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CAH521329-01 ST MARY'S HOSP OF SUPERIOR (Terminated)
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Main Details
Name
ST MARY'S HOSP OF SUPERIOR
Subdivision Name
ST. MARY'S - SUPERIOR CLINIC
Type
Critical Access Hospital
Rural
No
340B ID
CAH521329-01
Medicare Provider Number
521329
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
9/30/2010
Participating Start Date
1/1/2011
Participating Approval Date
12/10/2010
Last Recertification Date
9/4/2015
Termination Date
Termination Reason
10/1/2015
Other
Contacts
Authorizing Official
Essentia Health
Kim Pearson, Administrator
(715) 817-7017
Primary Contact
Essentia Health
Bryan Lundberg, 340b Program Manager
(218) 576-0745
Addresses
Street Address
3500 TOWER AVENUE
SUPERIOR, WI 54880
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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