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DSH050696F Keck Hospital of USC (Active)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
ESOPHAGEAL LAB
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696F
Medicare Provider Number
050696
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
3/9/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/15/2010
Last Recertification Date
8/22/2024
Contacts
Authorizing Official
Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677
Primary Contact
Keck Medicine of USC
Krist Azizian, Chief Pharmacy Officer
(323) 865-3588
Addresses
Street Address
1500 SAN PABLO STREET
SUITE 2265
LOS ANGELES, CA 90033-4612
Billing Address
Keck Hospital of USC
1500 San Pablo
Los Angeles, CA 90033
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
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