicago IL 60185 (630) 293-6356 N 06/01/1152108 Renal Dialysis 08/01/13 Fresenius Med Care Naperbrook I 0 2451 S Washington St Naperville IL 60565 (630) 428-9769 A 10/01/1351593 Renal Dialysis 03/01/10 08/30/13 Fresenius Medial Care Midway I 0 6201 W. 63rd Street Chicago IL 60674 (773) 229-8268 CP 01/01/1455809 Renal Dialysis 09/01/13 Fresenius Medial Care Midway I 0 6201 W. 63rd Street Chicago IL 60674 (773) 229-8268 P 01/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev. 08-2014

Page 68: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51613 Renal Dialysis 09/01/10 Fresenius Medical Care Lombard I 0 1940 Springer Drive Lombard IL 60148 (630) 693-0394 A 10/01/1051129 Renal Dialysis 01/01/09 Fresenius Medical Caqe - Streator I 0 2356 N BLOOMINGTON STREATOR IL 61364 (815) 673-2200 A 05/01/0950334 Renal Dialysis 01/01/05 Fresenius Medical Care – Kewanee I 0 230 W. South Street Kewanee IL 61443 (309) 854-0917

699 Renal Dialysis 01/01/05 08/30/13 Fresenius Medical Care - Niles I 0 9371 Milwaukee Avenue Niles IL 60714 (847) 518-8100 CP 01/01/1456103 Renal Dialysis 09/01/13 Fresenius Medical Care - Niles I 0 9371 Milwaukee Avenue Niles IL 60714 (847) 518-8100 P 01/01/1451353 Renal Dialysis 07/01/09 Fresenius Medical Care - West Chicago I 0 1850-63 Neltor Boulevard West Chicago IL 60185 (630) 293-5952 A 07/01/0955029 Renal Dialysis 09/01/13 Fresenius Medical Care Bridgeport I 0 825 W. 35th Street Chicago IL 60609 (773) 890-4330 P 12/01/1357780 Renal Dialysis 09/01/13 Fresenius Medical Care Burbank I 0 4811 W. 77th Street Burbank IL 60459 (708) 229-0584 P 12/01/1351924 Renal Dialysis 06/01/12 Fresenius Medical Care Chatham I 0 8710 S. Holland Road Chicago IL 60620 (773) 723-2536 A 10/01/1252038 Renal Dialysis 03/01/13 Fresenius Medical Care Cicero I 0 3000 S. Cicero Avenue Cicero IL 60677 (708) 652-7089 A 05/01/13

2106 Renal Dialysis 01/01/05 11/30/12 Fresenius Medical Care Crown Point I 0 851 Burrells Street Crown Point IN 46307-8898 (219) 663-9955 CP 02/01/1352006 Renal Dialysis 12/01/12 Fresenius Medical Care Crown Point I 0 851 Burrell Street Crown Point IN 46307 (219) 662-2648 P 02/01/1351586 Renal Dialysis 03/01/10 Fresenius Medical Care Deerfield I 0 405 Lake Cook Road Deerfield IL 60015 (847) 559-1374 A 09/01/1053400 Renal Dialysis 05/01/14 Fresenius Medical Care Desplaines I 0 1625 Oakton Place DesPlaines IL 60018 (773) 248-3105 A 08/01/14

2142 Renal Dialysis 01/01/05 Fresenius Medical Care Duquoin I 0 4 W. Main Street DuQuoin IL 62832 (618) 542-647752008 Renal Dialysis 12/01/12 Fresenius Medical Care Dyer I 0 2150 Gettler Street Dyer IN 46311 (219) 322-3710 P 02/01/1351217 Renal Dialysis 09/01/12 11/30/12 Fresenius Medical Care Dyer In I 0 2150 Gettler Street Dyer IN 46311-3710 (219) 322-3710 CP 02/01/1351614 Renal Dialysis 09/01/10 Fresenius Medical Care Elgin I 0 2130 Point Blvd Elgin IL 60125 (847) 425-3605 A 10/01/1056687 Renal Dialysis 09/01/13 Fresenius Medical Care Evergreen Park I 0 9730 S. Western Avenue Evergreen Park IL 60805 (708) 423-8833 P 12/01/1352048 Renal Dialysis 03/01/13 Fresenius Medical Care Galesburg I 0 765 N. Kellogg Street Galesburg IL 61401 (309) 945-4580 A 05/01/1352005 Renal Dialysis 12/01/12 Fresenius Medical Care Gary I 0 3290 Grant Street Gary IN 46408 (219) 980-2860 PN 02/01/13

2146 Renal Dialysis 01/01/05 Fresenius Medical Care Harrisburg I 0 275 Small Street Harrisburg IL 62946 (618) 252-110956223 Renal Dialysis 01/01/05 Fresenius Medical Care Hazel Crest I 0 17524 Carriageway Hazel Crest IL 60429 (708) 798-2899 P 02/01/1451148 Renal Dialysis 03/01/09 11/30/12 Fresenius Medical Care Hobart I 0 1310 W. Wisconsin Street Hobart IN 46342 (219) 947-9289 CP 02/01/1352002 Renal Dialysis 12/01/12 Fresenius Medical Care Hobart I 0 1310 W. Wisconsin Street Hobart IN 46342 (219) 947-9289 P 02/01/1353071 Renal Dialysis 09/01/13 Fresenius Medical Care Hoffman Estates I 0 3150 W. Higgins Road Hoffman Estates IL 60195 (847) 310-0074 P 12/01/1351923 Renal Dialysis 05/01/12 Fresenius Medical Care Joliet I 0 721 E. Jackson Street Joliet IL 60432 (815) 726-8619 A 10/01/1252093 Renal Dialysis 06/01/13 Fresenius Medical Care Logan Square I 0 2721 N. Spaulding Chicago IL 60647 (773) 292-2971 A 09/01/1352126 Renal Dialysis 07/01/13 Fresenius Medical Care Macomb I 0 523 E. Grant Street Macomb IL 61455 (309) 836-1662 A 11/01/1359283 Renal Dialysis 09/01/13 Fresenius Medical Care Marquette Park I 0 6535 S. Western Avenue P 12/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4 Rev. 08-2014

Page 69: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

55447 Renal Dialysis 09/01/13 Fresenius Medical Care Melrose Park I 0 1111 Superior Street Melrose Park IL 60160 (708) 338-1780 P 12/01/1351438 Renal Dialysis 10/01/09 06/30/11 Fresenius Medical Care Metropolis I 0 20 Hospital Drive Metropolis IL 62960 (618) 524-3046 CP 12/01/1151830 Renal Dialysis 11/01/11 Fresenius Medical Care Mundelein I 0 1402 Townline Road Mundelein Illinois 60060 (847) 949-3904 A 01/01/1252953 Renal Dialysis 09/01/13 Fresenius Medical Care Munster I 0 314 Ridge Road Munster IN 46321 (219) 836-9317 P 12/01/1352108 Renal Dialysis 08/01/13 Fresenius Medical Care Naperbrook I 0 2451S. Washington Street Naperville IL 60565 (630) 428-9769 A 11/01/1353686 Renal Dialysis 09/01/13 Fresenius Medical Care Norridge I 0 4701 Cumberland Avenue Norridge IL 60706 (708) 456-0152 P 12/01/13

680 Renal Dialysis 01/01/05 08/31/13 Fresenius Medical Care North Center I 0 2620 W. Addison Street Chicago IL 60618 (773) 248-0462 CP 12/01/1357392 Renal Dialysis 09/01/13 Fresenius Medical Care North Kilpatrick I 0 4800 N. Kilpatrick Chicago IL 60630 (773) 545-3693 P 12/01/1354562 Renal Dialysis 09/01/13 Fresenius Medical Care Northcenter I 0 2620 W. Addison Street Chicago IL 60618 (773) 248-0462 P 12/01/1352127 Renal Dialysis 09/01/13 Fresenius Medical Care Oak Forest I 0 5340A W. 159th Street Oak Forest IL 60452 (708) 535-0080 A 12/01/1352044 Renal Dialysis 12/01/12 Fresenius Medical Care Oak Park I 0 733 Madison Street Oak Park IL 60302 (708) 386-8757 PN 05/01/1350489 Renal Dialysis 01/01/05 Fresenius Medical Care Of Antioch I 0 311 Depot Antioch IL 60002 (847) 395-585450637 Renal Dialysis 01/01/05 08/30/13 Fresenius Medical Care Of Lakeview I 0 4008 N. Broadway Chicago IL 60613 (773) 248-3105 CP 01/01/1454071 Renal Dialysis 09/01/13 Fresenius Medical Care Of Lakeview I 0 4008 N. Broadway Chicago IL 60613 (773) 248-3105 P 01/01/1450993 Renal Dialysis 06/01/08 Fresenius Medical Care Of Mokena I 0 8910 W. 192nd Street Mokena IL 60448 (708) 478-1815 A 04/01/0850635 Renal Dialysis 01/01/05 Fresenius Medical Care Of Naperville I 0 516 w. 5Tth Street Naperville IL 60563 (630) 753-929550634 Renal Dialysis 01/01/05 Fresenius Medical Care Of Oswego I 0 1051 Station Drive Oswego IL 60543 (630) 554-478351733 Renal Dialysis 04/01/11 Fresenius Medical Care Palatine I 0 691 E. Dundee Road Palatine IL 60074 (847) 963-4299 A 06/01/1151527 Renal Dialysis 01/01/10 Fresenius Medical Care Plainfield I 0 2320 Michas Drive Plainfield IL 60586 (815) 230-2267 A 04/01/1058016 Renal Dialysis 09/01/13 Fresenius Medical Care Polk Street I 0 557 W. Polk Street Chicago IL 60607 (312) 834-0653 P 12/01/13

2143 Renal Dialysis 01/01/05 Fresenius Medical Care Randolph I 0 102 Memorial Drive Chester IL 62233 (618) 826-444155723 Renal Dialysis 09/01/13 Fresenius Medical Care Reoseland I 0 132 W. 111th Street Chicago IL 60628 (773) 995-1738 P 12/01/1351813 Renal Dialysis 11/01/11 Fresenius Medical Care River Forest I 0 103 Forest Avenue River Forest IL 60305 (708) 488-9258 A 11/01/1154507 Renal Dialysis 09/01/13 Fresenius Medical Care Rolling Meadows I 0 4180 Winnetka Avenue Rolling Meadows IL 60008 (847) 394-6250 P 12/01/1351071 Renal Dialysis 11/01/08 08/31/13 Fresenius Medical Care Roseland I 0 132 W. 111th Street Chicago IL 60628-4515 (773) 995-1783 CP 12/01/1351216 Renal Dialysis 04/01/09 Fresenius Medical Care Sandwich I 0 1310 N. Main Street Sandwich IL 60548 (815) 786-8470 A 04/01/1154648 Renal Dialysis 09/01/13 Fresenius Medical Care South Chicago I 0 9200 S. Chicago Ave Chicago IL 60617 (773) 734-7433 P 12/01/1352039 Renal Dialysis 03/01/13 Fresenius Medical Care South Deering I 0 10559 S. Torrence Avenue Chicago IL 60617 (773) 768-7100 A 05/01/1357820 Renal Dialysis 09/01/13 Fresenius Medical Care South Holland I 0 17225 S. Paxton Avenue South Holland IL 60473 (708) 474-8700 P 12/01/1353894 Renal Dialysis 09/01/13 Fresenius Medical Care South Shore I 0 2420 E. 79th Street Chicago IL 60649 (773) 374-9002 P 12/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5 Rev. 08-2014

