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DSH500014A PROVIDENCE HEALTH & SERVICES - WASHINGTON (Terminated)
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Main Details
Name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Subdivision Name
PROVIDENCE REGIONAL MEDICAL CENTER EVERETT PACIFIC CAMPUS
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH500014A
Medicare Provider Number
500014
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/7/2008
Participating Start Date
4/1/2005
Participating Approval Date
1/7/2008
Last Recertification Date
8/25/2015
Termination Date
Termination Reason
7/1/2016
Site closure
Contacts
Authorizing Official
Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044
Primary Contact
Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530
Addresses
Street Address
916 PACIFIC AVENUE
EVERETT, WA 98201
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History
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5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #
05/17/2012
5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #
01/02/2009
5/27/09 DOC RECD TO CONFIRM ELIG DSH ADJ%; 1/2/09 NAME CHANGE (WAS PROVIDENCE EVERETT MEDICAL CENTER); 11/10/08 ADDED SUBDIV NAME; 7/1/08-ADDED MEDICAID #; 9/26/05 - DELETE MEDICAID #
01/07/2008
May 2025
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