Blue Medicare Advantage PPO Contracted Providers

Transcription

1 Appendix D Blue Medicare Advantage PPO Contracted Providers Ambulatory Surgicenters... 2 Durable Medical Equipment... 3 Hearing Aid 5 Home Health Care.. 6 Home Infusion 8 Hospice... 9 Inpatient Metro Hospitals 10 Mental Health 12 Orthotic & Prosthetic. 13 Hospital Based Outpatient Surgery 15 Renal Dialysis 17 Skilled Nursing Facilities.. 22 Rev. 09/20/16 Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP SURGICENTER 05/01/16 APOLLO SURGICAL CENTER LLC 2750 S RIVER RD DES PLAINES IL (847) A 6/1/2016 SURGICENTER 04/01/15 DUPAGE EYE SURGERY CENTER LLC 2015 N MAIN ST WHEATON IL (630) SURGICENTER 02/01/16 ELMHURST OUTPATIENT SURGERY CTR 1200 S YORK RD ELMHURST IL (630) SURGICENTER 06/01/16 FULLERTON SURGERY CENTER 4849 W FULLERTON AVE CHICAGO IL (773) A 6/1/2016 SURGICENTER 05/01/15 GLEN ENDOSCOPY CENTER LLC 2551 COMPASS RD GLENVIEW IL (800) SURGICENTER 10/01/15 GOLF SURGICAL CENTER 8901 GOLF RD DES PLAINES IL (847) SURGICENTER 05/01/15 HOFFMAN ESTATES SURGERY CNTR LLC 1555 BARRINGTON RD HOFFMAN IL (847) SURGICENTER 07/01/15 MIDWEST CENTER FOR DAY SURGERY 3811 HIGHLAND AVE DOWNERS IL (630) SURGICENTER 07/01/15 NAPERVILLE SURGICAL CENTRE LLC 1263 RICKERT DR NAPERVILLE IL (630) SURGICENTER 01/01/15 NORTHWEST COMM DAY SURG CTR II 675 W KIRCHHOFF RD ARLINGTON IL (847) SURGICENTER 05/01/15 OAK LAWN ENDOSCOPY 9921 SOUTHWEST HIGHWAY OAK LAWN IL (708) SURGICENTER 07/01/15 PALOS HILLS SURGERY CENTER LLC S ROBERTS RD PALOS HILLS IL (708) SURGICENTER 10/01/15 PALOS SURGI CENTER LLC 7340 COLLEGE DR PALOS HEIGHTS IL (708) SURGICENTER 05/01/15 THE LAKE BLUFF IL ENDOSCOPY ASC 101 S WAUKEGAN RD LAKE BLUFF IL (847) SURGICENTER 07/01/15 TINLEY WOODS SURGERY CENTER S LAGRANGE RD TINLEY PARK IL (708) SURGICENTER 08/01/15 TRI CITIES SURGERY CENTER LLC 345 DELNOR DR GENEVA IL (630) SURGICENTER 05/01/16 UNITED SHOCKWAVE SERVICES LTD 120 N LAGRANGE RD LAGRANGE IL (708) A 8/1/2016 SURGICENTER 08/01/16 VALLEY AMBULATORY SURGERY CENTER 2210 DEAN ST ST CHARLES IL (630) A 9/1/2016 Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 2

3 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP DME 03/01/16 APRIA HEALTHCARE INC 1015 W DEITWEILLER DR PEORIA IL (309) DME 08/01/15 ARMOR MED SUPPLY LLC CHCAGO SOUTH S KEDZIE MARKHAM IL (708) DME 09/01/15 BASINGERS PHARMACY 2130 W JEFFERSON ST JOLIET IL (815) DME 01/01/14 BYRAM HEALTHCARE INC 3010 WOODCREEK DR DOWNERS IL (800) DME 05/01/16 COMPLIANT SLEEP SOLUTIONS CONVERG 7501 LEMONT RD WOODRIDGE IL (630) A 6/1/2016 DME 02/01/16 DJ O LLC 599 CARDIGAN RD SAINT PAUL MN (800) DME 01/01/14 DOUBEK MEDICAL SUPPLY INC S CICERO AVE ALSIP IL (708) DME 08/01/15 EMPI INC 599 CARDIGAN RD SAINT PAUL MN (800) DME 08/01/15 FITZSIMMONS SURGICAL SUPPLY 8000 W 186TH ST TINLEY PARK IL (708) DME 09/01/15 HEALTH TECHNOLOGY RESOURCES 1400 E LAKE COOK RD BUFFALO IL (847) DME 01/01/15 HOVEROUND CORPORATION 241 S FRONTAGE RD BURR RIDGE IL (800) DME 09/01/15 ILLINOIS SLEEP PROVIDER 8736 W OGDEN AVE LYONS IL (708) DME 03/01/16 LEHAN DRUG INC 1407 S 4TH ST DEKALB IL (815) DME 01/01/14 LINCARE INC 1701 HOWARD ST ELK GROVE IL (847) DME 01/01/14 LINCARE INC 700 N HENERIETTA ST EFFINGHAM IL (217) DME 01/01/14 MARK DRUG 548A W DUNDEE RD WHEELING IL (847) DME 08/01/15 MCKESSON PATIENT CARE SOLUTIONS 140 EX BLVD GLENDALE IL (856) DME 05/01/16 MEDLINE INDUSTRIES INC 1 MEDLINE PL MUNDELEIN IL (866) A 8/1/2016 DME 08/01/15 MERIT SLEEP TECHNOLOGIES INC 1300 S MAIN ST LOMBARD IL (630) DME 05/01/15 MINI MED DIST CORP TH AVE SCHILLER PARK IL (800) DME 01/01/15 MOBILITY SYSTEMS SOLUTIONS INC 9755 S 78TH AVE HICKORY HILLS IL (708) DME 02/01/15 NATIONAL SEATING AND MOBILITY INC 85 EISENHOWER LN SOUTH LOMBARD IL (630) DME 02/01/15 NATIONAL SEATING AND MOBILITY INC 3808 W SPRINGFIELD AVE CHAMPAIGN IL (217) DME 02/01/15 NATIONAL SEATING AND MOBILITY INC 4209 PFIEFFER RD BARTONVILLE IL (866) DME 02/01/15 NATIONAL SEATING AND MOBILITY INC S RIDGELAND AVE ALSIP IL (708) DME 08/01/16 OPTION HEALTH LTD 985 AVE OF THE CITIES SILVIS IL (309) A 9/1/2016 DME 01/01/16 ORBIT MED OF NAPERVILLE INC 1701 QUINCY AVE NAPERVILLE IL (630) DME 01/01/16 ORBIT MEDICAL OF CHICAGO INC 1419 W CARROLL AVE CHICAGO IL (866) DME 12/01/15 ORTHOFIX INC 875 N MICHIGAN AVE CHICAGO IL (800) DME 06/01/16 PACIFIC PULMONARY SERVICES 4511 N KEDZIE AVE CHICAGO IL (773) A 8/1/2016 DME 06/01/16 PACIFIC PULMONARY SERVICES 1521 WRIGHT BLVD SCHAUMBURG IL (847) A 8/1/2016 DME 06/01/16 PACIFIC PULMONARY SERVICES 1551 E 91ST DR MERRILLVILLE IN (219) A 8/1/2016 DME 06/01/16 PACIFIC PULMONARY SERVICES 2201 W TOWNLINE RD PEORIA IL (309) A 8/1/2016 DME 06/01/16 PACIFIC PULMONARY SERVICES 9935 S 76TH AVE BRIDGEVIEW IL (708) A 8/1/2016 DME 06/01/16 PACIFIC PULMONARY SERVICES 3384 N PUBLISHERS ROCKFORD IL (815) A 8/1/2016 DME 02/01/15 PATIENTS CHOICE 625 W UNIVERSITY DR ARLINGTON IL (847) DME 01/01/16 PREMIER MEDICAL PRODUCTS INC 1701 QUINCY AVE NAPERVILLE IL (630) DME 01/01/14 REHABTECH SUPPLY CORPORATION 655 W GRAND AVE ELMHURST IL (888) DME 01/01/14 RGH ENTERPRISES INC DBA EDGEPARK 1360 MADELINE LN ELGIN IL (800) DME 05/01/16 SIONA HEALTH CARE PRODUCTS INC 5011 N LINCOLN AVE CHICAGO IL (773) A 6/1/2016 DME 01/01/15 SLEEP RX LLC 7536 N ST LOUIS SKOKIE IL (847) DME 08/01/15 SLEEPMED THERAPIES INC 2357 HASSELL ROAD HOFFMAN IL (847)