Page 70: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

2145 Renal Dialysis 01/01/05 Fresenius Medical Care Southwestern I 0 7 Eastgate Plaza, Rt. 3&4 East Alton IL 62024 (618) 254-111751128 Renal Dialysis 01/01/09 Fresenius Medical Care Uptown I 0 4720 N MARINE DRIVE CHICAGO IL 60674 (773) 989-8082 A 05/01/0951800 Renal Dialysis 09/01/11 Fresenius Medical Care Waukegan Harbor I 0 110 N. West Street Waukegan IL 60085 (847) 599-1346 A 11/01/1151797 Renal Dialysis 08/01/11 Fresenius Medical Care West Batavia I 0 2580 West Fabyan Parkway Batavia IL 60510 (630) 406-1690 A 11/01/1155315 Renal Dialysis 09/01/13 Fresenius Medical Care West Belmont I 0 4943 West Belmont Avenue Chicago IL 60641 (773) 685-7500 P 12/01/1351799 Renal Dialysis 08/01/11 Fresenius Medical Care West Willow I 0 1444 W. Willow Street Chicago IL 60642 (773) 248-3105 A 11/01/11

656 Renal Dialysis 01/01/05 08/31/13 Fresenius Medical Center Of Polk Street I 0 557 W. Polk Street Chicago IL 60611 (312) 834-0653 CP 12/01/1350229 Renal Dialysis 01/01/05 07/01/11 Gambro Healthcare – Breese I 0 160 N. Main Street Breese IL 62230 (618) 526-737050339 Renal Dialysis 01/01/05 Garfield Kidney Center, LLC I 0 3250 W. Franklin Boulevard Chicago IL 60624 (773) 638-116050076 Renal Dialysis 01/01/05 Glendale Heights Dialysis Center I 0 520 E. North Avenue Glendale Heights IL 60139 (630) 858-8025

689 Renal Dialysis 01/01/05 Glenview Dialysis Center I 0 4248 Commercial Way Glenview IL 60025 (847) 824-200651943 Renal Dialysis 07/01/12 Grand Crossing Dialysis I 0 7319 S. Cottage Grove Avenue Chicago IL 60619-1909 (773) 783-3491 A 10/01/12

2005 Renal Dialysis 01/01/05 09/23/13 Granite City Dialysis Center I 0 9 American Village Shopping Ctr Granite City IL 62040 (618) 452-5858 C 02/01/142108 Renal Dialysis 01/01/05 Greenwood Avenue 8 Dialysis Center I 0 1111 E. 87th St Chicago IL 60619 (773) 375-5666

50625 Renal Dialysis 08/01/07 Hazel Crest Renal Center I 0 3470 W 183rd Street Hazel Crest IL 60429 (708) 799-3101 N 03/01/1358570 Renal Dialysis 11/01/13 Home Dialysis Service Elgin, LLC I 0 650 E. Terra Cotta Avenue Crystal Lake IL 60014 (779) 220-4395 A 01/01/1450570 Renal Dialysis 01/01/05 Illini Renal Dialysis I 0 507 East University Avenue Champaign IL 61820 (217) 378-7800

665 Renal Dialysis 01/01/05 Jackson Park Dialysis Center I 0 7531 S. Stony Island Chicago IL 60185 (773) 947-751050571 Renal Dialysis 01/01/05 Jacksonville Dialysis I 0 1515 West Walnut Jacksonville IL 62650 (217) 243-304251838 Renal Dialysis 12/01/11 Jerseyville Dialysis I 0 917 S. State Street Jerseyville IL 62052 (678) 498-9532 A 02/01/1251713 Renal Dialysis 08/01/10 Joliet Home Dialysis Network I 0 812 Campus Drive Joliet IL 60435 (815) 741-6830 R 05/01/1351120 Renal Dialysis 10/01/08 Kankakee County Dialysis I 0 581 William R Latham Sr Drive Bourbonnais IL 60914 (815) 936-3088 A 02/01/0951122 Renal Dialysis 10/01/08 Kennedy Home I 0 5590 N CUMBERLAND CHICAGO IL 60656 (773) 631-8296 A 05/01/09

2131 Renal Dialysis 01/01/05 Lake County Dialysis Services I 0 565 Lakeview Parkway Vernon Hills IL 60061 (847) 918-0592 AD 06/01/1351725 Renal Dialysis 03/01/11 Lake Park Dialysis I 0 1531 E. Hyde Park Boulevard Chicago IL 60615 (773) 363-9052 A 05/01/1151801 Renal Dialysis 10/01/11 Lakeview Home Dialysis LLC I 0 3023 N. Ashland Avenue Chicago Illinois 60657 (773) 525-3053 A 11/01/1150579 Renal Dialysis 01/01/05 Lakevilla Dialysis I 0 37809 N. IL Route 59 Lake Villa IL 60046 (847) 245-487251674 Renal Dialysis 12/01/10 Liberty Dialysis Hammond I 0 7214 Calumet Avenue Hammond IN 46325 (219) 228-4477 A 02/01/1150618 Renal Dialysis 01/01/05 Lincoln Dialysis I 0 2100 W. Fifth Lincoln IN 62656 (217) 782-679850572 Renal Dialysis 01/01/05 Lincoln Park Dialysis I 0 3157 N Lincoln Avenue Chicago IL 60657 (773) 348-0101

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6 Rev. 08-2014

Page 71: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50604 Renal Dialysis 01/01/05 Lincoln Park Pd D/b/a Skyline Home I 0 7009 W. Belmont Chicago IL 60634 (773) 637-73032003 Renal Dialysis 01/01/05 04/24/13 Lincolnland Dialysis Center I 0 1112 Center West Dr Springfield IL 62704 (217) 787-3310 C 10/01/13

50573 Renal Dialysis 01/01/05 Litchfield Dialysis I 0 915 St. Francis Way Litchfield IL 62056 (217) 324-220050559 Renal Dialysis 01/01/05 Little Village Dialysis I 0 2335 W. Cermak Road Chicago IL 60608 (773) 523-293951645 Renal Dialysis 09/01/10 Lockport Home Dialysis I 0 16626 W. 159th Street Lockport IL 60441 (815) 838-2918 A 01/01/11

683 Renal Dialysis 01/01/05 Logan Square Dialysis I 0 2659 N. Milwaukee Avenue Chicago IL 60647 (773) 276-369950621 Renal Dialysis 08/01/07 Loop Renal Center I 0 1101 S. Canal Chicago IL 60607-4901 (312) 341-9472 N 03/01/13

500 Renal Dialysis 01/01/05 Loyola University Medical Center I 0 1201 West Roosevelt Maywood IL 60153 (708) 216-9000500 Renal Dialysis 01/01/05 Loyola University Medical Center I 0 2160 S 1st Ave Maywood IL 60153 (708) 216-9000

50597 Renal Dialysis 01/01/05 Macon County Dialysis I 0 1090 West McKinley Decatur IL 62526 (217) 877-935151922 Renal Dialysis 07/01/12 Manteno Dialysis Centre, LLC I 0 One East Division Street Manteno IL 60950 (815) 937-8742 A 10/01/1250274 Renal Dialysis 01/01/05 08/12/11 Maple Avenye Kidney Center I 0 610 S. Maple Avenue Oak Park IL 60304 (708) 660-4100 CP 08/01/1155343 Renal Dialysis 04/01/14 Maple Avenye Kidney Center I 0 610 S. Maple Avenue Oak Park IL 60304 (708) 660-4100 P 05/01/1450576 Renal Dialysis 01/01/05 Marion Dialysis I 0 324 S. 4th Street Marion IL 62959 (618) 997-841050235 Renal Dialysis 01/01/05 Maryville Dialysis I 0 2130 Vadalabene Drive Maryville IL 62062 (618) 288-070351119 Renal Dialysis 10/01/08 Maryville Home Dialysis I 0 2136 B Vadalabene Drive Maryville IL 62062 (618) 288-6208 A 02/01/0950575 Renal Dialysis 01/01/05 Mattoon Dialysis I 0 200 Richmond Ave East Mattoon IL 61938 (217) 234-8468

2102 Renal Dialysis 01/01/05 11/30/12 Merilliville Dialysis Center I 0 8670 Broadway Merrillville IN 46410 (219) 791-1000 CP 02/01/1350590 Renal Dialysis 01/01/05 Merrillville Dialysis I 0 9223 Taft Merrillville IN 46410 (219) 793-903552004 Renal Dialysis 12/01/12 Merrillville Dialysis Center I 0 8670 Broadway Merrillville IN 46410 (219) 791-1000 P 02/01/1350585 Renal Dialysis 01/01/05 Metro East Dialysis I 0 5105 W. Main Belleville IL 62226 (618) 233-901851820 Renal Dialysis 07/01/11 Metropolis Dialysis Services LLC I 0 20 Hospital Drive Metropolis IL 62960 (618) 524-3046 PN 12/01/1150222 Renal Dialysis 01/01/05 Mmb Dialysis Midwest Kidney Centers, LLC I 0 523 E. Grant Street Macomb IL 61455 (309) 836-166259438 Renal Dialysis 02/01/14 Moline Home Training I 0 4650 38th Avenue Moline IL 4650 38th (309) 736-4250 A 05/01/1451953 Renal Dialysis 08/01/12 Morris Dialysis I 0 1551 Creek Drive Morris IL 60450-6857 (815) 942-3995 A 10/01/1250577 Renal Dialysis 01/01/06 Mount Vernon Dialysis I 0 4102 N. Water Tower Place Mt. Vernon IL 62864 (618) 244-3407 AD 06/01/13

38 Renal Dialysis 01/01/05 Mt Sinai Hospital Medical Center I 0 2750 W 15th Pl Chicago IL 60608 (773) 542-200050557 Renal Dialysis 01/01/05 Mt. Greenwood Dialysis I 0 3401W. 111th Street Chicago IL 60655 (773) 445-0558

647 Renal Dialysis 01/01/05 Naperville Dialysis Center I 0 100 Spaulding Drive Naperville IL 60566 (630) 717-71712141 Renal Dialysis 01/01/05 08/31/13 Neomedica – Hazel Crest I 0 17524 Carriageway Hazel Crest IL 60429 (708) 798-2899 CP 02/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 7 Rev. 08-2014

Page 72: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

2140 Renal Dialysis 01/01/05 08/31/13 Neomedica – Munster I 0 314 Ridge Road Munster IN 46321 (312) 654-2715 CP 12/01/1350063 Renal Dialysis 01/01/05 Neomedica – Roundlake I 0 401 Nippersink Round Lake IL 60073 (847) 740-5281

673 Renal Dialysis 01/01/05 08/31/13 Neomedica Bridgeport I 0 825 W. 35th Street Chicago IL 60609 (773) 890-4330 CP 12/01/13670 Renal Dialysis 01/01/05 08/31/13 Neomedica Cumberland I 0 4701 Cumberland Avenue Norridge IL 60656 (708) 456-0152 CP 12/01/13695 Renal Dialysis 01/01/05 08/31/13 Neomedica Evergreen Park I 0 9730 S. Western Avenue Evergreen Park IL 60805 (312) 654-1100 CP 12/01/13690 Renal Dialysis 01/01/05 Neomedica Gurnee I 0 101 Greenleaf Gurnee IL 60031 (312) 249-5555692 Renal Dialysis 01/01/05 08/31/13 Neomedica Hoffman Estates I 0 3150 W. Higgins Rpooad Hoffman Estates IL 60195 (847) 310-0074 CP 12/01/13649 Renal Dialysis 01/01/05 08/31/13 Neomedica Marquette Park I 0 2534 W. 69th St Chicago IL 60629 (773) 471-8525 CP 12/01/13693 Renal Dialysis 01/01/05 08/31/13 Neomedica Melrose Park I 0 1111 Superior Street Melrose Park IL 60160 (708) 338-1780 CP 12/01/13657 Renal Dialysis 01/01/05 08/31/13 Neomedica North I 0 4800 N. Kilpatrick Chicago IL 60630 (773) 545-3693 CP 12/01/13674 Renal Dialysis 01/01/05 08/31/13 Neomedica Rolling Meadows I 0 4180 Winnetka Avenue Rolling Meadows IL 60008 (847) 394-6250 CP 12/01/13668 Renal Dialysis 01/01/05 08/31/13 Neomedica South Chicago I 0 9200 S. Chicago Ave Chicago IL 60617 (773) 734-7433 CP 12/01/13694 Renal Dialysis 01/01/05 08/31/13 Neomedica South Holland I 0 17225 S. Paxton Avenue South Holland IL 60473 (708) 474-8700 CP 12/01/13642 Renal Dialysis 01/01/05 08/31/13 Neomedica South Shore I 0 2420 E. 79th Street Chicago IL 60649 (773) 374-9002 CP 12/01/13

