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DSH330397 INTERFAITH MEDICAL CENTER (Terminated)
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Main Details
Name
INTERFAITH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH330397
Medicare Provider Number
330397
Additional Details
Current Program Status
Terminated
Registration Date
7/1/2005
Participating Start Date
7/1/2005
Participating Approval Date
5/16/2005
Last Recertification Date
9/14/2020
Termination Date
Termination Reason
6/1/2021
Business decision by the Covered Entity
Contacts
Authorizing Official
Interfaith Medical Center
Charles Bove, COO
(718) 613-6465
Primary Contact
Interfaith Medical Center
Lynne Antonio, Director of Pharmacy
(718) 613-4730
Addresses
Street Address
1545 ATLANTIC AVENUE
BROOKLYN, NY 11213
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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