4 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP DME 05/01/15 THH ACQUISITION LLC I 780 S MCLEAN BLVD ELGIN IL (847) DME 01/01/14 UNITED SEATING AND MOBILITY LLC 335 EISENHOWER LN S LOMBARD IL (630) DME 01/01/15 WALGREEN MEDICAL SUPPLY LLC TH AVE MOKENA IL (888) DME 01/01/15 WALGREENS HOME CARE INC TH ST CRESTWOOD IL (800) DME 09/01/15 WOUND CARE SOLUTIONS INC 2003 W FULTON ST CHICAGO IL (312) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 4

5 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP HEARING AID SUPPLIER 01/01/15 TRU HEARING INC 5 REVERE DR NORTHBROOK IL (773) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 5

6 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP HOME HEALTH CARE 09/01/15 A 2 Z HEALTHCARE SERVICE LLC TH CT ORLAND PARK IL (708) HOME HEALTH CARE 03/01/15 ABCOR HOME HEALTH INC 3201 N WILKE RD ARLINGTON IL (847) HOME HEALTH CARE 04/01/16 ACE HEALTH CARE SERVICES LLC 4731 W MIDLOTHIAN TURNPIKE CRESTWOOD IL (708) HOME HEALTH CARE 04/01/16 ADDUS HEALTHCARE GOVERNORS HWY OLYMPIA IL (708) HOME HEALTH CARE 07/01/16 ADVANTAGE HOME HEALTH CARE INC 425 E US ROUTE 6 MORRIS IL (815) A 8/1/2016 HOME HEALTH CARE 03/01/16 ALC HOME HEALTH CARE INC 477 E BUTTERFIELD RD LOMBARD IL (630) A 6/1/2016 HOME HEALTH CARE 03/01/15 ALEXIAN BROTHERS HOME HEALTH AGE 1515 E LAKE ST HANOVER PARK IL (847) HOME HEALTH CARE 02/01/16 ALL FAMILY HEALTH CARE INC 6413 N KINZUA AVE CHICAGO IL (773) HOME HEALTH CARE 01/01/15 ALL QUALITY HOME HEALTH CARE LLC 395 E DUNDEE RD WHEELING IL (224) HOME HEALTH CARE 03/01/15 AMEDISYS HOME HEALTH 765 ELA RD LAKE ZURICH IL (847) HOME HEALTH CARE 03/01/15 AMEDISYS ILLINOIS OF TINLEY PARK CROSSING DR TINLEY PARK IL (708) HOME HEALTH CARE 02/01/16 AMERICHOICE HEALTH CARE INC 950 SKOKIE BLVD NORTHBROOK IL (847) HOME HEALTH CARE 05/01/15 ANGEL HEALTH CARE LLC 2625 BUTTERFIELD RD OAK BROOK IL (847) HOME HEALTH CARE 08/01/16 ANREX HEALTHCARE INC 6200 N HIAWATHA CHICAGO IL (773) A 9/1/2016 HOME HEALTH CARE 03/01/16 AT HOME HEALTH INC 3344 W PETERSON AVE CHICAGO IL (773) HOME HEALTH CARE 03/01/15 ATNT HOME HEALTH CARE INC WINTERSET DR ORLAND PARK IL (708) HOME HEALTH CARE 02/01/16 AUXILIUM HEALTHCARE SERVICES 129 FAIRFIELD WAY BLOOMINGDAL IL (224) HOME HEALTH CARE 09/01/15 AWESOME HOME HEALTH CARE S WESTERN AVE CHICAGO IL (773) HOME HEALTH CARE 03/01/16 BETTER CHOICE HOME HEALTH INC 7250 N CICERO AVE LINCOLNWOOD IL (847) HOME HEALTH CARE 04/01/16 BG HOME HEALTH PROVIDERS LLC 133 W RAND ROAD ARLINGTON IL (847) HOME HEALTH CARE 06/01/16 CARELINK HOME HEALTH LLC 33 W HIGGINS RD SOUTH IL (847) A 6/1/2016 HOME HEALTH CARE 07/01/16 CARESS HOME HEALTH CARE INC 3917 HOWARD STREET SKOKIE IL (847) A 9/1/2016 HOME HEALTH CARE 05/01/16 CHICAGOLAND HOME HLTH PROV INC 2604 DEMPSTER ST PARK RIDGE IL (847) A 6/1/2016 HOME HEALTH CARE 08/01/15 CHOICECARE HOME HEALTH INC 6400 W COLLEGE DR PALOS HTS IL (708) HOME HEALTH CARE 03/01/15 COMPLETE HOME HEALTH SERVICES INC PRINCE DR SOUTH IL (708) HOME HEALTH CARE 06/01/15 DIRECT HOME HEALTHCARE INC 4001 W DEVON AVE CHICAGO IL (773) HOME HEALTH CARE 03/01/15 DIVINE INTERVENTION HLTHCARE INC 4747 LINCOLN MALL DR MATTESON IL (708) HOME HEALTH CARE 06/01/16 EVERGREEN HOME HEALTHCARE 6069 DEMPSTER ST MORTON IL (847) A 8/1/2016 HOME HEALTH CARE 04/01/15 FAMILY HOME HEALTH SERVICES INC 2171 EXECUTIVE DR ADDISON IL (630) HOME HEALTH CARE 08/01/15 FIRST HOME HEALTH CARE SERVICES KILBOURN MIDLOTHIAN IL (708) HOME HEALTH CARE 11/01/15 GENTLE PRO HOME HEALTH CARE INC 2060 E ALGONQUIN RD SCHAUMBURG IL (847) HOME HEALTH CARE 11/01/15 GOVVAS HEALTHCARE SERVICES INC 670 N 1ST BANK DR PALATINE IL (847) HOME HEALTH CARE 02/01/15 GUARDIAN HOME HEALTH CARE LLC 181 WAUKEGAN RD NORTHFIELD IL (847) HOME HEALTH CARE 05/01/15 HANDS OF WELLNESS INC 1062 SIBLEY BLVD CALUMET CITY IL (708) HOME HEALTH CARE 06/01/15 HEALTHTRENDS LTD 200 E HOWARD AVE DES PLAINES IL (847) HOME HEALTH CARE 09/01/15 HOME CARE LIT CO OF MARY HOSP 2800 W 95TH ST EVERGREEN IL (708) HOME HEALTH CARE 07/01/16 HOME HEALTH CHOICE INC 8308 N LINCOLN AVE SKOKIE IL (847) A 8/1/2016 HOME HEALTH CARE 02/01/16 INTEGRATED HOME HEALTHCARE SRVCS 900 TECHNOLOGY WAY LIBERTYVILLE IL (847) HOME HEALTH CARE 01/01/14 INTERIM HEALTHCARE S CICERO OAK LAWN IL (708) HOME HEALTH CARE 02/01/15 KINDRED AT HOME CHICAGO HOME HLTH 7101 N CICERO AVE LINCOLNWOOD IL (847) HOME HEALTH CARE 01/01/15 LEXINGTON HOME HEALTH CARE INC 1300 S MAIN STREET LOMBARD IL (630) HOME HEALTH CARE 06/01/15 LIFECARE HOME HLTH SERVICES INC 3400 DUNDEE RD NORTHBROOK IL (847)