2135 Renal Dialysis 01/01/05 Nephron Dialysis I 0 5140 N. California Chicago IL 60625 (773) 293-210015 Renal Dialysis 01/01/05 Northshore University Healthsystem I 0 2650 Ridge Avenue Evanston IL 60201-1718 (847) 570-3100 TE 08/01/13

51580 Renal Dialysis 07/13/10 11/30/12 Northwest Indiana Dialysis I 0 569 Tyler Street Gary IN 45492-1829 (219) 885-3300 CP 02/01/13651 Renal Dialysis 01/01/05 03/01/13 Oak Park Community Dialysis I 0 733 Madison Street Oak Park IL 60302 (708) 386-8757 CP 05/01/13

50583 Renal Dialysis 01/01/05 Olney Dialysis I 0 117 N. Boone Street Olney IL 62450 (618) 393-423450059 Renal Dialysis 01/01/05 Olympia Fields Dialysis Center I 0 4557 B West Lincoln Hwy Matteson IL 60443 (708) 503-111251956 Renal Dialysis 08/01/12 Palos Park Dialysis I 0 13155 S. LaGrange Road Orland Park IL 60462-1162 (708) 923-0928 A 10/01/1251673 Renal Dialysis 12/01/10 Pittsfield Dialysis I 0 640 Washington St. Pittsfield IL 62363 (217) 285-2113 A 02/01/1150655 Renal Dialysis 01/01/05 PRS, LLC I 0 9300 Ballard Road DesPlaines IL 60616 (847) 294-230850464 Renal Dialysis 01/01/05 Quad Cities Kidney Center I 0 880 Crosstown Avenue Silvis IL 61282 (309) 762-5570

675 Renal Dialysis 01/01/05 Quad Cities Kidney Center Ltd I 0 400 John Deere Rd Moline IL 61265 (309) 762-55702104 Renal Dialysis 01/01/05 Quad Cities Kidney Ctr Ltd I 0 210 W. Elk St Geneseo IL 61254 (309) 736-1579

617 Renal Dialysis 01/01/05 Quality Renal Care Llc I 0 2203 Randall Rd Carpentersville IL 60110 (847) 426-645650724 Renal Dialysis 06/01/07 Quincy Medical Group I 0 1025 Maine Street Quincy IL 62301 (217) 222-6550 A 05/01/0952011 Renal Dialysis 11/01/12 RAI Centre West Springfield I 0 1112 Centre West Drive Springfield IL 62704 (217) 787-3310 A 03/01/1352013 Renal Dialysis 11/01/12 RAI Hamacher Waterloo I 0 509 Hamacher Drive Waterloo IL 62298 (618) 939-9003 A 03/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 8 Rev. 08-2014

Page 73: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

52018 Renal Dialysis 11/01/12 RAI Lincoln Hwy Fairview Heights I 0 821 Lincoln Hwy Fairview Heights IL 62208 (618) 632-9550 A 03/01/1352017 Renal Dialysis 11/01/12 RAI North Main Breese I 0 160 N. Main Street Breeze IL 62230 (618) 526-7370 A 03/01/1350322 Renal Dialysis 01/01/05 RCG - Morris Central Illinois I 0 1401 Lakewood Dr Morris IL 60450 (815) 942-609450354 Renal Dialysis 01/01/05 RCG – Central Illinois Canton I 0 210 W. Walnut Canton IL 61520 (309) 647-073150333 Renal Dialysis 01/01/05 RCG – Central Illinois Bloomington I 0 1505 Eastland Medical Plaza Bloomington IL 61701 (309) 664-2284 AD 09/01/1350324 Renal Dialysis 01/01/05 RCG – Central Illinois Decatur Home (was#50013) I 0 1830 S. 44th Street East Peoria IL 62521 (217) 423-676050332 Renal Dialysis 01/01/05 RCG – Central Illinois East Peoria I 0 3300 N. Main East Peoria IL 61611 (309) 698-658850331 Renal Dialysis 01/01/05 RCG – Central Illinois Pekin I 0 600 S. 13th Street Pekin IL 51554 (309) 353-762950427 Renal Dialysis 01/01/05 RCG - Merrionette Park I 0 11650 S. Kedzie Merrionette Park IL 60655 (708) 389-909950145 Renal Dialysis 01/01/05 RCG - Skokie I 0 9801 Woods Drive Skokie IL 60077 (847) 581-1620 AD 06/15/1150325 Renal Dialysis 01/01/05 RCG – Spring Valley I 0 12 Wolfer Industrial Drive Spring Valley IL 61362 (815) 664-458550326 Renal Dialysis 01/01/05 RCG – Spring Valley Central Illinois I 0 804 W. Madison Street Pontiac IL 61764 (815) 844-4340

638 Renal Dialysis 01/01/05 RCG Berwyn I 0 2601 S. Harlem, 1st Floor Berwyn IL 60402 (708) 484-730051735 Renal Dialysis 04/01/11 RCG Central Illinois Bloomington Capd I 0 1404 Eastland Drive Bloomington IL 61701 (309) 664-2284 A 06/01/1150148 Renal Dialysis 01/01/05 RCG -evanston I 0 2953 Central Street, 1st Fl Evanston IL 60201 (847) 869-943650146 Renal Dialysis 01/01/05 RCG -northwestern I 0 710 N. Fairbanks Ct Chicago IL 60611 (312) 274-020250330 Renal Dialysis 01/01/05 RCG –peoria Downtown I 0 410 W. Romeo B, Garrett Ave Peoria IL 61605 (309) 637-410050327 Renal Dialysis 01/01/05 RCG –peoria North Central Illinois I 0 10405 N. Juliet Court Peoria IL 61615 (309) 243-2200

631 Renal Dialysis 01/01/05 RCG South Suburban Kidney Group I 0 2609 W. Lincoln Highway Olympia Fields IL 60461 (708) 747-005050149 Renal Dialysis 01/01/05 RCG -villa Park I 0 200 E. North Avenue Villa Park IL 60181 (630) 617-880750323 Renal Dialysis 01/01/05 RCGCI – Decatur Home I 0 302 W. Hay Street Decatur IL 62526 (217) 876-686651951 Renal Dialysis 08/01/12 Renal Center New Lenox I 0 1890 Silver Cross Boulevard New Lenox IL 60451 (815) 740-7144 A 10/01/1251952 Renal Dialysis 08/01/12 Renal Center West Joliet I 0 1051 Essington Road Joliet IL 60435-2893 (815) 729-9240 A 10/01/12

616 Renal Dialysis 01/01/05 Renal Research Institute/d/b/a Champaign Urbana I 0 1405 W. Park Urbana IL 61801 (217) 328-410051672 Renal Dialysis 12/01/10 Robinson Dialysis I 0 1215 N. Allen Street Robinson IL 62454 (618) 544-7092 A 02/01/1150267 Renal Dialysis 01/01/05 Rockford Dialysis I 0 2400 N. Rockton Ave Rockford IL 61103 (815) 971-611850584 Renal Dialysis 01/01/05 Roxbury Dialysis Center I 0 622 Roxbury Road Rockford IL 61108 (815) 397-071350574 Renal Dialysis 01/01/05 Rushville Dialysis I 0 Route 2, Box 99A Rushville IL 62681 (217) 322-265252056 Renal Dialysis 04/01/13 Satellite Dialysis Of Glenview I 0 2601 Compass Road Glenview IL 60026 (847) 832-0001 A 07/01/1350558 Renal Dialysis 01/01/05 Sauget Dialysis I 0 2061 Goose Lake Road Sauget IL 62206 (618) 332-7801

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 9 Rev. 08-2014

Page 74: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50294 Renal Dialysis 01/01/05 Shelbyville Community Dialysis I 0 410 S. HeinleIn Drive Shelbyville IL 62565 (630) 690-464263 Renal Dialysis 01/01/05 Sherman Family Health Centers I 0 4900 South Route 31 Crystal Lake IL 60012 (847) 742-980064 Renal Dialysis 01/01/05 Silver Cross Hospital I 0 1900 Silver Cross Blvd. New Lenox IL 60451-9509 (815) 300-1100 TE

52586 Renal Dialysis 02/01/14 Silverbridge Home Training I 0 2410 Alift Lane Elgin Il 60124 (847) 289-5628 A 05/01/1450341 Renal Dialysis 01/01/05 Skyline Home Dialysis Fka Montclare Dialysis I 0 7009 Belmont Avenue Chicago IL 60634 (773) 889-605151452 Renal Dialysis 12/01/09 South Barrington Dialysis Ctr Llc I 0 33 W Higgins Road South Barrington IL 60010-9115 (847) 783-4700 A 02/01/1050627 Renal Dialysis 01/01/05 South Holland Renal Center I 0 16136 S. Park Avenue South Holland IL 60473 (708) 331-0200 PN 11/01/08

653 Renal Dialysis 01/01/05 Southside Dialysis Center I 0 7721 S. Western Avenue Chicago IL 60620 (773) 471-040050564 Renal Dialysis 01/01/05 Springfield Central Dialysis I 0 932 N. Rutledge Street Springfield IL 62702 (217) 788-368850563 Renal Dialysis 01/01/05 Springfield Montvale I 0 2930 S. Montvale Springfield IL 62704 (217) 793-278751954 Renal Dialysis 08/01/12 Springfield South Dialysis I 0 Springfield South Dialysis Springfield IL 62703-5944 (217) 528-1745 A 10/01/1252007 Renal Dialysis 12/01/12 St Margaret Mercy Dialysis Center, Llc I 0 5454 S. Hohman Avenue Hammond IN 46320 (219) 933-2089 P 02/01/13

2103 Renal Dialysis 01/01/05 11/30/12 St. Margaret Mercy Dialysis Center I 0 5454 S. Hohman Avenue Hammond IN 46320 (219) 933-2089 CP 02/01/1350578 Renal Dialysis 01/01/05 Stony Creek Dialysis I 0 9115 S. Cicero Avenue Oak Lawn IL 60453 (708) 423-030051702 Renal Dialysis 03/01/11 Stony Island Avenue I 0 8725 S. Stony Island Avenue Chicago IL 60617 (773) 221-7320 A 05/01/1150347 Renal Dialysis 01/01/05 Summit Medical Care I 0 1310 A W Eighteen Street Chicago IL 60608 (312) 491-970050366 Renal Dialysis 01/01/05 Sun Health I 0 2121 Oneida Street Joliet IL 60435 (815) 744-930050562 Renal Dialysis 01/01/05 Sycamore Dialysis Was Dekalb Dialysis I 0 2200 Gateway Drive Sycamore IL 60178 (815) 758-025050561 Renal Dialysis 01/01/05 Taylorville Dialysis I 0 901 W. Spresser Taylorville IL 62568 (217) 824-546050353 Renal Dialysis 01/01/05 The Jch Dialysis Center, Llc I 0 917 S. State Street Jerseyville IL 62552 (217) 223-840055220 Renal Dialysis 02/01/14 Timber Creek Dialysis I 0 1001 S. Annie Glidden Road DeKalb IL 60115 (815) 748-3074 A 05/01/1450582 Renal Dialysis 01/01/05 Trc Childrens Dialysis Center I 0 2611 N Halsted Chicago IL 60614 (773) 549-2010 A 08/01/1450019 Renal Dialysis 01/01/05 Tri-cities Dialysis, Llc. I 0 306 Randall Road Geneva IL 60504 (630) 851-4812

