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DSH330084 ALICE HYDE MEDICAL CENTER (Terminated)
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Main Details
Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH330084
Medicare Provider Number
330084
Additional Details
Current Program Status
Terminated
Registration Date
8/2/2010
Participating Start Date
10/1/2011
Participating Approval Date
8/5/2010
Last Recertification Date
8/29/2023
Termination Date
Termination Reason
11/27/2023
Other
Contacts
Authorizing Official
Alice Hyde Medical Center/Champlain Valley Physicians Hospital
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065
Primary Contact
Alice Hyde Medical Center
Michael Sprague Dufort, Director of Pharmacy
(518) 481-2404
Addresses
Street Address
133 PARK STREET
MALONE, NY 12953-0729
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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09/29/11 participating 10/01/10 to 6/30/11, not participating 7/1/11 to 9/30/11, reinstated 10/1/11; 12/29/2010 DOC. RECD. TO CONFIRM ELIG. DSH ADJ %
09/29/2011
12/29/2010- DOC. RECD. TO CONFIRM ELIG. DSH ADJ %
08/02/2010
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