7 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP HOME HEALTH CARE 10/01/15 MIRANDA HOME HEALTHCARE S KEDZIE AVE FLOSSMOOR IL (708) HOME HEALTH CARE 01/01/15 NORTHWEST COMM HOSP HOME CARE 3060 SALT CREEK LANE ARLINGTON IL (847) HOME HEALTH CARE 04/01/16 NORTHWESTERN ILLINOIS HOME HEALTH 151 TENNEY ST KEWANEE IL (309) HOME HEALTH CARE 01/01/14 NORTHWESTERN MED HOME HLTH HOSPIC 690 E NORTH AVE CAROL STREAM IL (630) HOME HEALTH CARE 01/01/15 O AND P HOME HEALTH CARE INC 4950 MAIN ST SKOKIE IL (847) HOME HEALTH CARE 10/01/15 PALOS COMMUNITY HOSP HOME HEALTH E 127TH ST LEMONT IL (630) HOME HEALTH CARE 01/01/15 PEAK HOME HLTHC DBA NEWSOME HOME 920 ESSINGTON RD JOLIET IL (815) HOME HEALTH CARE 09/01/15 PHOENIX HOME CARE LLC 200 S FRONTAGE RD BURR RIDGE IL (630) HOME HEALTH CARE 09/01/15 PREMIER POINT HOME HEALTH NFP 4701 N SHERIDAN RD CHICAGO IL (773) HOME HEALTH CARE 01/01/14 PRIVATE HOME CARE UNLIMITED 5517 N CUMBERLAND CHICAGO IL (773) HOME HEALTH CARE 06/01/16 PRUDENT CHOICE HOME HLTH CARE COR 1699 E WOODFIELD RD SCHAUMBURG IL (847) A 8/1/2016 HOME HEALTH CARE 08/01/16 RESILIENCE HOME HEALTH CORP 31 KENDALL POINT DR OSWEGO IL (630) A 9/1/2016 HOME HEALTH CARE 07/01/16 SERENITY HOME HEALTHCARE 6677 N LINCOLN AVE LINCOLNWOOD IL (773) A 8/1/2016 HOME HEALTH CARE 06/01/15 SHAY HEALTHCARE SERVICES 5730 W 159TH ST OAK FOREST IL (708) HOME HEALTH CARE 01/01/15 SILVER CROSS HOME HEALTH 1900 SILVER CROSS BLVD NEW LENOX IL (815) HOME HEALTH CARE 03/01/16 SOLARIS HOME HEALTHCARE INC 3330 DUNDEE RD NORTHBROOK IL (847) HOME HEALTH CARE 05/01/15 STAR HOME HEALTH SERVICES INC /2 SOUTH KEDZIE CHICAGO IL (773) HOME HEALTH CARE 05/01/15 TOTAL HOME HEALTHCARE 4001 WEST DEVON CHICAGO IL (773) HOME HEALTH CARE 01/01/15 URBAN HEALTH LLC 224 S MILWAUKEE AVE WHEELING IL (312) HOME HEALTH CARE 01/01/15 VANGUARD HEALTH AND WELLNESS 1585 ELLINWOOD AVE DES PLAINES IL (855) HOME HEALTH CARE 07/01/15 WHOLE LIFE HOME HEALTH 7501 N MILWAUKEE AVE NILES IL (847) HOME HEALTH CARE 03/01/16 WOUND AND REHAB HM HLTH CARE INC 700 BUSSE HIGHWAY PARK RIDGE IL (847) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 7

8 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP HOME INFUSION 01/01/14 CENTRAL DUPAGE SPECIAL HLTH ASSOC 690 E NORTH AVE CAROL STREAM IL (630) HOME INFUSION 06/01/16 IV SOLUTIONS LLC 420 LAKE COOK RD DEERFIELD IL (847) A 6/1/2016 HOME INFUSION 01/01/14 METRO INFECTIOUS DISEASE CONSULTS 901 MCCLINTOCK DR BURR RIDGE IL (630) HOME INFUSION 01/01/15 OPTION CARE ENTERPRISES 2050 S FINLEY RD LOMBARD IL (630) HOME INFUSION 08/01/16 OPTION HEALTH LTD 321 W LAKE ST ELMHURST IL (630) A 9/1/2016 HOME INFUSION 06/01/15 OPTION HEALTH LTD 985 AVE OF THE CITIES SILVIS IL (309) HOME INFUSION 08/01/15 RUSH UNIVERSITY MED CNTR 1725 W HARRISON ST CHICAGO IL (312) HOME INFUSION 01/01/16 RX CONSULT INC DBA HEALTH OPTIONS 110 S MARKET ST SPARTA IL (618) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 8

9 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP HOSPICE 04/01/16 ACCORD HOSPICE INC 1247 LYNN TERRACE HIGHLAND IL (847) HOSPICE 03/01/15 ALEXIAN BROTHERS HOSPICE 1515 E LAKE ST HANOVER PARK IL (630) HOSPICE 01/01/15 CNS HOME HEALTH 690 E NORTH AVE CAROL STREAM IL (630) HOSPICE 09/01/14 COVENANT HOME SERVICES 3755 E MAIN ST ST CHARLES IL (630) HOSPICE 04/01/15 FAMILY CENTERED HOSPICE 2171 EXECUTIVE DR ADDISON IL (630) HOSPICE 07/01/15 HOSPICE ADVANTAGE 16W485 S FRONTAGE BURR RIDGE IL (708) HOSPICE 03/01/16 HOSPICE OF GREATER CHICAGO LLC 1727 S INDIANA AVE CHICAGO IL (630) HOSPICE 02/01/16 INTEGRATED PALLIATIVE HOSPICE LLC 900 TECHNOLOGY WAY LIBERTYVILLE IL (847) HOSPICE 01/01/15 LEXINGTON HOSPICE SERVICES LLC 1300 S MAIN STREET LOMBARD IL (630) HOSPICE 09/01/15 LITTLE COMPANY OF MARY HOSPICE 9800 SOUTHWEST HWY OAK LAWN IL (708) HOSPICE 10/01/15 PALOS COMMUNITY HOSPITAL HOSPICE E 127TH ST LEMONT IL (630) HOSPICE 01/01/14 RAINBOW HOSPICE AND PALLIATIVE 1550 BISHOP CT MOUNT IL (847) HOSPICE 08/01/15 RESIDENTIAL HOSPICE ILLINOIS 1431 OPUS PLACE DOWNERS IL (855) HOSPICE 01/01/14 VITAS INNOVATVE HOSPICE CARE CHGO 1340 S DAMEN AVE CHICAGO IL (312) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 9