112 Renal Dialysis 01/01/05 University Of Illinois Medical Center I 0 1859 W. Taylor Chicago IL 60612 (312) 996-644452133 Renal Dialysis 10/01/13 US Renal Care Advanced Home Therapies I 0 200 E. North Avenue Villa Park IL 60181-1221 (630) 530-5237 A 11/01/1352130 Renal Dialysis 10/01/13 US Renal Care Bolingbrook I 0 396 Remington Blvd Bolingbrook IL 60440-4311 (630) 759-1943 A 11/01/1352129 Renal Dialysis 10/01/13 US Renal Care Oak Brook I 0 1201 Butterfield Road Downers Grove IL 60515-1074 (630) 968-0306 A 10/15/1352132 Renal Dialysis 10/01/13 US Renal Care Villa Park I 0 200 E North Avenue Villa Park IL 60181-1221 (630) 530-5237 A 11/01/1352131 Renal Dialysis 10/01/13 USRC Streamwood I 0 149 E. Irving Park Road Streamwood IL 60107-2950 (630) 289-2104 A 11/01/1351121 Renal Dialysis 10/01/08 Vandalia Dialysis I 0 301 Mattes Avenue Vandalia IL 62471 (618) 283-1366 A 02/01/09

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 10 Rev. 08-2014

Page 75: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #

Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50199 Renal Dialysis 01/01/05 04/18/11 Waterloo Home Training I 0 509 Hammacher Waterloo IL 62298 (618) 939-3133 C 07/01/1151113 Renal Dialysis 10/01/08 Wayne County Dialysis I 0 303 NW 11th Street Fairfield IL 62837-1203 (618) 842-7204 A 02/01/0950701 Renal Dialysis 01/01/08 Wellbound Of Evanston I 0 8950 Gross Point Road Skokie IL 60077 (847) 965-1901 01/01/0851839 Renal Dialysis 12/01/11 West Lawn Dialysis I 0 7000 S. Pulaski Road Chicago IL 60629 (773) 284-5324 A 02/01/12

2136 Renal Dialysis 01/01/05 West Metro Dialysis Center I 0 1044 N. Mozart Street Chicago IL 60622 (773) 772-9400676 Renal Dialysis 01/01/05 West Suburban Dialysis Center I 0 518 N. Austin Blvd Oak Park IL 60302 (708) 386-5550 AD 05/16/08

2110 Renal Dialysis 01/01/05 West Suburban Kidney Services, Inc/d/b/a North I 0 911 W. North Avenue Melrose Park IL 60160 (708) 344-6122 AD 06/01/1150580 Renal Dialysis 01/01/05 Whiteside Dialysis I 0 2600 N. Locust Sterling IL 61081 (815) 626-317351703 Renal Dialysis 03/01/11 Woodlawn Dialysis I 0 5060 S. State Street Chicago IL 60609-5328 (773) 924-2149 AD, TE 08/01/1251704 Renal Dialysis 03/01/11 Woodlawn Home Dialysis I 0 5841 S. Maryland Ave Chicago IL 60637 (773) 363-9938 A 05/01/1151644 Renal Dialysis 09/01/10 Woodridge Home Dialysis I 0 7425 Janes Avenue Woodridge IL 60517 (253) 382-1855 A 01/01/1151683 Renal Dialysis 01/01/11 Yorkville Dialysis Llc I 0 1400 N. Beecher Road Yorkville IL 60560-4812 (630) 851-4812 A 03/01/11

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 11 Rev. 08-2014

Page 76: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date1045 Skilled Nursing 01/01/06 Abington of Glenview I 0.5 3901 Glenview Road Glenview IL 60025-2467 (847) 729-0000 A 01/13/06

50159 Skilled Nursing 10/01/01 Alden Des Plaines I 0.5 1221 Golf Road Des Plaines IL 60016-1213 (847) 768-1300 P 05/01/0350246 Skilled Nursing 05/01/14 Alden Estates of Barrington I 0.5 1420 S. Barrington Barrington IL 60010 (847) 382-6664 A 05/01/1451916 Skilled Nursing 05/01/14 Alden Estates of Shorewood I 0.5 710 W. Black Road Shorewood IL 60404 (815) 230-8700 A 05/01/1451211 Skilled Nursing 06/01/14 Alden Estates of Skokie Inc. I 0.5 4660 Old Orchard Road Skokie IL 60070 (847) 676-4800 A 06/01/14

939 Skilled Nursing 01/01/96 Alden Lakeland Manor I 0.5 820 West Lawrence Ave Chicago IL 60640 (312) 769-25705089 Skilled Nursing 05/22/08 Alden Northshore Rehab & Health I 0.5 5050 Touhy Ave Skokie IL 60077-3542 (847) 679-6100 R 01/01/091117 Skilled Nursing 02/01/09 Alden Nursing Center-Evanston I 0.5 2520 Gross Point Road Evanston IL 60201 (847) 328-6000 R 02/01/09

783 Skilled Nursing 06/01/14 Alden Nursing Ctr - Naperville I 0.5 1525 Oxford Ln Naperville IL 60565 (630) 983-0300 A 06/01/145090 Skilled Nursing 04/01/00 Alden Orland Park Rehab. I 0.5 16450 S. 97th Ave. Orland Park IL 60467 (708) 403-6500 A 05/12/00

714 Skilled Nursing 05/01/14 Alden Poplar Creek Rehabilitation & Hlthcare I 0.5 1545 Barrington Road Hoffman Estates IL 60194 (847) 884-0011 A 06/01/141010 Skilled Nursing 05/01/14 Alden Valley Ridge Rehabilitation & Hlthcare I 0.5 275 E Army Trail Rd Bloomingdale IL 60108 (630) 898-9616 A 06/01/14

53064 Skilled Nursing 04/01/13 Aria Post Acute Care I 0.5 4600 N Frontage Road Hillside IL 60162-1761 (847) 933-2600 A 12/01/131130 Skilled Nursing 12/14/98 09/11/13 Aria Post Acute Care I 0.5 4600 N. Frontage Road Hillside IL 60162 (708) 544-9933 C 10/01/13

733 Skilled Nursing 01/01/96 05/31/11 Ballard Nursing Center I 0.5 9300 Ballard Road Des Plaines IL 60016 (847) 294-2300 CP 08/01/115401 Skilled Nursing 08/16/00 Beacon Hill I 0.5 2044 S Finley Road Lombard IL 60148 (630) 691-5850 A 09/01/001103 Skilled Nursing 10/01/06 06/01/12 Beecher Manor Nursing Rehab I 0.5 1201 Dixie Highway Beecher IL 60401-4040 (708) 946-2600 C 06/01/12

759 Skilled Nursing 07/28/10 Bethany Terrace Nursing Centre I 0.5 8425 Waukegan Road Morton Grove IL 60053 (847) 965-8100 W 08/01/1050714 Skilled Nursing 07/01/13 Brandel Care Center I 0.5 2155 Pfingsten Road Northbrook IL 60062 (847) 480-6350 A 07/01/1350011 Skilled Nursing 01/01/96 04/01/13 Brentwood North Health Care Center I 0.5 3705 Deerfield Road Riverwoods IL 60015 (847) 947-9000 C 04/01/1351091 Skilled Nursing 09/01/08 Brentwood North Healthcare & Rehab I 0.5 3705 Deerfield Road Riverwoods IL 60015 (847) 947-9000 TE 08/01/12

1107 Skilled Nursing 12/01/12 Bronzeville Park Nursing Living I 0.5 3400 S Indiana Ave Chicago IL 60616-3841 (312) 842-5000 R 12/01/121199 Skilled Nursing 01/01/02 02/29/12 Burgess Square Healthcare Center I 0.5 5801 S. Cass Ave. Westmont IL 60559-2300 (630) 971-2645 CP 06/01/12

51871 Skilled Nursing 03/01/12 Burgess Square Healthcare Center I 0.5 5801 S. Cass Ave. Westmont IL 60559-2300 (630) 971-2645 P 06/01/1251845 Skilled Nursing 12/01/11 Care Center of Abingdon I 0.5 801 W Martin Street Abingdon IL 61410-1401 (309) 462-2356 A 01/01/1251812 Skilled Nursing 06/04/12 Carlinville Rehab and Health Care Center I 0.5 751 N. Oak Street Carlinville IL 62626 (217) 854-2511 W 06/01/12

1002 Skilled Nursing 06/27/06 Carlton At The Lake, Inc I 0.5 725 West Montrose Ave. Chicago IL 60613 (773) 929-1700 R 03/30/071151 Skilled Nursing 02/27/09 Chicagoland Methodist Senior Services I 0.5 1415 W. Foster Ave Chicago IL 60640-2288 (773) 769-5500 N 10/01/11

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1 Rev.08-2014

Page 77: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50335 Skilled Nursing 03/01/08 Claremont Extended Healthcare I 0.5 150 N. Welland Road Buffalo Grove Il 60089 (847) 465-0200 R 05/01/0851778 Skilled Nursing 10/01/13 Claremont of Hanover Park I 0.5 2000 W Lake St Hanover Park IL 60133-4302 (847) 933-4600 R 10/01/13

947 Skilled Nursing 02/11/99 Clark Manor Convalescent Ctr. I 0.5 7433 N. Clark Chicago IL 60626 (773) 338-8778 R 04/01/9950507 Skilled Nursing 07/17/11 Community Convalescent Center I 0.5 1136 N. Mill Street Naperville IL 60563 (630) 355-3300 A 01/01/12

780 Skilled Nursing 01/01/96 02/01/12 Community Convalescent Center I 0.5 1136 North Mill Street Naperville IL 60563 (630) 355-3300 C 01/01/121127 Skilled Nursing 12/10/10 06/01/12 Countryside Care Center I 0.5 2330 W Galena Blvd Aurora IL 60506 (630) 896-4686 06/01/12

51927 Skilled Nursing 03/01/12 Countryside Care Center I 0.5 2330 W Galena Blvd Aurora IL 60506 (630) 896-4686 R & P 09/01/121126 Skilled Nursing 05/01/10 06/01/12 Crestwood Care Centre I 0.5 14255 S Cicero Ave Crestwood IL 60445-2154 (708) 371-0400 C 06/01/12

907 Skilled Nursing 11/01/01 06/04/13 Decatur Memorial Hospital SNF I 0.5 2300 N. Edward St. Decatur IL 62526-4163 (217) 877-8121 C 07/01/131169 Skilled Nursing 09/01/05 04/01/12 Dolton Health Care Rehab. I 0.5 14325 Blackstone Ave. Dolton IL 60416-1323 (708) 849-5000 C 04/01/12

793 Skilled Nursing 03/15/10 DuPage Convalescent Center I 0.5 400 N. County Farm Rd. Wheaton IL 60187 (630) 665-6400 R 03/01/1050054 Skilled Nursing 03/01/10 07/30/11 Elmbrook Healthcare Rehab Center I 0.5 127 W. Diversey Avenue Elmhurst IL 60126 (630) 530-5225 C 10/01/13

