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DSH010001A SOUTHEAST HEALTH MEDICAL CENTER (Terminated)
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Main Details
Name
SOUTHEAST HEALTH MEDICAL CENTER
Subdivision Name
SOUTHEAST HEALTH PAIN MANAGEMENT
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH010001A
Medicare Provider Number
010001
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
5/10/2024
Participating Start Date
7/1/2024
Participating Approval Date
5/14/2024
Last Recertification Date
8/27/2024
Termination Date
Termination Reason
4/1/2025
Change of covered entity type
Contacts
Authorizing Official
Southeast Health Medical Center
Robert Derek Miller, Senior Vice President, CFO
(334) 793-8701
Primary Contact
Southeast Health
Jacey Cox, Director of Pharmacy
(334) 793-8113
Addresses
Street Address
208 HAVEN DRIVE
DOTHAN, AL 36301
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (01/01/2010) until terminated effective date: (01/01/2024); reinstatement effective date: (07/1/2024)
05/14/2024
8/17/11 ADDED SHIP ADD
08/17/2011
April 2025
April 2025
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