10 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP INPATIENT - METRO 01/01/14 ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL (630) INPATIENT - METRO 01/01/14 ADVENTIST GLEN OAKS HOSPITAL 701 WINTHROP AVE GLENDALE IL (630) INPATIENT - METRO 01/01/14 ADVENTIST HINSDALE HOSPITAL 120 N OAK ST HINSDALE IL (630) INPATIENT - METRO 01/01/14 ADVENTIST LAGRANGE MEMORIAL HOSP 5101 S WILLOW SPRINGS RD LA GRANGE IL (708) INPATIENT - METRO 01/01/16 ADVOCATE BROMENN MEDICAL CTR 1304 FRANKLIN AVE NORMAL IL (309) INPATIENT - METRO 01/01/14 ADVOCATE CHRIST HOSP MED CNTR 4440 W 95TH ST OAK LAWN IL (708) INPATIENT - METRO 01/01/14 ADVOCATE CONDELL MEDICAL CENTER 801 S MILWAUKEE AVE LIBERTYVILLE IL (847) INPATIENT - METRO 01/01/14 ADVOCATE GOOD SAMARITAN HOSPITAL 3815 HIGHLAND AVE DOWNERS IL (630) INPATIENT - METRO 01/01/14 ADVOCATE GOOD SHEPHERD HOSPITAL 450 W HIGHWAY 22 BARRINGTON IL (847) INPATIENT - METRO 01/01/14 ADVOCATE ILLINOIS MASONIC MED CNT 836 W WELLINGTON AVE CHICAGO IL (773) INPATIENT - METRO 01/01/14 ADVOCATE LUTHERAN GENERAL HOSP 1775 DEMPSTER ST PARK RIDGE IL (847) INPATIENT - METRO 01/01/14 ADVOCATE SHERMAN HOSPITAL 1425 N RANDALL RD ELGIN IL (847) INPATIENT - METRO 01/01/14 ADVOCATE SOUTH SUBURBAN HOSPITAL S KEDZIE AVE HAZEL CREST IL (708) INPATIENT - METRO 01/01/14 ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO IL (773) INPATIENT - METRO 01/01/14 ALEXIAN BROTHERS BEHAVIORAL HLTH 1650 MOON LAKE BLVD HOFFMAN IL (847) INPATIENT - METRO 01/01/14 ALEXIAN BROTHERS MEDICAL CENTER 800 BIESTERFIELD RD ELK GROVE IL (847) INPATIENT - METRO 01/01/14 CENTRAL DUPAGE HOSPITAL 25 N WINFIELD RD WINFIELD IL (630) INPATIENT - METRO 11/01/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) INPATIENT - METRO 01/01/15 COMMUNITY FIRST MEDICAL CENTER 5645 W ADDISON ST CHICAGO IL (773) INPATIENT - METRO 01/01/14 COPLEY MEMORIAL HOSPITAL 2000 OGDEN AVE AURORA IL (630) INPATIENT - METRO 01/01/14 DELNOR COMMUNITY HOSPITAL 300 RANDALL RD GENEVA IL (630) INPATIENT - METRO 01/01/14 EDWARD HOSPITAL 801 S WASHINGTON ST NAPERVILLE IL (630) INPATIENT - METRO 01/01/14 ELMHURST MEM HOSPITAL MAIN CAMPUS 155 E BRUSH HILL RD ELMHURST IL (331) INPATIENT - METRO 01/01/14 HOLY CROSS HOSPITAL 2701 W 68TH ST CHICAGO IL (773) INPATIENT - METRO 01/01/15 INGALLS MEMORIAL HOSPITAL 1 INGALLS DR HARVEY IL (708) INPATIENT - METRO 11/01/15 KINDRED CHGO CENTRAL HOSPITAL 4058 W MELROSE ST CHICAGO IL (773) INPATIENT - METRO 11/01/15 KINDRED HOSP NORTHLAKE 365 E NORTH AVE NORTHLAKE IL (708) INPATIENT - METRO 11/01/15 KINDRED HOSPITAL SYCAMORE 225 EDWARD ST SYCAMORE IL (815) INPATIENT - METRO 01/01/14 KISHWAUKEE COMMUNITY HOSPITAL 1 KISH HOSPITAL DR DEKALB IL (815) INPATIENT - METRO 01/01/14 LINDEN OAKS HOSPITAL 852 WEST ST NAPERVILLE IL (630) INPATIENT - METRO 01/01/14 LITTLE COMPANY OF MARY HOSP 2800 W 95TH ST EVERGREEN IL (708) INPATIENT - METRO 01/01/14 MACNEAL HOSPITAL 3249 S OAK PARK AVE BERWYN IL (708) INPATIENT - METRO 01/01/14 MARIANJOY REHABILITATION HOSPITAL 26 W 171 ROOSEVELT RD WHEATON IL (630) INPATIENT - METRO 01/01/14 MOUNT SINAI HOSPITAL 1500 S. CALIFORNIA CHICAGO IL (773) INPATIENT - METRO 01/01/14 NORTHSHORE EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON IL (847) INPATIENT - METRO 01/01/14 NORTHSHORE GLENBROOK HOSPITAL 2100 PFINGSTEN RD GLENVIEW IL (847) INPATIENT - METRO 01/01/14 NORTHSHORE HIGHLAND PARK HOSPITAL 777 PARK AVE WEST HIGHLAND IL (847) INPATIENT - METRO 01/01/14 NORTHSHORE SKOKIE HOSPITAL 9600 GROSS POINT RD SKOKIE IL (847) INPATIENT - METRO 01/01/14 NORTHWEST COMMUNITY HOSPITAL 800 W CENTRAL RD ARLINGTON IL (847) INPATIENT - METRO 01/01/14 PALOS COMMUNITY HOSPITAL S 80TH AVE PALOS HEIGHTS IL (708) INPATIENT - METRO 01/01/14 PRESENCE COVENANT MEDICAL CENTER 1400 W PARK ST URBANA IL (217) INPATIENT - METRO 01/01/14 PRESENCE HOLY FAMILY MEDICAL CTR 100 N RIVER RD DES PLAINES IL (847)

11 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP INPATIENT - METRO 01/01/14 PRESENCE MERCY MEDICAL CENTER 1325 N HIGHLAND AVE AURORA IL (630) INPATIENT - METRO 01/01/14 PRESENCE RESURRECTION MED CTR 7435 W TALCOTT AVE CHICAGO IL (773) INPATIENT - METRO 01/01/14 PRESENCE ST FRANCIS HOSPITAL 355 RIDGE AVE EVANSTON IL (847) INPATIENT - METRO 01/01/14 PRESENCE ST JOSEPH HOSP CHICAGO 2900 N LAKE SHORE DR CHICAGO IL (773) INPATIENT - METRO 01/01/14 PRESENCE ST JOSEPH HOSP ELGIN 77 N AIRLITE ST ELGIN IL (847) INPATIENT - METRO 01/01/14 PRESENCE ST JOSEPH MEDICAL CTR 333 N MADISON ST JOLIET IL (815) INPATIENT - METRO 01/01/14 PRESENCE ST MARY ELIZABETH MDCT 2233 W DIVISION ST CHICAGO IL (312) INPATIENT - METRO 01/01/14 PRESENCE ST MARYS HOSPITAL 500 W COURT ST KANKAKEE IL (815) INPATIENT - METRO 01/01/14 PRESENCE UNITED SAMARITANS MED CT 812 N LOGAN AVE DANVILLE IL (217) INPATIENT - METRO 01/01/14 RML SPECIALTY HOSPITAL 5601 S COUNTY LINE RD HINSDALE IL (630) INPATIENT - METRO 07/01/15 SAINT ANTHONY HOSPITAL 2875 W 19TH ST CHICAGO IL (773) INPATIENT - METRO 01/01/14 SCHWAB REHABILITATION HOSPITAL 1401 S CALIFORNIA AVE CHICAGO IL (773) INPATIENT - METRO 01/01/14 SILVER CROSS HOSPITAL 1900 SILVER CROSS BLVD NEW LENOX IL (815) INPATIENT - METRO 01/01/14 ST ALEXIUS MEDICAL CENTER 1555 BARRINGTON RD HOFFMAN IL (847) INPATIENT - METRO 01/01/14 ST BERNARD HOSPITAL 326 W 64TH ST CHICAGO IL (773) INPATIENT - METRO 01/01/14 ST JAMES HOSPITAL AND HLTH CNTRS 1423 CHICAGO RD CHICAGO IL (708) INPATIENT - METRO 01/01/14 SWEDISH COVENANT HOSPITAL 5145 N CALIFORNIA AVE CHICAGO IL (773) INPATIENT - METRO 03/01/16 THOREK MEMORIAL HOSPITAL 850 W IRVING PARK RD CHICAGO IL (773) INPATIENT - METRO 01/01/14 UNIVERSITY OF CHICAGO MEDICAL CEN 5841 S MARYLAND AVE CHICAGO IL (773) INPATIENT - METRO 01/01/14 VALLEY WEST COMMUNITY HOSPITAL 11 E PLEASANT AVE SANDWICH IL (815) INPATIENT - METRO 01/01/14 WEISS MEMORIAL HOSPITAL 4646 N MARINE DR CHICAGO IL (773) INPATIENT - METRO 01/01/14 WEST SUBURBAN MEDICAL CENTER 3 ERIE COURT OAK PARK IL (708) INPATIENT - METRO 01/01/14 WESTLAKE HOSPITAL INC 1225 W LAKE ST MELROSE PARK IL (708) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 11