1047 Skilled Nursing 01/01/96 03/01/13 Elmcare/Elmhurst Mem. Hosp. - Transitional I 0.5 200 Berteau Elmhurst IL 60126 (630) 833-8200 C 03/01/13764 Skilled Nursing 01/01/96 Elmhurst Extended Care Center I 0.5 200 E. Lake Street Elmhurst IL 60126 (630) 516-5000 R 12/01/13

59048 Skilled Nursing 02/01/14 Evergreen Living and Rehab Center I 0.5 10124 S. Kedzie Ave. Evergreen Park IL 60805 (708) 907-7000 PN, TE 06/01/141195 Skilled Nursing 01/01/01 01/31/14 Evergreen Healthcare Center I 0.5 10124 S. Kedzie Ave. Evergreen Park IL 60803 (708) 636-9200 CP 06/01/141049 Skilled Nursing 01/01/96 Fairfield Mem. Hospital S.C.U. I 0.5 303 Northwest 11th Street Fairfield IL 62837 (618) 842-26111168 Skilled Nursing 02/02/99 Fairmont Care Centre I 0.5 5061 N. Pulaski Road Chicago IL 60630 (773) 604-8112 A 05/01/991084 Skilled Nursing 11/01/09 12/01/12 Fairview Baptist Home I 0.5 250 Village Drive Downers Grove IL 60516 (630) 769-6200 C 12/01/12

50114 Skilled Nursing 01/12/00 Forest Villa Nursing & Rehab. I 0.5 6840 W. Touhy Avenue Niles IL 60714-4520 (847) 647-6400785 Skilled Nursing 02/01/09 Friendship Village of Schaumburg I 0.5 350 W. Schaumburg Road Schaumburg IL 60194-3464 (847) 884-5000 N&TE 05/01/11

50220 Skilled Nursing 01/01/96 Gateway Regional Medical Center I 0.5 2100 Madison Ave. Granite City IL 62040 (618) 798-3013 PN 10/16/03954 Skilled Nursing 01/01/96 Glen Crest Nursing & Rehab. I 0.5 2451 W. Touhy Chicago IL 60645 (773) 338-6800952 Skilled Nursing 01/01/96 GlenBridge Nursing & Rehab. I 0.5 8333 W. Golf Road Niles IL 60714 (847) 966-9190

1033 Skilled Nursing 01/01/96 Glenshire Nursing & Rehab. I 0.5 22660 S. Cicero Ave. Richton Park IL 60471 (708) 747-6120974 Skilled Nursing 01/01/96 Glenview Terrace Nursing Ctr. I 0.5 1511 Greenwood Road Glenview IL 60025 (847) 729-9090710 Skilled Nursing 01/01/96 Gottlieb Mem. Hospital Extended Care I 0.5 701 W. North Ave. Melrose Park IL 60160 (708) 681-3200921 Skilled Nursing 06/01/10 Graham Hospital Extended Care I 0.5 210 W Walnut St. Canton IL 61520-2444 (309) 647-5240 A 06/01/10

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2 Rev.08-2014

Page 78: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50208 Skilled Nursing 01/01/96 08/01/13 Grant Hospital (SNF) I 0.5 550 W. Webster Chicago IL 60614 (773) 883-2000 C 08/01/1350128 Skilled Nursing 02/01/09 Greek American Rehab nursing Center I 0.5 220 N. First St. Wheeling IL 60090-2980 (847) 459-8700 A 02/01/0951823 Skilled Nursing 11/01/11 Greenville Regional Hospital d/b/a Fair Oaks I 0.5 200 Healthcare Drive Greenville IL 62246-1154 (618) 664-1230 A 01/01/12

725 Skilled Nursing 07/01/02 Hammond Henry District Hosp ECF I 0.5 210 W. Elk Street Geneseo IL 61254-1067 (309) 944-6431 A 07/09/021050 Skilled Nursing 02/10/12 Harmony Nursing & Rehab. Center I 0.5 3919 W. Foster Ave. Chicago IL 60625-6056 (773) 588-9500 R 02/01/12

50414 Skilled Nursing 05/01/14 Health Resource Solutions I 0.5 1806 S. Highland Avenue Lombard IL 60148 (312) 604-3740 A 08/01/141159 Skilled Nursing 10/01/98 Heartstone at Centegra I 0.5 527 W. South Street Woodstock IL 60098 (815) 334-5077 N 09/01/13

51970 Skilled Nursing 04/01/14 Helia Healthcare of Yorkville I 0.5 1308 Game Farm Road Yorkville IL 60560 (630) 553-5811 A 05/01/14901 Skilled Nursing 01/01/96 09/10/13 Highland Park Hosp. SNF Unit I 0.5 718 Glenview Ave. Highland Park IL 60035 (847) 432-8000 C 10/01/13

51611 Skilled Nursing 01/01/14 Highland Park Nursing Rehab. Center I 0.5 50 Pleasant Ave Highwood IL 60040-1813 (847) 432-9142 A 02/01/1451038 Skilled Nursing 10/01/08 10/20/11 Holy Family Health Care Center I 0.5 2380 E. Dempster St. Des Plaines IL 60016-4839 (847) 296-3335 C 11/01/11

732 Skilled Nursing 06/01/10 Hoopeston Com. Mem. Hosp. Nursing Home I 0.5 701 E. Orange St. Hoopeston IL 60942 (217) 283-5531 A 06/01/101103 Skilled Nursing 05/01/14 Jackson Square Nursing & Rehabilitation I 0.5 5130 W. Jackson Boulevard Chicago IL 60644 (773) 921-8000 A 05/01/14

52143 Skilled Nursing 09/01/13 Lake Forest Place I 0.5 1100 Pembridge Drive Lake Forest IL 60045-4228 (847) 604-8800 A 12/01/1351902 Skilled Nursing 04/01/13 Lakeview Rehab and Nursing Center I 0.5 735 E Diversey Chicago IL 60614-2337 (773) 348-4055 A 03/01/1350387 Skilled Nursing 10/01/12 Lexington Health Care Center of Lombard I 0.5 2100 S Finley Road Lombard IL 60148-4830 (630) 495-4000 A 10/01/1250376 Skilled Nursing 01/30/12 Lexington Health Care Chicago Ridge I 0.5 10300 Southwest Hwy. Chicago Ridge IL 60415-1426 (708) 425-1100 A 10/01/1250377 Skilled Nursing 12/01/12 Lexington Health Care Elmhurst I 0.5 420 W Butterfield Road Elmhurst IL 60126-4980 (630) 832-2300 A 12/01/1250378 Skilled Nursing 09/01/12 Lexington Health Care LaGrange I 0.5 4735 Willow Springs Road LaGrange IL 60525-6130 (708) 352-6900 A 09/01/1250379 Skilled Nursing 08/01/12 Lexington Health Care Lake Zurich I 0.5 900 S Rand Road Lake Zurich IL 60047-2450 (847) 726-1200 A 07/01/1250382 Skilled Nursing 11/01/12 Lexington Health Care Orland Park I 0.5 14601 S John Humphrey Dr Orland Park IL 60462 (708) 349-8300 A 11/01/1250380 Skilled Nursing 10/01/12 Lexington Health Care Schaumburg I 0.5 675 S Roselle Road Schaumburg IL 60193-3100 (847) 352-5500 A 10/01/1250384 Skilled Nursing 11/01/12 Lexington Health Care Streamwood I 0.5 815 E Irving Park Road Streamwood IL 60107-3073 (630) 837-5300 A 11/01/1250383 Skilled Nursing 12/01/12 Lexington Health Care Wheeling I 0.5 730 W Hintz Road Wheeling IL 60090-5501 (847) 537-7474 A 12/01/1250385 Skilled Nursing 12/01/12 Lexington Healthcare Bloomingdale I 0.5 165 S. Bloomingdale Road Bloomingdale IL 60108 (630) 980-8700 A 12/01/1250734 Skilled Nursing 05/01/14 Lieberman Center for Health and I 0.5 9700 Gross Point Road Skokie IL 60076 (847) 674-7210 A 05/01/1450479 Skilled Nursing 05/01/14 LifeCare Home Health Services I 0.5 3400 Dundee Road Northbrook IL 60062 (847) 205-4444 A 05/01/14

1143 Skilled Nursing 05/01/14 Lutheran Home Services I 0.5 800 W Oakton St Arlington IL 60004 (847) 253-3710 A 05/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3 Rev.08-2014

Page 79: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

50721 Skilled Nursing 02/01/08 Manor Care at Arlington Heights I 0.5 715 W. Central Road Arlington Hgts IL 60005 (847) 392-2020 A 06/01/0850672 Skilled Nursing 02/01/08 Manor Care at Naperville I 0.5 200 Martin Ave. Naperville IL 60540 (630) 355-4111 P 07/01/0850685 Skilled Nursing 02/01/08 Manor Care at South Holland I 0.5 2145 E. 170th Street South Holland IL 60473 (708) 895-3255 P 08/01/0850676 Skilled Nursing 11/17/10 Manor Care Health Serv. Oak Lawn East I 0.5 9401 S. Kostner Ave. Oak Lawn IL 60453 (708) 423-7882 A 03/10/0850688 Skilled Nursing 02/01/08 Manor Care Health Services - Elk Grove I 0.5 1920 Nerge Road Elk Grove Village IL 60007 (847) 301-0550 R 11/01/1350695 Skilled Nursing 04/30/11 Manor Care Health Services - Hinsdale I 0.5 600 West Ogden Ave. Hinsdale IL 60521 (630) 325-9630 P 07/01/0850693 Skilled Nursing 02/01/08 Manor Care Health Services - Westmont I 0.5 512 E. Ogden Ave. Westmont IL 60559 (630) 323-4400 P 07/01/0850696 Skilled Nursing 03/14/12 Manor Care Health Services Elgin I 0.5 180 S. State St. Elgin IL 60123-6429 (847) 742-3310 A 03/01/1250675 Skilled Nursing 02/01/08 Manor Care Health Services Northbrook I 0.5 3300 Milwaukee Avenue Northbrook IL 60062 (847) 795-9799 R 11/01/1350674 Skilled Nursing 08/01/14 Manor Care Health Services Oak Lawn West I 0.5 6300 W. 95th Street Oak Lawn IL 60453-2256 (708) 599-8800 A 08/01/1450677 Skilled Nursing 03/18/14 Manor Care Health Services Palos Heights I 0.5 11860 Southwest Highway Palos Heights IL 60463 (708) 361-4555 A 04/01/1450689 Skilled Nursing 06/01/14 Manor Care Homewood I 0.5 940 Maple Road Homewood IL 60430 (708) 799-0244 A 08/01/1450686 Skilled Nursing 03/20/14 Manor Care of Palos Heights (East) I 0.5 7850 W College Dr Palos Heights IL 60463 (708) 361-6990 A 04/01/1450673 Skilled Nursing 06/01/14 Manor Care of Rolling Meadows I 0.5 4225 Kirchoff Road Rolling Meadows IL 60008 (847) 397-2400 A 06/01/1450679 Skilled Nursing 05/01/14 Manor Care of Wilmette I 0.5 432 Poplar Drive Wilmette IL 60091 (847) 256-5000 A 07/01/1450687 Skilled Nursing 08/11/12 Manor Health Services Libertyville I 0.5 1500 S Milwaukee Ave. Libertyville IL 60048-3723 (847) 816-3200 A 02/01/1050373 Skilled Nursing 01/01/05 MarianJoy Rehab. Hospital & Clinic I 0.5 26 W. 171 Roosevelt Rd. Wheaton IL 60187-6078 (630) 909-8000 TE 09/01/12

