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DSH050300A ST. MARY MEDICAL CENTER (Active)
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Main Details
Name
ST. MARY MEDICAL CENTER
Subdivision Name
ST. MARY MEDICAL CENTER OUTPATIENT SURGERY PAVILION
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050300A
Medicare Provider Number
050300
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
9/2/2010
Participating Start Date
10/1/2010
Participating Approval Date
9/14/2010
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
St Mary Medical Center
Eugene Gutierrez, Chief Financial Officer
(760) 946-8105
Primary Contact
St Mary Medical Center
Winna Asuming, Director of Pharmacy
(760) 946-4238
Addresses
Street Address
18122 US HWY 18
APPLE VALLEY, CA 92307
Billing Address
St. Mary Medical Center
PO BOX 696431
SAN ANTONIO, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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