12 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP MENTAL HEALTH 11/01/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 12

13 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP ORTHOTIC & PROSTHETIC 02/01/16 BALLERT ORTHOPEDIC OF CHICAGO FRONT ST WOOD DALE IL (630) ORTHOTIC & PROSTHETIC 03/01/15 BALLERT ORTHOPEDIC OF CHICAGO 2434 W PETERSON AVE CHICAGO IL (773) ORTHOTIC & PROSTHETIC 02/01/16 BALLERT ORTHOPEDIC OF CHICAGO 1250 N MILL ST NAPERVILLE IL (630) ORTHOTIC & PROSTHETIC 02/01/16 BALLERT ORTHOPEDIC OF CHICAGO 233 E ERIE ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 03/01/16 HANGER PROSTHETICS & ORTHOTIC INC 1910 S MT ZION RD DECATUR IL (217) ORTHOTIC & PROSTHETIC 03/01/16 HANGER PROSTHETICS AND ORTHOTICS 3691 COUGAR DR PERU IL (815) ORTHOTIC & PROSTHETIC 08/01/15 HANGER PROSTHETICS AND ORTHOTICS 311 W ROMEO B GARRETT AVE PEORIA IL (309) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHO EAST 100 TOWER DR BURR RIDGE IL (630) ORTHOTIC & PROSTHETIC 03/01/16 HANGER PROSTHETICS ORTHOTICS 719 N WILLIAM KUMPF BLVD PEORIA IL (309) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 4525 W LINCOLN HWY MATTESON IL (708) ORTHOTIC & PROSTHETIC 03/01/16 HANGER PROSTHETICS ORTHOTICS 7 BRONZE POINTE SOUTH BELLEVILLE IL (618) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 694 ESSINGTON RD JOLIET IL (815) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 75 MARKET ST ELGIN IL (847) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 4255 WESTBROOK DR AURORA IL (630) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 35 TOWER CT GURNEE IL (847) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 1123 EMERSON ST EVANSTON IL (847) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS W 160TH ST ORLAND PARK IL (708) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS S CICERO AVE OAK LAWN IL (708) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS W CERMAK RD WESTCHESTER IL (708) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 4801 W PETERSON AVE CHICAGO IL (773) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS S KEDZIE AVE HAZEL CREST IL (708) ORTHOTIC & PROSTHETIC 01/01/14 HANGER PROSTHETICS ORTHOTICS 1 S 224 SUMMIT AVE OAKBROOK IL (630) ORTHOTIC & PROSTHETIC 08/01/16 HANGER PROSTHETICS ORTHOTICS 4255 WESTBROOK DR AURORA IL (630) A 9/1/2016 ORTHOTIC & PROSTHETIC 07/01/15 NATURALLY YOURS INC 7219 KINGERY HWY WILLOWBROOK IL (630) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 401 HARRISON ST OAK PARK IL (708) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 5202 OLD ORCHARD RD SKOKIE IL (847) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 1S376 SUMMIT AVE OAK BROOK IL (630) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 10 N FAIRLANE DR JOLIET IL (847) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 1551 BOND ST NAPERVILLE IL (630) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 1725 W HARRISON ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 1740 W TAYLOR ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 2835 N SHEFFIELD CHICAGO IL (773) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 617 E GOLF RD ARLINGTON IL (847) ORTHOTIC & PROSTHETIC 01/01/14 SCHECK AND SIRESS PROSTHETICS INC 8641 W 95TH ST HICKORY HILLS IL (708) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate 13

14 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 14

15 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP OUTPATIENT SURGERY 01/01/14 ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL (630) OUTPATIENT SURGERY 01/01/14 ADVENTIST GLEN OAKS HOSPITAL 701 WINTHROP AVE GLENDALE IL (630) OUTPATIENT SURGERY 01/01/14 ADVENTIST HINSDALE HOSPITAL 120 N OAK ST HINSDALE IL (630) OUTPATIENT SURGERY 01/01/14 ADVENTIST LAGRANGE MEMORIAL HOSP 5101 S WILLOW SPRINGS RD LA GRANGE IL (708) OUTPATIENT SURGERY 01/01/16 ADVOCATE BROMENN MEDICAL CTR 1304 FRANKLIN AVE NORMAL IL (309) OUTPATIENT SURGERY 01/01/14 ADVOCATE CHRIST HOSP MED CNTR 4440 W 95TH ST OAK LAWN IL (708) OUTPATIENT SURGERY 01/01/14 ADVOCATE CONDELL MEDICAL CENTER 801 S MILWAUKEE AVE LIBERTYVILLE IL (847) OUTPATIENT SURGERY 01/01/14 ADVOCATE GOOD SAMARITAN HOSPITAL 3815 HIGHLAND AVE DOWNERS IL (630) OUTPATIENT SURGERY 01/01/14 ADVOCATE GOOD SHEPHERD HOSPITAL 450 W HIGHWAY 22 BARRINGTON IL (847) OUTPATIENT SURGERY 01/01/14 ADVOCATE ILLINOIS MASONIC MED CNT 836 W WELLINGTON AVE CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 ADVOCATE LUTHERAN GENERAL HOSP 1775 DEMPSTER ST PARK RIDGE IL (847) OUTPATIENT SURGERY 01/01/14 ADVOCATE SHERMAN HOSPITAL 1425 N RANDALL RD ELGIN IL (847) OUTPATIENT SURGERY 01/01/14 ADVOCATE SOUTH SUBURBAN HOSPITAL S KEDZIE AVE HAZEL CREST IL (708) OUTPATIENT SURGERY 01/01/14 ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 ALEXIAN BROTHERS BEHAVIORAL HLTH 1650 MOON LAKE BLVD HOFFMAN IL (847) OUTPATIENT SURGERY 01/01/14 ALEXIAN BROTHERS MEDICAL CENTER 800 BIESTERFIELD RD ELK GROVE IL (847) OUTPATIENT SURGERY 01/01/14 CENTRAL DUPAGE HOSPITAL 25 N WINFIELD RD WINFIELD IL (630) OUTPATIENT SURGERY 11/01/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) OUTPATIENT SURGERY 01/01/15 COMMUNITY FIRST MEDICAL CENTER 5645 W ADDISON ST CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 COPLEY MEMORIAL HOSPITAL 2000 OGDEN AVE AURORA IL (630) OUTPATIENT SURGERY 01/01/14 DELNOR COMMUNITY HOSPITAL 300 RANDALL RD GENEVA IL (630) OUTPATIENT SURGERY 01/01/14 EDWARD HOSPITAL 801 S WASHINGTON ST NAPERVILLE IL (630) OUTPATIENT SURGERY 01/01/14 ELMHURST MEM HOSPITAL MAIN CAMPUS 155 E BRUSH HILL RD ELMHURST IL (331) OUTPATIENT SURGERY 01/01/14 HOLY CROSS HOSPITAL 2701 W 68TH ST CHICAGO IL (773) OUTPATIENT SURGERY 01/01/15 INGALLS MEMORIAL HOSPITAL 1 INGALLS DR HARVEY IL (708) OUTPATIENT SURGERY 11/01/15 KINDRED CHGO CENTRAL HOSPITAL 4058 W MELROSE ST CHICAGO IL (773) OUTPATIENT SURGERY 11/01/15 KINDRED HOSP NORTHLAKE 365 E NORTH AVE NORTHLAKE IL (708) OUTPATIENT SURGERY 11/01/15 KINDRED HOSPITAL SYCAMORE 225 EDWARD ST SYCAMORE IL (815) OUTPATIENT SURGERY 01/01/14 KISHWAUKEE COMMUNITY HOSPITAL 1 KISH HOSPITAL DR DEKALB IL (815) OUTPATIENT SURGERY 01/01/14 LINDEN OAKS HOSPITAL 852 WEST ST NAPERVILLE IL (630) OUTPATIENT SURGERY 01/01/14 LITTLE COMPANY OF MARY HOSP 2800 W 95TH ST EVERGREEN IL (708) OUTPATIENT SURGERY 01/01/14 MACNEAL HOSPITAL 3249 S OAK PARK AVE BERWYN IL (708) OUTPATIENT SURGERY 01/01/14 MARIANJOY REHABILITATION HOSPITAL 26 W 171 ROOSEVELT RD WHEATON IL (630) OUTPATIENT SURGERY 01/01/14 MOUNT SINAI HOSPITAL 1500 S. CALIFORNIA CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 NORTHSHORE EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON IL (847) OUTPATIENT SURGERY 01/01/14 NORTHSHORE GLENBROOK HOSPITAL 2100 PFINGSTEN RD GLENVIEW IL (847) OUTPATIENT SURGERY 01/01/14 NORTHSHORE HIGHLAND PARK HOSPITAL 777 PARK AVE WEST HIGHLAND IL (847) OUTPATIENT SURGERY 01/01/14 NORTHSHORE SKOKIE HOSPITAL 9600 GROSS POINT RD SKOKIE IL (847) OUTPATIENT SURGERY 01/01/14 NORTHWEST COMMUNITY HOSPITAL 800 W CENTRAL RD ARLINGTON IL (847) OUTPATIENT SURGERY 01/01/14 PALOS COMMUNITY HOSPITAL S 80TH AVE PALOS HEIGHTS IL (708) OUTPATIENT SURGERY 01/01/14 PRESENCE COVENANT MEDICAL CENTER 1400 W PARK ST URBANA IL (217) OUTPATIENT SURGERY 01/01/14 PRESENCE HOLY FAMILY MEDICAL CTR 100 N RIVER RD DES PLAINES IL (847)