1110 Skilled Nursing 02/01/14 Mayfield Care Center I 0.5 5905 W Washington Blvd Chicago IL 60644 (773) 261-7074 A1110 Skilled Nursing 02/14/14 Mayfield Care Center I 0.5 5905 W Washington Blvd Chicago IL 60644 (773) 261-7074 A 08/01/14

51926 Skilled Nursing 05/01/13 McKinley Court I 0.5 500 W McKinley Ave Decatur IL 62526-3281 (217) 875-0020 A 05/01/13970 Skilled Nursing 01/01/14 Meadowbrook Manor I 0.5 431 Remington Blvd Bolingbrook IL 60440-4918 (630) 759-1112 A 02/01/14

50455 Skilled Nursing 01/01/14 Meadowbrook Manor of LaGrange I 0.5 339 S. 9th Ave. LaGrange IL 60525-6429 (630) 759-1112 A 02/02/1459900 Skilled Nursing 02/01/14 Medina Nursing Center I 0.5 402 S. Center Street Durand IL 61024 (815) 248-2151 A 05/01/1451500 Skilled Nursing 12/01/09 Mercy Harvard Care Center I 0.5 901 Grant St. Harvard IL 60033-1821 (815) 943-2961 A 03/01/10

1149 Skilled Nursing 07/01/13 Michaelsen Health Center I 0.5 831 N Batavia Ave Batavia IL 60510 (630) 879-4300 R 07/01/13778 Skilled Nursing 11/19/08 Norridge Healthcare & Nursing Center I 0.5 7001 W. Cullom Ave. Norridge IL 60634 (708) 457-0700 W 12/01/08

1083 Skilled Nursing 03/01/10 Oak Brook Healthcare Centre I 0.5 2013 Midwest Road Oak Brook IL 60523-1312 (630) 495-0220 TE 05/01/111026 Skilled Nursing 01/01/96 Oakton Pavillion, Inc. I 0.5 1660 Oakton Place Des Plaines IL 60018 (847) 299-5588

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4 Rev.08-2014

Page 80: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

911 Skilled Nursing 05/01/96 Our Lady of the Resurrection I 0.5 5645 W. Addison Chicago IL 60634 (773) 282-70001060 Skilled Nursing 07/28/10 P. A. Peterson Home I 0.5 1311 Parkview Ave Rockford IL 61107 (815) 399-8832 W 08/01/10

50599 Skilled Nursing 01/01/14 Park Place Christian Community I 0.5 1150 S. Euclid Avenue Elmhurst IL 60126 (630) 909-7370 A 08/01/1450317 Skilled Nursing 01/01/05 Passavant Area Hospital I 0.5 1600 W. Walnut Street Jacksonville IL 62650 (217) 245-9541 A 03/08/0550244 Skilled Nursing 06/01/14 Prairie Manor Nursing and Rehab I 0.5 345 Dixie Highway Chicago Heights IL 60411 (847) 905-3000 A 08/01/1451755 Skilled Nursing 06/01/11 Presence Ballard Nursing Center I 0.5 9300 W Ballard Road Des Plaines IL 60016-4904 (847) 478-6382 N 11/01/1351051 Skilled Nursing 11/01/12 Presence Cor Mariae Center I 0.5 3330 Maria Linden Drive Rockford IL 61114-5480 (815) 877-7416 A 11/01/1350038 Skilled Nursing 06/25/08 Presence Mary Haven Nursing and Rehab I 0.5 1700 E. Lake Ave Glenview IL 60025 (847) 729-1300 N 11/01/1351005 Skilled Nursing 10/01/08 Presence Resurrection Life Center I 0.5 7370 W. Talcott Ave Chicago IL 60631-3751 (773) 594-7400 N 11/01/13

5411 Skilled Nursing 07/29/08 Presence Resurrection Nursing and Rehab I 0.5 1001 N. Greenwood Avenue Park Ridge IL 60068 (847) 692-5600 W 08/01/086 Skilled Nursing 01/01/96 Presence Saint Mary and Elizabeth Medical I 0.5 2233 W. Division Street Chicago IL 60622-3043 (312) 770-2000 N 12/01/13

51055 Skilled Nursing 11/01/13 Presence St. Anne Center I 0.5 4405 Highcrest Road Rockford IL 61107 (815) 229-1999 A 11/01/131201 Skilled Nursing 11/01/13 Presence Villa Scalabrini Nursing and Rehab. I 0.5 480 N Wolf Road Northlake IL 60164 (708) 562-0040 R 11/01/13

975 Skilled Nursing 01/01/96 Proctor Skilled Nursing Ctr. I 0.5 5409 N. Knoxville Ave. Peoria IL 60614 (309) 691-109351053 Skilled Nursing 05/01/12 Provena Mcauley Manor I 0.5 400 W Sullivan Road Aurora IL 60506-1452 (630) 859-3700 A 05/01/12

1019 Skilled Nursing 04/01/10 Providence Healthcare and Rehab. I 0.5 3450 Saratoga Avenue Downers Grove IL 60515 (630) 969-2900 N & R 04/01/101021 Skilled Nursing 04/01/10 Providence Healthcare and Rehab. I 0.5 13259 S Central Ave Palos Hts IL 60463 (708) 597-1000 N & R 04/01/10

781 Skilled Nursing 06/01/10 Providence Healthcare Rehab. South Holland I 0.5 16300 Wausau Avenue South Holland IL 60473 (708) 596-5500 R 06/01/101196 Skilled Nursing 08/23/11 Renaissance at 87th Street I 0.5 2940 W 87th Street Chicago IL 60652-3832 (773) 434-8787 A 09/01/11

50036 Skilled Nursing 12/01/08 Renaissance at Midway I 0.5 4437 S. Cicero Ave. Chicago IL 60632-4333 (773) 884-0484 A 12/01/0850787 Skilled Nursing 05/01/14 Renaissance Park South I 0.5 10935 S. Halsted Chicago IL 60628 (773) 928-2000 A 05/01/14

1189 Skilled Nursing 01/01/10 Resenaissance At South Shore, Inc I 0.5 2425 E. 71st. St. Chicago IL 60649-2612 (773) 721-5000 A 01/01/10976 Skilled Nursing 01/01/96 Richland Memorial Hospital SNF I 0.5 800 E. Locust Street Olney IL 62450 (618) 395-2131795 Skilled Nursing 06/01/14 Rolling Hills Manor I 0.5 3615 16th Street Zion IL 60099 (847) 746-8382 A 08/01/14

50739 Skilled Nursing 04/01/09 Rosewood Care Center of Joliet I 0.5 3401 Hennepin Drive Joliet IL 60431-1080 (815) 436-5900 W 05/01/0950745 Skilled Nursing 04/01/09 Rosewood Care Center Rockford I 0.5 1660 S Mulford Road Rockford IL 61108-6760 (815) 397-8700 W 05/01/09

40 Skilled Nursing 02/01/97 Rush Oak Park Hospital I 0.5 520 S. Maple Ave. Oak Park IL 60304-1022 (708) 383-930050704 Skilled Nursing 11/29/10 02/01/11 Salem Village Nursing Home I 0.5 1314 Rowell Ave Joliet IL 60433-2866 (815) 727-5451 AC 03/01/11

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 5 Rev.08-2014

Page 81: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

1158 Skilled Nursing 10/01/98 Schwab Rehabilitation Center I 0.5 1401 S. California Ave. Chicago IL 60608-1858 (773) 522-2010 R 05/01/08955 Skilled Nursing 01/01/95 Sherman West Court I 0.5 1950 Larkin Ave Elgin IL 60123 (847) 742-7070 08/01/11934 Skilled Nursing 01/01/96 South Suburban Hosp. SNF I 0.5 17800 S. Kedzie Ave. Hazel Crest Il 60429 (708) 799-8000

1022 Skilled Nursing 01/01/96 St. Anthony's Health Center I 0.5 915 East Fifth Street Alton IL 62002-0340 (616) 463-51185407 Skilled Nursing 06/25/08 St. Benedict Nursing and Rehab I 0.5 6930 W Touhy Ave Niles IL 60714-4522 (867) 647-0003 W5410 Skilled Nursing 06/25/08 11/30/13 St. Francis Extended Care Facility I 0.5 500 Asbury Ave Evanston IL 60202 (847) 869-3600 C 01/01/14

757 Skilled Nursing 01/01/96 St. John's Hospital North Gen LTC I 0.5 800 East Carpenter Springfield IL 62702 (217) 544-64645448 Skilled Nursing 06/30/01 St. Joseph Hospital, SNF I 0.5 2900 North Lake Shore Dr. Chicago IL 60657 (773) 975-3000 PN 08/01/011156 Skilled Nursing 12/07/10 St. Mary and Elizabrth Medical Center I 0.5 2233 W. Division Chicago IL 60622-8151 (312) 770-2000 A 10/01/11

919 Skilled Nursing 01/01/96 10/01/12 St. Mary's Hosp. ECF I 0.5 111 Spring Street Streator IL 61364 (815) 673-2311 C 10/01/12967 Skilled Nursing 01/01/96 St. Vincent Mem. Hospital SNF I 0.5 201 East Pleasant Taylorville IL 62568 (217) 824-3331922 Skilled Nursing 01/01/96 Swedish Covenant Hosp. ECF I 0.5 5145 North California Ave. Chicago IL 60625 (773) 878-8200 R 08/01/08

51929 Skilled Nursing 03/01/12 Symphony of Crestwood Care Centre I 0.5 14255 S Cicero Ave Crestwood IL 60445-2154 (708) 371-0400 N 12/01/1351934 Skilled Nursing 04/01/13 Symphony of Joliet I 0.5 306 N. Larkin Ave. Joliet IL 60435 (815) 744-5560 N 12/01/1351931 Skilled Nursing 03/01/12 10/01/13 Symphony of Lincoln I 0.5 2202 N. Kickapoo St. Lincoln IL 62656 (217) 735-1538 N 10/01/13

968 Skilled Nursing 10/20/11 The Imperial Grove Pavillion I 0.5 1366 W. Fullerton Ave. Chicago IL 60614 (773) 248-9300 R 11/01/1152142 Skilled Nursing 09/01/13 The Moorings of Arlington Heights I 0.5 811 E. Central Road Arlington Hgts. IL 60005-3244 (888) 601-3027 A 12/01/1350262 Skilled Nursing 08/01/14 The Tillers Nursing & Rehab Center I 0.5 4390 Rt 71 Oswego IL 60543 (630) 554-1001 A 09/01/1458763 Skilled Nursing 09/01/13 The Villa at South Holland LLC I 0.5 16300 Wausau Ave. South Holland IL 60473-2158 (708) 596-5500 A 01/01/14

1063 Skilled Nursing 02/01/96 12/01/13 Transitional Care Center/Evanston & I 0.5 2650 Ridge Ave. Evanston IL 60201 (847) 570-2900 C 01/01/1452090 Skilled Nursing 07/01/13 VHS of Illinois d/b/a Macneal Hospital I 0.5 3249 S Oak Park Ave Berwyn IL 60402-3429 (708) 783-3002 A 09/01/1352090 Skilled Nursing 07/01/13 VHS of Illinois d/b/a/ Macneal Hospital I 0.5 3249 S Oak Park Ave Berwyn IL 60402-3429 (708) 783-3002 A 09/01/1351589 Skilled Nursing 08/01/10 VHS West Suburban Medical Center SNF I 0.5 Erie at Austin Oak Park IL 60302 (708) 363-6200 PN 08/01/1051588 Skilled Nursing 08/01/10 VHS Westlake Hospital Inc I 0.5 1225 Superior Street Melrose Park IL 60160 (708) 681-3000 PN 08/01/1051811 Skilled Nursing 06/04/12 Villa Health Care East I 0.5 100 Marian Parkway Sherman IL 62684 (217) 744-2299 W 06/01/1259146 Skilled Nursing 02/01/14 Warren Barr Living and Rehab I 0.5 66 W Oak St. Chicago IL 60610 (312) 705-5100 PN 04/01/1450189 Skilled Nursing 01/01/96 01/31/14 Warren Barr Pavilion I 0.5 66 West Oak Chicago Il 60610 (312) 337-5400 CP 04/01/14

977 Skilled Nursing 01/01/96 West Suburban Hospital I 0.5 Erie at Austin Oak Park IL 60302 (708) 363-6200

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 6 Rev.08-2014

Page 82: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider #Provider

TypeEffective

DateCancel

Date Provider Name ClassDay

Charge Address City State Zip TelephoneChange

CodeChange

Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

2100 Skilled Nursing 03/09/07 Westminster Place I 0.5 3200 Grant Street Evanston IL 60201 (847) 492-4802 N 12/01/1350368 Skilled Nursing 06/22/05 Whitehall of Deerfield I 0.5 3000 Waukegan Road Deerfield IL 60015 (847) 945-4600 PN 05/08/0650359 Skilled Nursing 07/01/13 Windsor Park Manor I 0.5 110 Windson Park Drive Carol Stream IL 60188-1986 (630) 682-4491 A 07/01/1352092 Skilled Nursing 08/01/13 Winning Wheels Inc I 0.5 701 E Third St. Prophetstown IL 61277-1334 (815) 537-5168 A 09/01/1351650 Skilled Nursing 10/01/10 Wynscape Health and Rehab. I 0.5 2180 W. Manchester Road Wheaton IL 60187-4580 (630) 665-4330 A 01/01/11

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 7 Rev.08-2014

Page 83: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

50211 Substance Use Disorder 07/01/13 Advocate Addiction Treatment Prog X * 701 Lee Street Des Plaines IL 60016 (847) 795-3900402 Substance Use Disorder 02/01/99 Alexian Behavioral Health Hospital X * 1650 Moon Lake Blvd. Hoffman Estates IL 60007 (847) 882-1600

50396 Substance Use Disorder 11/01/13 Arlington Center for Recovery X * 1655 S Arlington Hts Rd Arlington Hgts IL 60005 (847) 427-9680 A 11/01/131818 Substance Use Disorder 11/01/13 Ben Gordon Center X * 12 Health Services Dr. Dekalb IL 60115 (817) 756-4875 A 11/01/13

50203 Substance Use Disorder 09/01/12 Care Addiction Treatment Program X * 309 Hamilton Street Geneva IL 60134-2182 (630) 402-0144 C 09/01/1351118 Substance Use Disorder 12/01/08 Center for Alcohol and Drug Services X * 4230 11th St. Rock Island IL 61201-6746 (309) 788-4571 A 10/01/1151602 Substance Use Disorder 07/01/10 Center for Alcohol and Drug Services X * 621 17th Ave. East Moline IL 61244-2036 (563) 322-2667 A 10/01/1052100 Substance Use Disorder 08/01/13 Centerpointe Hospital X * 815 East 5th St Alton IL 62002-6471 (636) 441-7300 A 10/01/13

363 Substance Use Disorder 01/01/95 Central DuPage Hospital X * 25 North Winfield Road Winfield IL 60190 (630) 933-1600552 Substance Use Disorder 11/01/13 Chestnut Health Systems Inc. X * 702 W. Chestnut St Bloomington IL 61701-2814 (309) 820-3500 A 10/01/13339 Substance Use Disorder 01/01/95 Christ Hospital X * 4440 W. 95th Street Oak Lawn IL 60453 (708) 684-1337 TE 08/01/13

51355 Substance Use Disorder 08/01/09 Confidential Care LTD X * 720 45th St. Munster IN 46321-2818 (219) 934-6410 TE 08/01/101829 Substance Use Disorder 03/01/00 Cornell Interventions X * 901 West Jackson Blvd. Chicago IL 60607 (312) 421-0817 A 03/01/091838 Substance Use Disorder 12/01/00 Families and Adolescents in Recovery Inc. X * 2010 E. Algonquin Road Schaumburg IL 60173-4185 (847) 359-5191 A 09/01/13

801 Substance Use Disorder 01/01/95 Franciscan St. Margaret Mercy Hospital X * 24 JOLIET STREET DYER IN 46311 (219) 865-2141 N 05/01/1152080 Substance Use Disorder 05/01/13 Gateway FDT Chicago River North X * 444 North Orleans St. Chicago IL 60654-8193 (312) 464-9451 A 08/01/13

557 Substance Use Disorder 12/01/10 Gateway Foundation X * 600 W. Lincoln Ave Caseyville IL 62232-1329 (618) 345-4398 TE 07/01/1351546 Substance Use Disorder 04/01/10 Gateway Foundation , Inc X * 400 Mercy Lane Aurora IL 60506 (630) 966-7400 TE 07/01/1351547 Substance Use Disorder 04/01/10 Gateway Foundation Carbondale X * 1080 E Park St. Carbondale IL 62901 (618) 529-1151 TE 07/01/1351543 Substance Use Disorder 04/01/10 Gateway Foundation Inc X * 25480 W. Cedar Crest Lane Lake Villa IL 60506 (847) 356-8205 TE 07/01/1351542 Substance Use Disorder 04/01/10 Gateway Foundation Inc. X * 3828 W. Taylor St Chicago IL 60624 (773) 826-1916 AD& TE 07/01/1351544 Substance Use Disorder 04/01/10 Gateway Foundation Inc. X * 2200 Lake Victoria Dr. Springfield IL 62703-5596 (217) 529-9266 TE 07/01/1351541 Substance Use Disorder 04/01/10 Gateway Foundation Inc. Chop NW X * 4301 W Grand Ave. Chicago IL 60651 (773) 862-2279 TE 07/01/1352078 Substance Use Disorder 05/01/13 Gateway Foundation Pekin X * 11 South Capital Pekin IL 61554-4106 (309) 346-7800 A 09/01/1351545 Substance Use Disorder 04/01/10 Gateway Foundation Swansea X * 1 Bronze Point Swansea IL 62220-1435 (618) 234-9002 N & AD 10/01/13

77 Substance Use Disorder 01/01/95 Good Samaritan Hospital - Advocate X * 3815 Highland Avenue Downers Grove IL 60515 (630) 275-5900

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 1

Rev. 08-2014

Page 84: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

1831 Substance Use Disorder 12/01/10 Haymarket Center X * 120 N. Sangamon Chicago IL 60607 (312) 226-7984 A 01/01/111814 Substance Use Disorder 11/20/97 Hazelden Chicago X * 867 N. Dearborn Street Chicago IL 60610-3310 (312) 943-35341834 Substance Use Disorder 06/08/04 Healthcare Alternative Systems, Inc. X * 2755 W. Armitage Chicago IL 60647-4244 (773) 252-3100

580 Substance Use Disorder 01/01/95 Human Service Center X * 1200 Hamilton Blvd. Peoria IL 61606-1525 (309) 671-8040 A 10/01/11569 Substance Use Disorder 11/01/13 Human Services Center X * 10257 State Route #3 Red Bud IL 62278 (618) 282-6233 A 11/01/13

25 Substance Use Disorder 01/01/96 Ingalls Memorial Hospital X * One Ingalls Drive Harvey IL 60426 (708) 333-230051620 Substance Use Disorder 09/01/10 12/01/13 K P Counseling Inc. X * 461 N. Mulford Road Rockford IL 61107-5190 (779) 368-0060 C 01/01/1451701 Substance Use Disorder 02/01/11 Kingdom Living Outreach Serv. Inc X * 20303 S. Crawford Ave. Olympia Fields IL 60461 (708) 747-9399 A 04/01/11

497 Substance Use Disorder 01/01/95 Linden Oaks Hospital X * 852 West Street Naperville IL 60540 (630) 305-5500593 Substance Use Disorder 11/01/13 Lutheran Social Services of IL Behav. X * 675 Varsity Drive Elgin IL 60120 (847) 741-2600 A 11/01/13

52125 Substance Use Disorder 09/01/13 Maryville Residential Treatment Center X * 1150 N River Road Des Plaines IL 60016-1214 (847) 768-5373 A 11/01/1351944 Substance Use Disorder 09/01/12 New Hope Recovery Center X * 2835 N. Sheffield Chicago IL 60657 (773) 883-3916 A 09/01/13

15 Substance Use Disorder 01/01/95 NorthShore University Health System X * 2650 Ridge Avenue Evanston IL 60201-1718 (847) 570-3100 N 10/01/08334 Substance Use Disorder 01/01/95 Northwest Community Hospital X * 800 W. Central Rd. Arlington Hgts IL 60005 (847) 618-1000

51689 Substance Use Disorder 02/01/11 11/30/13 Northwestern Lake Counseling X * 17 W Grand Ave. Fox Lake IL 60020-1209 (847) 587-8400 CA 01/01/1451751 Substance Use Disorder 04/01/11 Pillars Commnity Service X * 8020 W. 87th St. Hickory Hills IL 60457-1189 (708) 745-5277 A 08/01/1151753 Substance Use Disorder 04/01/11 Pillars Community Service X * 333 N LaGrange Road LaGrange Park IL 60526-5646 (708) 745-7211 A 08/01/11

607 Substance Use Disorder 11/22/10 Prairie Center for Sub. Abuse X * 718 W Killarney Urban IL 61801 (217) 328-4500 A 12/01/10340 Substance Use Disorder 01/01/95 Presence Holy Family Medical Center X * 100 N. River Road DesPlaines IL 60016 (847) 813-3841 N 10/01/13

50595 Substance Use Disorder 05/01/07 Presence Resurrection Behavioral Health X * 2001 Butterfield Road Downers Grove IL 60515 (847) 493-3600 N & TE 08/01/13415 Substance Use Disorder 01/01/95 Presence St. Joseph Hospital X * 2900 North Lake Shore Dr. Chicago IL 60657 (773) 665-3000 N 10/01/13117 Substance Use Disorder 01/01/95 Proctor Community X * 5409 North Knoxville Ave. Peoria IL 61614 (309) 691-1000 A 09/01/13564 Substance Use Disorder 11/01/13 Project Coat X * 9730 S. Western Avenue Evergreen IL 60805 (708) 425-3000 A 11/01/13

51625 Substance Use Disorder 09/01/10 Radius Foundation Inc. X * 11952 S Harlem Ave Palos Heights IL 60463 (708) 923-0800 A 10/01/1152089 Substance Use Disorder 07/01/13 Restore Counseling & Recovery Inc. X * 7210 E State St. Rockford IL 61108-2622 (815) 708-7392 A 09/01/1353648 Substance Use Disorder 03/01/14 Rosecrance Belvidere Clinic X * 915 Alexandra Drive Belvidere IL 61008 (888) 928-5278 A 05/01/14