16 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP OUTPATIENT SURGERY 01/01/14 PRESENCE MERCY MEDICAL CENTER 1325 N HIGHLAND AVE AURORA IL (630) OUTPATIENT SURGERY 01/01/14 PRESENCE RESURRECTION MED CTR 7435 W TALCOTT AVE CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 PRESENCE ST FRANCIS HOSPITAL 355 RIDGE AVE EVANSTON IL (847) OUTPATIENT SURGERY 01/01/14 PRESENCE ST JOSEPH HOSP CHICAGO 2900 N LAKE SHORE DR CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 PRESENCE ST JOSEPH HOSP ELGIN 77 N AIRLITE ST ELGIN IL (847) OUTPATIENT SURGERY 01/01/14 PRESENCE ST JOSEPH MEDICAL CTR 333 N MADISON ST JOLIET IL (815) OUTPATIENT SURGERY 01/01/14 PRESENCE ST MARY ELIZABETH MDCT 2233 W DIVISION ST CHICAGO IL (312) OUTPATIENT SURGERY 01/01/14 PRESENCE ST MARYS HOSPITAL 500 W COURT ST KANKAKEE IL (815) OUTPATIENT SURGERY 01/01/14 PRESENCE UNITED SAMARITANS MED CT 812 N LOGAN AVE DANVILLE IL (217) OUTPATIENT SURGERY 01/01/14 RML SPECIALTY HOSPITAL 5601 S COUNTY LINE RD HINSDALE IL (630) OUTPATIENT SURGERY 07/01/15 SAINT ANTHONY HOSPITAL 2875 W 19TH ST CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 SCHWAB REHABILITATION HOSPITAL 1401 S CALIFORNIA AVE CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 SILVER CROSS HOSPITAL 1900 SILVER CROSS BLVD NEW LENOX IL (815) OUTPATIENT SURGERY 01/01/14 ST ALEXIUS MEDICAL CENTER 1555 BARRINGTON RD HOFFMAN IL (847) OUTPATIENT SURGERY 01/01/14 ST BERNARD HOSPITAL 326 W 64TH ST CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 ST JAMES HOSPITAL AND HLTH CNTRS 1423 CHICAGO RD CHICAGO IL (708) OUTPATIENT SURGERY 01/01/14 SWEDISH COVENANT HOSPITAL 5145 N CALIFORNIA AVE CHICAGO IL (773) OUTPATIENT SURGERY 03/01/16 THOREK MEMORIAL HOSPITAL 850 W IRVING PARK RD CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 UNIVERSITY OF CHICAGO MEDICAL CEN 5841 S MARYLAND AVE CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 VALLEY WEST COMMUNITY HOSPITAL 11 E PLEASANT AVE SANDWICH IL (815) OUTPATIENT SURGERY 01/01/14 WEISS MEMORIAL HOSPITAL 4646 N MARINE DR CHICAGO IL (773) OUTPATIENT SURGERY 01/01/14 WEST SUBURBAN MEDICAL CENTER 3 ERIE COURT OAK PARK IL (708) OUTPATIENT SURGERY 01/01/14 WESTLAKE HOSPITAL INC 1225 W LAKE ST MELROSE PARK IL (708) Change Codes: A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 16

17 MEDICARE ADVANTAGE PPO APPENDIX D PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP RENAL DIALYSIS 01/01/15 AFFILIATED DIALYSIS LLC 715 LAKE ST OAK PARK IL (309) RENAL DIALYSIS 01/01/15 AFFILIATED DIALYSIS OF GLEN ELLYN 800 ROOSEVELT GLEN ELLYN IL (309) RENAL DIALYSIS 01/01/15 AFFILIATED HOME DIALYSIS LLC 2462 WASHINGTON RD WASHINGTON IL (309) RENAL DIALYSIS 01/01/15 AFFILIATED HOME DIALYSIS LLC 1014 BONAVENTURE DR ELK GROVE IL (309) RENAL DIALYSIS 01/01/14 ALTON DIALYSIS 309 HOMER ADAMS PKWAY ALTON IL (618) RENAL DIALYSIS 01/01/14 ARLINGTON HEIGHTS PD 17 W GOLF RD ARLINGTON IL (847) RENAL DIALYSIS 01/01/14 AURORA DIALYSIS CENTER 455 MERCY LN AURORA IL (630) RENAL DIALYSIS 01/01/14 AUSTIN COMMUNITY KIDNEY CENTER 4800 W CHICAGO AVE CHICAGO IL (773) RENAL DIALYSIS 04/01/16 AVANTUS HOME TH-CHAMPAIGN URB 901 W UNIVERSITY AVE CHAMPAIGN IL (217) A 6/1/2016 RENAL DIALYSIS 01/01/14 BARRINGTON CREEK DIALYSIS W NORTHWEST HWY LAKE IL (847) RENAL DIALYSIS 01/01/14 BENTON DIALYSIS 1151 RTE 14 WEST BENTON IL (618) RENAL DIALYSIS 01/01/14 BEVERLY DIALYSIS 8109 SOUTH WESTERN AVE CHICAGO IL (773) RENAL DIALYSIS 01/01/14 BIG OAKS DIALYSIS 5623 W TOUHY AVE NILES IL (847) RENAL DIALYSIS 01/01/14 BLUE ISLAND DIALYSIS CENTER S WESTERN AVE BLUE ISLAND IL (708) RENAL DIALYSIS 11/01/14 CENTER FOR RENAL REPLACEMENT LLC 7301 N LINCOLN LINCOLNWOOD IL (847) RENAL DIALYSIS 01/01/14 CENTRALIA DIALYSIS 1231 STATE ROUTE 161 EAST CENTRALIA IL (618) RENAL DIALYSIS 01/01/14 CHAMPAIGN URBANA 1405 W PARK ST URBANA IL (217) RENAL DIALYSIS 01/01/14 CHICAGO DIALYSIS CENTER 1806 W HUBBARD ST CHICAGO IL (312) RENAL DIALYSIS 01/01/14 CHICAGO HEIGHTS DIALYSIS 177 B JOE ORR RD CHICAGO IL (630) RENAL DIALYSIS 01/01/14 CHICAGO WESTSIDE DIALYSIS 1340 S DAMEN CHICAGO IL (312) RENAL DIALYSIS 01/01/14 CHURCHVIEW DIALYSIS 417 WARE AVE ROCKFORD IL (815) RENAL DIALYSIS 01/01/14 COBBLESTONE DIALYSIS 836 DUNDEE AVE ELGIN IL (847) RENAL DIALYSIS 01/01/14 COUNTRY HILLS DIALYSIS 4215 W 167TH ST COUNTRY CLUB IL (708) RENAL DIALYSIS 10/01/15 CRYSTAL SPRINGS DIALYSIS 720 COG CIR CRYSTAL LAKE IL (815) RENAL DIALYSIS 01/01/14 DECATUR EASTWOOD DIALYSIS 794 E WOOD ST DECATUR IL (217) RENAL DIALYSIS 01/01/14 DIALYSIS CENTER OF AMERICA 5401 S WENTWORTH AVE CHICAGO IL (773) RENAL DIALYSIS 01/01/14 DIALYSIS CENTER OF AMERICA 2277 W HOWARD ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 DIALYSIS CENTER OF AMERICA CAL SAG RD CRESTWOOD IL (708) RENAL DIALYSIS 01/01/14 DIALYSIS CENTER OF AMERICA 9160 W 159TH ST ORLAND PARK IL (708) RENAL DIALYSIS 01/01/14 DIALYSIS SERVICES CONGRESS PKWY 3410 W VAN BUREN ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 DIALYSIS SERVICES OF ALSIP S CICERO AVE ALSIP IL (708) RENAL DIALYSIS 01/01/14 DIALYSIS SERVICES OF WILLOWBROOK 6300 KINGERY HWY WILLOWBROOK IL (630) RENAL DIALYSIS 01/01/14 DIXON KIDNEY CENTER 1131 N GALENA AVE DIXON IL (815) RENAL DIALYSIS 01/01/14 DOWNERS GROVE DIALYSIS CENTER 3825 HIGHLAND AVE DOWNERS IL (630) RENAL DIALYSIS 01/01/14 DSI RENAL ARLINGTON HEIGHTS 17 W GOLF RD ARLINGTON IL (847) RENAL DIALYSIS 01/01/14 DSI RENAL BUFFALO GROVE 1291 W DUNDEE RD BUFFALO IL (800) RENAL DIALYSIS 01/01/14 DSI RENAL SCHAUMBURG 1156 S ROSELLE RD SCHAUMBURG IL (847) RENAL DIALYSIS 01/01/14 DVA RENAL HEALTHCARE IND 932 N RUTLEDGE ST SPRINGFIELD IL (217) RENAL DIALYSIS 04/01/16 EAST CHICAGO DIALYSIS CENTER 1207 E CHICAGO AVE EAST CHICAGO IN (219) A 9/1/2016 RENAL DIALYSIS 01/01/14 EDWARDSVILLE DIALYSIS 235 S BUCHANAN ST EDWARDSVILLE IL (618) RENAL DIALYSIS 01/01/14 EFFINGHAM DIALYSIS 904 MEDICAL PARK DR EFFINGHAM IL (217) RENAL DIALYSIS 01/01/14 ELK GROVE DIALYSIS CENTER 901 BIESTERFIELD RD ELK GROVE IL (847)

18 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP RENAL DIALYSIS 01/01/14 ELK GROVE HOME DIALYSIS CENTER 901 BIESTERFIELD RD ELK GROVE IL (847) RENAL DIALYSIS 01/01/14 EMERALD KIDNEY CENTER 710 W 43RD ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 EVANSTON RENAL CENTER 1922 DEMPSTER ST EVANSTON IL (847) RENAL DIALYSIS 01/01/14 FMC DIALYSIS SVC OF WESTCHESTER 2400 WOLF RD WESTCHESTER IL (708) RENAL DIALYSIS 04/01/16 FMC DUPAGE HOME DIALYSIS 501 WEST LAKE ST ELMHURST IL (630) AD 6/1/2016 RENAL DIALYSIS 04/01/16 FMC OF CARBONDALE 1425 E MAIN ST CARBONDALE IL (618) A 6/1/2016 RENAL DIALYSIS 01/01/14 FMC OF SOUTHSIDE DIALYSIS CNTR 3134 W 76TH ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 FMC ROSS DIALYSIS ENGLEWOOD 6333 S GREEN ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 FMC WILLIAMSON COUNTY 900 SKYLINE DR MARION IL (618) RENAL DIALYSIS 01/01/14 FREEPORT DIALYSIS 1028 KONKLE BLVD FREEPORT IL (815) RENAL DIALYSIS 01/01/14 FRESENIUS DUPAGE WEST DIALYSIS 450 E ROOSEVELT WEST CHICAGO IL (630) RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE BOLINGBROOK 329 REMINGTON BLVD BOLINGBROOK IL (630) RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE DES PLAINES 1625 OAKTON PL DES PLAINES IL (847) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE HAZEL CREST CARRIAGE WAY HAZEL CREST IL (708) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE HOFFMAN ESTATE 3150 W HIGGINS ROAD HOFFMAN IL (847) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE LOGAN SQUARE 2721 N SPAULDING CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE MELROSE PARK 1111 SUPERIOR STREET MELROSE PARK IL (708) A 6/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE OF NAPERVILLE 516 W 5TH ST NAPERVILLE IL (630) RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE RIVER FOREST 103 FOREST AVE RIVER FOREST IL (708) RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE ROLLING MEADOW 4180 WINNETKA AVE ROLLING IL (847) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE SOUTH CHICAGO 9200 S CHICAGO CHICAGO IL (773) A 8/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE SOUTH SHORE 2420 E 79TH ST CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE SOUTHWESTERN 7 EASTGATE PLZ EAST ALTON IL (618) A 8/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE WAUKEGAN HARBO 101 N WEST STREET WAUKEGAN IL (847) RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE WEST BATAVIA 2580 WEST FABYAN PARKWAY BATAVIA IL (630) RENAL DIALYSIS 04/01/16 FRESENIUS MED CARE WEST BELMONT 4943 WEST BELMONT CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE WEST CHICAGO 1859 N NELTOR BLVD WEST CHICAGO IL (630) RENAL DIALYSIS 01/01/14 FRESENIUS MED CARE WEST WILLOW 1444 W WILLOW STREET CHICAGO IL (773) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE 4800 N KILPATRICK CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 10/01/15 FRESENIUS MEDICAL CARE ANTIOCH 311 DEPOT ST ANTIOCH IL (547) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE BRIDGEPORT 825 W 35TH ST CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE BURBANK 4811 W 77TH ST BURBANK IL (708) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE CHATHAM 8710 S HOLLAND RD CHICAGO IL (773) A 9/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE CROWN PT 851 BURRELL ST CROWN POINT IN (219) A 8/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE DEERFIELD 405 LAKE COOK RD DEERFIELD IL (847) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE DUQUION 825 SUNSET AVE DU QUOIN IL (618) A 8/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE DYER 2150 GETTLER ST DYER IN (219) A 8/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE ELGIN 2130 POINT BLVD ELGIN IL (847) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE ELMHURST 133 E BRUSH HILL RD ELMHURST IL (630) A 9/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE GALESBURG 765 N KELLOGG ST GALESBURG IL (309) A 9/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE GARY 3290 GRANT ST GARY IN (219) A 6/1/2016 RENAL DIALYSIS 10/01/15 FRESENIUS MEDICAL CARE GURNEE 101 S GREEN LEAF ST GURNEE IL (847) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE HIGHLAND P 1657 OLD SKOKIE RD HIGHLAND PARK IL (847) A 9/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE HOBART 1330 W WISCONSIN ST HOBART IN (219) A 8/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE JOLIET 721 E JACKSON ST JOLIET IL (815) A 8/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE JOLIET TH INFANTRY DR JOLIET IL (815) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE KEWANEE 230 W SOUTH ST KEWANEE IL (309) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE LAKEVIEW 4008 N BROADWAY ST CHICAGO IL (773) A 8/1/