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 2

Rev. 08-2014

Page 85: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

53591 Substance Use Disorder 03/01/14 Rosecrance Crystal Lake X * 422 Tracy Court Crystal Lake IL 60014 (815) 363-6132 A 05/01/1452087 Substance Use Disorder 07/01/13 Rosecrance Frankfort Office X * 20635 Abbey Woods Ct North Frankfort IL 60423-3181 (815) 387-5600 A 08/01/1352084 Substance Use Disorder 07/01/13 Rosecrance Greendale House X * Rosecrance Greendale House Rockford IL 61109-1575 (815) 391-4095 A 08/01/1350292 Substance Use Disorder 07/01/11 Rosecrance Griffin Williamson X * 1601 University Dr. Rockford IL 61107-5317 (815) 391-1000 PN 07/01/1350052 Substance Use Disorder 07/01/11 Rosecrance Harrison Campus X * 3815 Harrison Avenue Rockford IL 61108 (815) 391-1000 PN 07/01/1352085 Substance Use Disorder 07/01/13 Rosecrance Marlowe House X * 1365 University Dr. Rockford IL 61107-5319 (815) 229-9190 A 08/01/1351987 Substance Use Disorder 07/01/12 Rosecrance McHenry County X * 4501 Prime Parkway McHenry IL 60050-8350 (815) 363-6132 AD 02/01/1452124 Substance Use Disorder 09/01/13 Rosecrance Naperville Office X * 608 Washington St. Naperville IL 60540 (815) 387-5600 A 11/01/1352121 Substance Use Disorder 09/01/13 Rosecrance Northbrook Office X * 1200 Shermer Road Northbrook IL 60062 (815) 387-5600 A 11/01/1352123 Substance Use Disorder 09/01/13 Rosecrance Oak Park Office X * 120 S Marion St. Oak Park IL 60302-2809 (815) 387-5600 A 11/01/1352083 Substance Use Disorder 07/01/13 Rosecrance Triage Center X * 526 W State St Rockford IL 61101-1214 (815) 387-5600 A 08/01/1351152 Substance Use Disorder 03/01/09 Serenity House Counsel Services X * 891 S Route 53 Addison IL 60101 (630) 620-7924 A 05/01/0950069 Substance Use Disorder 03/01/02 Share Program X * 1776 Moonlake Blvd. Hoffman Estates IL 60194 (847) 882-4181

64 Substance Use Disorder 01/01/95 Silver Cross Hospital X * 1900 Silver Cross Blvd. New Lenox IL 60451-9509 (815) 300-1100 TE 08/01/1251818 Substance Use Disorder 11/01/11 Soft Landing Interventions X * 1601 Bond Street Naperville IL 60563 (630) 261-9220 AD 08/01/13

561 Substance Use Disorder 05/01/10 Sojourn House, Inc. X * 565 N. Turner Ave. Freeport IL 61032 (815) 232-5121 A 06/01/10559 Substance Use Disorder 11/01/13 South Suburban Council X * 1909 Checker Square East Hazel Crest IL 60429 (708) 957-2854559 Substance Use Disorder 11/01/13 South Suburban Council on Alcohol X * 1901 Checker Square East Hazel Crest IL 60429 (708) 957-2854 A 11/01/13248 Substance Use Disorder 01/01/97 St. Elizabeth's Hospital X * 211 S. Third Street Belleville IL 62220 (618) 234-2120576 Substance Use Disorder 01/01/95 Stepping Stones Recovery Center X * 1621 Theodore Street Joliet IL 60435 (815) 744-4555

1821 Substance Use Disorder 06/01/99 The Advantage Group X * 400 Haber Road Cary IL 60013 (815) 444-6400

51895 Substance Use Disorder 04/01/12The Child, Adolescent and Family Recovery Center, LLC X * 900 North Shore Dr. Lake Bluff IL 60044 (847) 457-6730 A 05/01/12

51921 Substance Use Disorder 07/01/12 The Way Back Inn X * 1915 West Roosevelt Road Broadview IL 60155-2925 (708) 344-3301 A 09/01/12579 Substance Use Disorder 03/25/11 The Wells Center X * 1300 Lincoln Avenue Jacksonville IL 62650-3112 (217) 243-1871 A 04/01/11

50012 Substance Use Disorder 08/01/01 Therapeutic Interventions Inc. X * 1545 Hicks Road Rolling Meadows IL 60008-1222 (847) 991-4800 C 12/01/13

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 3

Rev. 08-2014

Page 86: HMO Illinois, Blue Advantage HMO and Blue Precision … › pdf › standards › hmo › appendix_d.pdf · Date Cancel Date Provider Name Class Day Charge Address City State Zip

Provider # Provider Type

Effective Date

Cancel Date Provider Name Class

Day Charge Address City State Zip Telephone

Change Code

Change Date

Appendix D HMO Illinois, Blue Advantage HMO and Blue Precision Contracting Providers

51946 Substance Use Disorder 11/01/12 Timberline Knolls X * 40 Timberline Lemont IL 60439 (630) 257-9600 N 04/01/141822 Substance Use Disorder 09/01/10 Triangle Center X * 120 N. 11th Springfield IL 62703 (217) 544-9858

51588 Substance Use Disorder 08/01/10 VHS Westlake Hospital Inc X * 1225 SUPERIOR STREET MELROSE PARK IL 60160 (708) 681-3000 PN 08/01/1050713 Substance Use Disorder 04/01/08 Weckler and Associates Ltd X * 68 Ambrogio Dr. Gurnee IL 60031 (847) 662-5588 A 07/01/08

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association*Day charge depends on the type of utilization

Change Codes:A: NewC: CancelN: Prov. Name P: Prov. NumberR: ReinstateAC: Accrediation CancelAD: AddressCP: Cancel prov # changedPN: Name and Number TE: Telephone NumberTI: Transfer into a classTO: Transfer out of a class 4

Rev. 08-2014


Community Blue Medicare HMO and Security Blue HMO 2016 ... · Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) group each medication

Community Blue Medicare HMO and Security Blue HMO 2016 ... · Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) group each medication

Anthem Blue Cross Traditional HMO 2021

Anthem Blue Cross Traditional HMO 2021

HMO Blue - BCBS Electronic Sales Kit

HMO Blue - BCBS Electronic Sales Kit

Summary of Benefits - Blue Cross Blue Shield of Nebraska · Blue Cross Blue Shield Nebraska MA Core HMO and Choice HMO-POS. Summary of Benefits. January 1, 2018 — December 31, 2018.

Summary of Benefits - Blue Cross Blue Shield of Nebraska · Blue Cross Blue Shield Nebraska MA Core HMO and Choice HMO-POS. Summary of Benefits. January 1, 2018 — December 31, 2018.

2016 Provider Directory - Blue Cross Blue Shield … Provider Directory Blue Cross Medicare Advantage Basic (HMO) SM Blue Cross Medicare Advantage Premier Plus (HMO-POS) SM Y0096_BEN_OK_HMOPRDR16

2016 Provider Directory - Blue Cross Blue Shield … Provider Directory Blue Cross Medicare Advantage Basic (HMO) SM Blue Cross Medicare Advantage Premier Plus (HMO-POS) SM Y0096_BEN_OK_HMOPRDR16

Blue Shield 65 Plus (HMO), Blue Shield Inspire …...blue of california Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and Blue Shield Vital (HMO) Provider Directory/Directorio

Blue Shield 65 Plus (HMO), Blue Shield Inspire …...blue of california Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and Blue Shield Vital (HMO) Provider Directory/Directorio

Blue Cross Medicare Advantage (HMO/HMO-POS)SM · PDF fileY0096_BEN_TMP_MAPRDIRCVR14a Approved 08132013 850275.0414 Blue Cross Medicare Advantage (HMO/HMO-POS)SM 2014 Provider Directory

Blue Cross Medicare Advantage (HMO/HMO-POS)SM · PDF fileY0096_BEN_TMP_MAPRDIRCVR14a Approved 08132013 850275.0414 Blue Cross Medicare Advantage (HMO/HMO-POS)SM 2014 Provider Directory

Blue Advantage HMO

Blue Advantage HMO

Dental HMO Voluntary - Blue Shield of California€¦ · SG-) Blue Shield of California Plan dental HMO Dental HMO Voluntary Resumen de beneficios Desde el 1 de enero de 2019 ESTA

Dental HMO Voluntary - Blue Shield of California€¦ · SG-) Blue Shield of California Plan dental HMO Dental HMO Voluntary Resumen de beneficios Desde el 1 de enero de 2019 ESTA

MIIA - Blue Cross Blue Shield Proposed Benefits. Plan Offerings HMO Blue New England (HMO) Blue Care Elect Preferred (PPO)

MIIA - Blue Cross Blue Shield Proposed Benefits. Plan Offerings HMO Blue New England (HMO) Blue Care Elect Preferred (PPO)

Blue Cross and Blue Shield of Illinois 2010 Quality ... · 2010. 1. HMO ILLINOIS / BLUEADVANTAGE HMO . All HMO Geoaccess standards were met in 2009 as reported in 2010. Analysis of

Blue Cross and Blue Shield of Illinois 2010 Quality ... · 2010. 1. HMO ILLINOIS / BLUEADVANTAGE HMO . All HMO Geoaccess standards were met in 2009 as reported in 2010. Analysis of

Codes that require Prior Approval for Blue Medicare HMO ... · (HMO) January 2020 Page 2 SPECIAL NOTES: Please refer to the Blue Medicare HMO/PPO and Experience Health Medicare Advantage

Codes that require Prior Approval for Blue Medicare HMO ... · (HMO) January 2020 Page 2 SPECIAL NOTES: Please refer to the Blue Medicare HMO/PPO and Experience Health Medicare Advantage

Blue Shield 65 Plus (HMO) / Blue Shield 65 Plus Choice ...€¦ · Blue Shield 65 Plus (HMO) / Blue Shield 65 Plus Choice Plan (HMO ... (800) 776-4466, de 8:00 a. m. a 8:00 p. m.,

Blue Shield 65 Plus (HMO) / Blue Shield 65 Plus Choice ...€¦ · Blue Shield 65 Plus (HMO) / Blue Shield 65 Plus Choice Plan (HMO ... (800) 776-4466, de 8:00 a. m. a 8:00 p. m.,

Summary of Benefits 2021 Blue Advantage (HMO) and Blue ... · 2 MEDIC VANTA 2021 Blue Advantage (HMO) | Blue Advantage (PPO) Summary of Benefits Plans may offer supplemental benefits

Summary of Benefits 2021 Blue Advantage (HMO) and Blue ... · 2 MEDIC VANTA 2021 Blue Advantage (HMO) | Blue Advantage (PPO) Summary of Benefits Plans may offer supplemental benefits

Blue Cross Medicare Advantage (HMO/HMO … Approved 08132013 850275.0414 Blue Cross Medicare Advantage (HMO/HMO-POS)SM 2014 Provider Directory January 1, 2014 - December 31, 2014 ...

Blue Cross Medicare Advantage (HMO/HMO … Approved 08132013 850275.0414 Blue Cross Medicare Advantage (HMO/HMO-POS)SM 2014 Provider Directory January 1, 2014 - December 31, 2014 ...

Blue Cross and Blue Shield of Illinois Provider Manual HMO ... · BCBSIL Provider Manual — May 2018 1 Blue Cross and Blue Shield of Illinois Provider Manual HMO Medical Service

Blue Cross and Blue Shield of Illinois Provider Manual HMO ... · BCBSIL Provider Manual — May 2018 1 Blue Cross and Blue Shield of Illinois Provider Manual HMO Medical Service

2020 SUMMARY OF BENEFITS · 2020-01-28 · This Summary of Benefits booklet gives you a summary of what Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare

2020 SUMMARY OF BENEFITS · 2020-01-28 · This Summary of Benefits booklet gives you a summary of what Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare

Anthem Blue Cross High HMO

Anthem Blue Cross High HMO

Horizon Blue Cross Blue Shield of New · Horizon Blue Cross Blue Shield of New Horizon Medicare Blue Advantage (HMO) Horizon Medicare Blue Select (HMO-POS) Horizon Medicare Blue Rx

Horizon Blue Cross Blue Shield of New · Horizon Blue Cross Blue Shield of New Horizon Medicare Blue Advantage (HMO) Horizon Medicare Blue Select (HMO-POS) Horizon Medicare Blue Rx

Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and ......blue of california Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and Blue Shield Vital (HMO) Provider Directory/Directorio

Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and ......blue of california Blue Shield 65 Plus (HMO), Blue Shield Inspire (HMO) and Blue Shield Vital (HMO) Provider Directory/Directorio