19 PROVIDER TYPE ORGANIZATION NAME OFFICE ADDRESS 1 CITY STATE ZIP RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE LOMBARD 1940 SPRINGER DR LOMBARD IL (630) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE MACOMB 523 E GRANT ST MACOMB IL (309) RENAL DIALYSIS 10/01/15 FRESENIUS MEDICAL CARE MCHENRY 4212 W ELM ST MCHENRY IL (815) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE MCLEAN CNT 1505 EASTLAND MEDICAL PLAZA BLOOMINGTON IL (309) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE MIDWAY 6201 W 63RD ST CHICAGO IL (773) A 8/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE MOKENA 8910 W 192ND ST MOKENA IL (708) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE MUNDELEIN 1402 TOWNLINE RD MUNDELEIN IL (847) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE MUNSTER 314 RIDGE RD MUNSTER IN (219) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE NAPERBROOK 2451 S WASHINGTON ST NAPERVILLE IL (630) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE NILES 9371 MILWAUKEE AVE NILES IL (847) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE NORRIDGE 4701 CUMBERLAND AVE NORRIDGE IL (708) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE NORTHCNTR 2620 W ADDISON ST CHICAGO IL (773) A 8/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE NORTHFIELD 480 CENTRAL AVE NORTHFIELD IL (847) A 8/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE OAK FOREST 5340 A W 159TH ST OAK FOREST IL (708) A 6/1/2016 RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE OAK PARK 733 MADISON ST OAK PARK IL (708) A 6/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE OF OSWEGO 1051 STATION DR OSWEGO IL (630) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE OTTAWA 1601 MERCURY CIR OTTAWA IL (815) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE PALATINE 691 E DUNDEE RD PALATINE IL (847) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE PLAINFIELD 2320 MICHAS DR PLAINFIELD IL (815) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE RANDOLPH 102 MEMORIAL DR CHESTER IL (618) A 8/1/2016 RENAL DIALYSIS 10/01/15 FRESENIUS MEDICAL CARE ROUND LAKE 401 NIPPERSINK RD ROUND LAKE IL (847) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE S DEERING S TORRENCE AVE CHICAGO IL (773) A 6/1/2016 RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE SANDWICH 1310 N MAIN ST SANDWICH IL (815) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE STEGER 219 E 34TH ST STEGER IL (708) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE STREATOR 2356 N BLOOMINGTON ST STREATOR IL (815) RENAL DIALYSIS 01/01/14 FRESENIUS MEDICAL CARE UPTOWN 4720 N MARINE DR CHICAGO IL (773) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE WATERLOO 624 VORIS JOST DR WATERLOO IL (618) RENAL DIALYSIS 04/01/16 FRESENIUS MEDICAL CARE WAUKEGAN 110 N. WEST ST WAUKEGAN IL (847) RENAL DIALYSIS 01/01/14 FRESENIUS OF LAKE BLUFF 101 WAUKEGAN RD LAKE BLUFF IL (847) RENAL DIALYSIS 01/01/14 GLENDALE HEIGHTS DIALYSIS CNTR 130 E ARMY TRAIL RD GLENDALE IL (630) RENAL DIALYSIS 01/01/14 GLENVIEW DIALYSIS CENTER 4248 COMMERCIAL WAY GLENVIEW IL (847) RENAL DIALYSIS 01/01/14 GRAND CROSSING DIALYSIS 7319 S COTTAGE GROVE AVE CHICAGO IL (773) RENAL DIALYSIS 01/01/14 GRANITE CITY DIALYSIS CENTER 9 AMERICAN VILL SHOPPING CTR GRANITE CITY IL (618) RENAL DIALYSIS 01/01/14 GREENWOOD DIALYSIS CENTER 1111 E 87TH ST CHICAGO IL (773) RENAL DIALYSIS 01/01/14 HAZEL CREST RENAL CENTER 3470 W 183RD ST HAZEL CREST IL (708) RENAL DIALYSIS 12/01/15 HOME DIALYSIS SERVICE ELGIN LLC 650 E TERRA COTTA AVE CRYSTAL LAKE IL (224) RENAL DIALYSIS 05/01/16 HOME DIALYSIS SERVICE ROCKFORD LL 6940 VILLAGREEN VIEW ROCKFORD IL (779) A 6/1/2016 RENAL DIALYSIS 04/01/16 HOME DIALYSIS SERVICES PEORIA 719 MAIN ST PEORIA IL (815) RENAL DIALYSIS 12/01/15 HOME DIALYSIS SRVS HICKORY HILLS 719 MAIN ST PEORIA IL (708) RENAL DIALYSIS 04/01/16 HOME DIALYSIS SVS OLYM FLDS LLC 3214 VOLLMER RD OLYMPIA IL (708) RENAL DIALYSIS 04/01/16 HOME HEMO DIALYSIS NETWORK LLC S BELL RD HOMER GLEN IL (708) A 8/1/2016 RENAL DIALYSIS 01/01/14 ILLINI RENAL DIALYSIS 507 E UNIVERSITY AVE CHAMPAIGN IL (217) RENAL DIALYSIS 01/01/14 JACKSON PARK DIALYSIS 7531 S STONY ISLAND AVE CHICAGO IL (773) RENAL DIALYSIS 01/01/14 JACKSONVILLE DIALYSIS 1515 W WALNUT JACKSONVILLE IL (217) RENAL DIALYSIS 01/01/14 JERSEYVILLE DIALYSIS 917 S STATE ST JERSEYVILLE IL (618) RENAL DIALYSIS 01/01/14 KANKAKEE COUNTY DIALYSIS 581 WILLIAM R LATHAM SR DR BOURBONNAIS IL (815) RENAL DIALYSIS 01/01/14 KENNEDY HOME DIALYSIS 5513 N CUMBERLAND AVE CHICAGO IL (773) RENAL DIALYSIS 01/01/14 KENWOOD DIALYSIS 4259 S COTTAGE GROVE AVE CHICAGO IL (773)